In this guide 5 sections
This is a Part D step therapy denial. If the plan has already issued its initial decision, the next step is usually a level 1 appeal called a redetermination. The denial notice should explain how and where to file it.
What to do first
- 1.Call the number on the denial notice or plan membership card. Say, “I am appealing the step therapy denial and requesting an expedited redetermination.”
- 2.Contact the prescriber the same day. Ask the prescriber to send the plan a supporting statement explaining the medical reason the exception should be approved.
- 3.Include your name, address, Medicare Number, the drug being appealed, why you disagree, and any supporting information from the prescriber.
- 4.Keep the denial notice and proof of anything submitted. A level 1 appeal generally must be requested within 65 days of the date on the initial denial notice. If it is late, include the reason.
What the prescriber should explain
Ask the prescriber to identify the required drugs that were already tried, the results, and the medical reason the prescribed drug should be covered. Medicare requires a prescriber statement explaining why an exception should be approved.
When to request an expedited appeal
Request a fast appeal if waiting for the standard decision could seriously jeopardize your life, health, or ability to regain maximum function. The plan must decide a qualifying expedited appeal within 72 hours. A standard benefit appeal can take up to 7 days.
What happens if the plan denies the appeal
If the plan upholds the denial, the decision letter should explain how to request level 2 review by the Part D Independent Review Entity. That request generally must be filed within 60 days of the plan’s redetermination decision. A qualifying fast level 2 review also has a 72 hour decision timeframe.
Where to get help
Call 1-800-MEDICARE at 1-800-633-4227 for questions about Part D appeal rights. You can also contact your local State Health Insurance Assistance Program for free, personalized Medicare counseling.
Questions families ask
Can the prescriber request the expedited appeal?
Yes. You, your representative, or your prescriber can request a redetermination. A prescriber can support the expedited request by telling the plan that the standard timeframe may seriously jeopardize your life, health, or ability to regain maximum function.
What if I already paid for the drug?
A request to be reimbursed for a drug already purchased must be made in writing. Expedited coverage determinations do not apply to payment requests for drugs already furnished.
How long does the plan have to decide?
For a level 1 Part D appeal, the timeframe is 72 hours for a qualifying fast appeal, 7 days for a standard benefit appeal, and 14 days for a payment appeal.
What if I miss the 65 day deadline?
You may still request the appeal, but you must explain why it was filed late.
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