Medicare drug not covered? You can help patient appeal

For patients who need to veer from their drug plan's formulary, the assistance of their physicians will be essential.

By David Glendinning, AMNews staff. March 20, 2006.

Washington -- A Medicare patient shows up at his primary care physician's office distraught because his Part D plan doesn't cover the drug he's been taking for years. Suddenly he's faced with out-of-pocket charges he can't afford and a prescription that he can't get filled.

This scenario might become more common at the end of this month.

After March 31, Medicare drug plans can stop paying for federally mandated transitional supplies of noncovered medications that are prescribed to beneficiaries who enrolled in the drug program in its first few months. Patients then will need to start paying on their own for the medications or consult their physicians about switching to similar drugs that will be covered.

But many beneficiaries will be unable to afford the drugs that they previously had been receiving through Medicaid or another program, and some of them won't be able to switch to another medication for medical reasons. That's where the Medicare appeals process comes in.

If a drug plan denies a patient's request for coverage of a certain drug, the beneficiary or physician can take the request through as many as five levels of appeal. The process starts with the insurer, moves onto adjudicators hired by the government and, in cases where the dollar value of the drugs in question is high enough, can end up in the federal court system if all of the other appeals levels are exhausted.

While beneficiaries can initiate and renew appeals, in many cases physicians will need to become involved if they want to see their patients receive drugs that are not on plans' approved lists.