Key Takeaways

  • Medicare Part D plans may reject coverage of a medication for reasons related to prior authorization, quantity limits, and formulary restrictions.

  • Counselors can help Medicare beneficiaries navigate Part D appeals through both the plan and independent review entities.

There are many reasons for why a Medicare Part D plan may deny coverage for a prescription drug, but these are some more common reasons:

  • Prior authorization: a beneficiary must get prior approval from the plan before it will cover a specific drug
  • Step therapy: the plan requires the beneficiary to try a different or less expensive drug first
  • Quantity limits: the plan only covers a certain amount of a drug over a certain period of time, such as 30 pills per month
  • Off-formulary: the drug is not on the plan’s list of covered drugs

This FAQ, developed for us by the Medicare Rights Center, answers common questions about Part D appeals, including which categories of drugs are generally covered or not covered under Medicare Part D plans, how a person with Medicare should purse a denial of coverage, timing of the appeals process, and how to help your clients get additional assistance with affording their drug costs. 

Also included below is a slide presentation which you can use with your staff and volunteers to train on this topic.