Dear Marci,
My Part D plan is refusing to pay for a prescription I need. Is there anything I can do?
— Jeremy (Mesa, Colorado)
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Dear Jeremy,
If your Part D plan says no to your request to pay for a specific prescription, you should ask for an exception. In order to ask for an exception, you should make a formal, written request to the plan asking for it to pay for the drug. You can ask for an exception to:
- Cover a drug that is not on your plan’s formulary
- Override plan restrictions, such as prior authorization, step therapy or quantity limits.
- Put your drug on a lower cost tier (you cannot ask a tier exception if your drug is in a specialty tier or you want access to a brand-name drug at the same copay tier as a generic drug)
You cannot usually use the exception process if your prescription is excluded from Medicare coverage by law. However, you may be able to ask for an exception if you can show that your doctor prescribed your drug for a medication that is not explicitly excluded. Explicitly excluded drugs are drugs that are never covered by Medicare.
If you have formally asked for an exception and your plan turns you down, you should appeal. Your plan should send you in writing a letter titled “Notice of Denial of Medicare Prescription Drug Coverage.” This letter will detail the appeals process. Before you can begin the appeals process, you must have already asked for an exception and been officially denied in writing.
The appeals process is the same whether you are in a Medicare private health plan with drug coverage, or in a stand-alone private drug plan.
After you have received the denial notice, you have 60 days from the date on the notice to submit your appeal. Under certain circumstances you may be able to appeal after 60 days if you have “good cause”.
The plan must respond no later than seven calendar days from the date it received the request. If it is an emergency, you or your doctor can ask for an “expedited” redeterminaton. Your plan must respond to an expedited appeal with in 72 hours.
If your plan decides to reverse its own denial of coverage, the plan must authorize coverage no later than seven calendar days (72 hours for an expedited appeal) from the date it receives your appeal request. If the case involves a reimbursement request, the plan must authorize reimbursement within seven days and pay within 30 calendar days from the date it receives your appeal request. If your plan does not authorize coverage or provide reimbursement within these timeframes, file a complaint with your plan and notify the Independent Review Entity (IRE).
If the plan denies you again, you have the right to have your case reviewed by the Independent Review Entity (IRE). Maximus Federal Services is currently the private contractor that handles Medicare prescription drug appeals. Maximus is independent and not affiliated with any Medicare private drug plan.
To appeal to Maximus you must appeal with in 60 days of the date on the second denial notice from the plan. You or your doctor should send all your documents to Maximus. If your plan raised new reasons for denying coverage in its second notice, your doctor may want to update his/ her letter of medical necessity to address those new reasons. Maximus must return a decision within seven days for standard appeals and 72 hours for expedited appeals.
If you disagree with Maximus’s decision, you can appeal to higher levels including requesting a hearing from an Administrative Law Judge (ALJ), a review from the Medicare Appeals Council, and Judicial Review.
—Marci
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Health Tip of the Week
In 2002, 1.6 million people were seen in an Emergency Department because of a fall. The CDC’s National Center for Injury Prevention and Control has released a check list of hazards that might increase the risk of falling and how to fix these hazards. The check list can be found here. Here are some of the obstacles the CDC includes in its check list and how to fix them.
- If you have throw rugs on the floor, either remove the rugs or use double-sided tape or a non-slip backing so that the rugs do not move.
- If there are many wires from lamps, telephones and computers on the floor, tape or coil the wires next to a wall so they are not in the middle of the floor to prevent tripping over them.
- If you only have one light switch for lights on your stairs, have an electrician put another one in so you can have one at the top and one at the bottom.
- Keep stairs free of clutter.
- Do not use a chair as a step stool. If you need to use a step stool, make sure to use one with a bar to hold onto.
- If your bathtub or shower is slippery, use a non-slip rubber mat or self-stick strips on the floor of the bathtub or shower.
- If you have trouble getting in and out of the bathtub, have someone install grab bars.
- If the path from your bedroom to the bathroom is dark, use a nightlight. Some nightlights go on automatically after dark.
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The popular strategy of giving people healthcare information in the form of myths and truths might be flawed, according to a study by Dr. Ian Skurnik, a psychologist and assistant professor of marketing at the University of Toronto. The flaw in this method has to do with the way we remember what we read and are told.
According to studies, the information you are given is remembered, but which part is fact and which part is myth is not always remembered correctly. According to Dr. Skurnik in a New York Times article, “In laying down a memory trace, the human brain seems to encode the memory of the claim separately from its context–who said it, when and other particulars, including the important fact that the claim is not true.” Dr. Skurnik calls this “the illusion of truth” because you are familiar with the claim, and most people think familiar information is the truth.
To test this theory with health-related claims, Dr. Skurnik and his team studied 64 volunteers. Half of the volunteers were college students age 18-25 and the other half were healthy adults between the ages of 71 to 86. They gave the volunteers a couple dozen pieces of unrelated medical information such as, “aspirin destroys tooth enamel.” They arbitrarily said half the statements were true and half were false. Each statement was read out loud and then also displayed on a computer screen at least once. Half of the statements appeared on the list three times.
A half an hour later they were shown another list that had all of statements on them and some new ones. They were asked to identify which were true, which were false and which were new. They were asked the same questions three days later.
The results showed that the younger adults were more likely remember correctly than the older adults. Seeing the statement three times helped the younger people remember it correctly, but it exacerbated the memory issues for the older people.
This study is significant because it illustrates how the memory works and that if you are familiar with something you might remember it as a truth just on the basis of familiarity and not because it is the truth. This is important because today people consult lots of different sources for their health care needs and not all of these sources are accurate. This could lead people to remember the wrong information.
Dr. Joanne Schwartzberg, who oversees the health literacy program of the American Medical Association, points out how important this is when patients are talking to their doctors. She says that patients should not hesitate to ask their doctor questions and make sure they understand their advice correctly.
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