How Do I Appeal If My Medicare Part D Drug Costs Go Up?

There’s no getting around it: Medicare Part D appeals are a hassle, and the process takes a long time. However, it is absolutely possible to win the battle – we’ve had clients win cases, and we want to share with you how to do it.

Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Why would my drug no longer be covered by my Part D plan?

If you’re on a drug plan, you can run a comparison on the Medicare.gov website. That comparison will show you how much you’ll pay for drugs over the course of the next year.

From there, one of two things can happen:

1. The insurance company changes their formulary
2. The drug requires prior authorization

A company changing their formulary is rare, but is has happened. What happens in this scenario is that the company no longer covers your drug, but they give you a limited supply for 1 month, and you can talk to your doctor about getting on a different drug that serves the same purpose.

Prior authorization is something you must get from your doctor in order for the drug to be covered. This just means that the doctor signs off on a form that says this particular drug is the only one that works for you.

So, in the appeals process, you’re basically explaining that yes, the drug isn’t being covered, but you’re asking for an exception because other drugs don’t work for you.

Download the Medicare Part D Cheat Sheet

Is filing an appeal worth it?

From our experience, it has been about 50/50. Half of the time, we’re successful, and the other half, the process is extremely challenging and lengthy, and everyone wished they hadn’t started the process in the first place.

So, before you start the appeals process, we recommend that you try everything else in your power. Can you ask your doctor about trying an identical drug that is covered by your insurance? Can you ask your doctor for prior authorization?

Most importantly, talk to your agent before choosing your drug plan. They’ll be able to see whether the plan requires prior authorization, which can save you from this hassle.

Nevertheless, life happens, and if filing an appeal is the last resort, it’s worth a try.

How do you file a Part D appeal?

From our experience, the client sends in a letter stating their case. To find out where to send the letter, ask your prescriber – they will show you a notice that explains how to contact your Medicare drug plan.

In that letter, you’ll explain what has happened. So, you’d say something like:

“I ran a drug comparison on Medicare.gov on this date, and the website showed that this drug was covered under your plan. That’s why I selected this plan.
Now, I’m being told that the drug isn’t covered.”

Also, threatening to turn the company into the Department of Insurance can go a long way. If you’ve really been wronged, the carrier will take that very seriously, because they definitely don’t want to deal with the Department of Insurance.

Last year, we had a client send a letter to the insurance carrier with this basic information, and they received a response rather quickly. They said that they received the appeal and that they would cover the prescription.

It won’t work everytime, but it’s definitely worth a try.

From here, if you don’t agree with the decision, you can go through a few more steps, which include an Independent Review Entity, a judge, the Appeals Council, and even a federal district court.

From our experience, these aren’t worth the hassle and your time. However, if your case is serious and expensive enough, talk with your agent about taking these steps. You can also read about them on Medicare’s website.

Download the Medicare Part D Cheat Sheet