Background
In 2006 new prescription drug coverage under Medicare became available to elderly and disabled people entitled
to Medicare Part A or enrolled in Medicare Part B. Medicare Part D benefits are provided by numerous private
insurance plans, each of which has its own Formulary, which changes every year and sometimes during the year.
These Medicare Part D Plans are required to post their Formularies on line. Visit our links to
Formularies and forms for many of the Medicare Part D Plans in Maine.
Patients with Limited Income
If your Medicare patients have limited incomes, they may be entitled to extra help with their prescription costs,
through the Medicare Savings program, the Drugs for the Elderly program or full Maine Care. You could refer
them to their local
Area Agency on Aging (1-877-353-3771) or their local
Department of Health and Human Services
office for more information/help applying.
Prescriber’s Role in Getting Drugs Covered
Each Part D Plan has its own Formulary of medications it will cover. The Formularies all have various restrictions
on certain medications, including Prior Authorization requirements, Step Therapy requirements, and Quantity
Limits.
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NOTE: Part D Plans are not allowed to deny coverage or impose restrictions for drugs in six specific
classes, if a person was already on the drug when he/she enrolled in the Part D Plan. These classes, referred
to as the Six Classes of Clinical Concern, include immunosuppressants (for prophylaxis of organ transplant
rejection), antidepressants, antipsychotics, anticonvulsants, antiretrovirals and antineoplastics.
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If your patient needs a Medicare drug that does not fall within the Six Classes exception, and the prescribed
medication is not on his/her Plan’s Formulary, or is on the Formulary but has a restriction on it,
or in some cases if the co-pay is too high, your patient will need your help.
How you can help if the drug you prescribe is not on the Formulary, has a restriction or, in some cases, if the
co-pay is too high:
If you believe there is a therapeutically equivalent medication on the patient’s Formulary, you could write a
new prescription.
OR
If you believe that your patient needs the medication you prescribed (or needs the amount you prescribed if
that exceeds the Plan’s Quantity Limits), your patient will need your help in filing a Coverage Determination
request (sometimes called an Exception) with the Part D Plan.
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Coverage Determination forms for many Maine Part D Plans can be found in our links to
Formularies and forms. Also, the CMS website has a
standard form for coverage determinations under Medicare Part D, which can be used with all Part D plans,
together with
instructions for completing the form. In some cases, you can call the Part D Plan’s PA line and make your
request over the phone.
You can also call LSE’s Medicare Part D Appeals Unit for help. (1-877-774-7772)
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In filing a Coverage Determination request, you will need to provide the Plan with a diagnosis and a reason
why the prescription is medically necessary. Also,
- If the prescribed medication is not on the Plan’s Formulary, you will need to explain why your patient cannot
take any of the medications that are on the Formulary, either because none would be as effective as the prescribed
medication, or would have adverse effects, or both.
- If there is a Prior Authorization requirement on the medication, you will need to address the Plan’s PA
criteria. (The Part D Plans may post the criteria on-line, or you can call the Plan.)
- If there is a step therapy requirement, you will need to explain that your patient has tried and failed
the step therapy drug(s), or explain why he/she should not start with those drugs (because they would not
be as effective as the prescribed drug, or would have adverse effects.)
- If there is a Quantity Limit restriction, and your prescription exceeds it, you will need to explain why
your patient needs more than the quantity limit.
- If you are trying to get your patient’s co-pay reduced, you are asking for a Tiering Exception
and should
write that on the form. You will need to state why your patient cannot take any of the cheaper medications on
the Formulary, either because they would not be as effective as the drug you prescribed, or would have adverse
effects, or both. (Tiering Exceptions are not available in all circumstances, including if the drug is on the
Plan’s Specialty Tier.)
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NOTE: Normally, a Part D Plan has 72 hours to issue a decision on a Coverage Determination.
However, if you ask for an Expedited Decision and state that failure to issue an immediate decision
will seriously jeopardize the patient’s life or health or his/her ability to regain maximum function,
the Plan must issue a decision within 24 hours.
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Appeals
If the Medicare Part D Plan denies your Coverage Determination request, your patient has the right to
Appeal
the denial, but must file the Appeal within 60 days of the denial. There are five levels of Appeal. The written
Decision from the Part D Plan denying the Coverage Determination must contain instructions about how to Appeal.
The Appeal will need to include a strong statement from you as to why your patient needs the medication
(as discussed above.)
The Medicare Part D Unit of Legal Services for the Elderly can help your patients with the Appeals.
1-877-774-7772
Other Resources for Providers:
The Centers for Medicare & Medicaid Services website has extensive
Prescription Drug Coverage Information for
Providers.
