There are ways to appeal a denial of prescription drug coverage by Medicare. The first step is to file an exception request with your Medicare plan. Medicare must respond within 72 hours (sooner if your doctor states it is an emergency). If the plan denies the coverage of that medication, the you can begin the appeals process.
Step One: Ask the insurer for a redetermination. Include a statement from your doctor explaining why you need the medication.
Step Two: If the redetermination is denied, then ask for an independent board decision. An independent review entity will reconsider the decision and issue their new decision within seven days.
Step Three: If the independent review entity denies the coverage, then you can request a hearing before an Administrative Law Judge. To qualify the amount in controversy must exceed $160.
Step Four: If the judge denies the coverage, you can appeal to the Medicare Appeals Council and issue a statement explaining why you disagree with the decision.
Final Relief: If the coverage is still denied and the amount in controversy exceeds $1600 you can request a hearing in federal district court.
For assistance with elder law issues, please contact Stouffer Legal at 443-470-3599.
