To find out why your prescription was not filled:
- You could ask the pharmacist for an explanation.
The pharmacist may or may not be able to explain the reason why you were
denied coverage. Depending on the reason for the denial, you may be entitled
to request an Appeal or an Exception;
to obtain your drug.
There are several reasons why your Part D plan might refuse to cover
your drug. Use the links at the bottom of this page
to find out what to do next.
- If the pharmacist does not give you a reason for the denial, or if you want
an official denial so you can start the Appeal Process, you, or your representative
or your doctor, should contact
your Part D plan and request a "Coverage Determination."
A "Coverage Determination" is your Part D plan's official
decision about the prescription drug benefits you are entitled to receive.
If you need assistance requesting a "Coverage Determination,"
you can ask your prescribing doctor or someone you trust to request a
"Coverage Determination" for you.
| NOTE:
If someone other than your prescribing doctor is going to request
a "Coverage Determination" for you, you will need to submit
a written statement to your Part D plan authorizing someone to act for you.
You can get a standard
Authorization form from the Social Security website.
|
What happens next?
Your Part D plan must contact you within 72 hours to explain the
reason why it would not cover your drug.
What if I can't wait 72 hours?
You can request an Expedited Coverage Determination.
If you or your doctor believes that waiting 72 hours might seriously
jeopardize your health, life, or ability to regain maximum function,
you or your doctor can call your Part D plan and request an Expedited
Coverage Determination.
Your Part D plan will decide if you qualify for an Expedited Coverage
Determination depending on the seriousness of your health condition.
| NOTE: Your Part
D plan MUST grant a request for an Expedited Coverage Determination
if your doctor personally calls your Part D plan and states that waiting
72 hours for a decision might seriously jeopardize your health, life, or
ability to regain maximum function. |
If your Part D plan grants the request for an Expedited Coverage Determination,
it must contact you within 24 hours to explain the reason why it
would not cover your drug.
What if the Coverage Determination is unfavorable?
There are several reasons why your Part D plan might refuse to cover
your drug. Follow the links below to find out what to do next.
