You shopped carefully for the right Medicare Part D drug insurance plan, figuring it would help with the cost of the Lipitor your doctor prescribed for your high cholesterol. But your pharmacist tells you that your insurance plan will only cover the cholesterol drug Lovastatin, or you'll have to pay a lot more than you thought for the Lipitor. What do you do?
First, ask your pharmacist to tell you exactly why the plan won't pay. Then, try to get in touch with your doctor. She may say you can switch meds -- perhaps to a low-cost generic that your plan will cover. Or she may be willing to call your insurance company to explain why you must take a specific drug. But if your insurer still won't budge, you'll have to file a formal appeal. The Medicare Part D appeals process is complex, and can take months to complete. But there are ways to improve your chances of winning.
To start, keep a record of all your prescriptions, meetings, and phone calls. Then, get the Medicare Part D Coverage Determination Request Form from your pharmacist, insurer, or from Medicare.gov. Once you fill out the form, you can fax it to your plan.
If you need the drugs right away, you can request an expedited appeal, which your insurance company is supposed to resolve within 24 hours. But your doctor will have to certify that it is an emergency. If it's not urgent, a standard review should get you an answer within 72 hours.
If you can afford it, go ahead and buy the drugs even if you think the price is too high. That is safer than skipping pills until things get sorted out. Even if you pay up front, you won't lose your right to appeal, although you won't get a 24-hour review. If you win, you will be reimbursed for the extra cost. "Be sure to keep every receipt and every bit of proof of what your costs were," says Patricia Nemore, senior policy attorney for the Center for Medicare Advocacy, a non-profit that assists seniors with legal disputes.
Now it's time to get your prescribing physician involved in a big way. Unlike other Medicare appeals, where a doctor's opinion is helpful but not necessary, successful Part D reviews require the aggressive support of your physician. "The doctor's office is the linchpin," says Robert Hayes, president of the Medicare Rights Center, a New York based advocacy group. "At a minimum, the doctor has to justify why this patient needs this drug and only this drug, and why no substitute will work."
Don't be surprised if your doctor is reluctant to do much. Every insurance plan has different requirements, and the forms can be time-consuming to fill out. For very expensive drugs, some plans even require doctors to submit medical journal articles to prove their patient is taking the right medication. There is one bit of good news: Many plans have recently agreed to use the standard coverage determination request form for your initial filing.
If your appeal is denied, you can ask your plan to reconsider. If it is rejected again -- and don't be surprised if it is -- it may be time to seek legal help. One place for advice is your State Health Insurance Assistance Program (SHIP). You can find yours at medicare.gov/contacts/static/allStateContacts.asp. Your Area Agency on Aging may also know where you can get assistance. Call Medicare's Eldercare Locator at 800 677-1116 for the nearest office. Another stop may be your local senior center. "Ask for an advocate who has got experience with this," says Hilary Dalin, the director of education and counseling for the Health Assistance Partnership, a group that trains Medicare counselors.
A lawyer or other advocate can help you through the rest of the appeals process. The next step is an independent review by an outside contractor hired by Medicare. To win at that level, you'll need lots of detailed proof, in writing, that you must take a specific drug. If the plan denies your appeal, you have 60 days to ask for outside review.
If you still don't get help, your next stop is a special Medicare judge. After that, your only recourse will be federal court.
You can read more at the Web site of the Center for Medicare Advocacy, medicareadvocacy.org. Just click on "Healthcare Rights Review." Don't be discouraged. The process can be daunting. But if you are taking costly drugs, it may be well worth the trouble.
By Howard Gleckman