Part D – Formulary Appeals/Exceptions & Problem Reporting

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Physicians may need to help a patient by filing a prior authorization for a medication or appeal a medication’s tier.  Here’s a brief glossary of terms that may assist you in working with your patient’s prescription drug plan (source: Appeals Letter).

Coverage determinations:  The first decision made by a plan regarding the prescription drug benefits an enrollee is entitled to receive under the plan, including a decision not to provide or pay for a Part D drug, a decision concerning an exception request, and a decision on the amount of cost sharing for a drug.

Exceptions:  An exception request is a type of coverage determination request. Through the exceptions process an enrollee can request an off-formulary drug, an exception to the plan’s tiered cost sharing structure, and an exception to the application of a cost utilization management tool (e.g., step therapy requirement, dose restriction, or prior authorization requirement).

Appeals:  The process by which an enrollee may challenge a plan’s coverage determination.  There are five levels in the appeals process: redetermination by the plan, reconsideration by the Part D QIC, an ALJ hearing, review by the Medicare Appeals Council, and review by a federal district court.

CMS has directed every prescription drug plan to have an expedited request process to communicate coverage decisions no less than 24 hours after receiving an expedited request, or 72 hours after receiving a standard request. For more about the exceptions and appeals process, please click here to open a publication which explains how to file a complaint, coverage determination, or appeal.

CMS is committed to making sure that beneficiaries covered under Part D get the drugs they need.  However, in the event that backup systems fail, we are urging people to call 1-800-MEDICARE immediately so we can resolve the issue and get them their medication.

Part D Appeals Process Fact Sheet

Standardized Form – This standardized exceptions form was designed to assist physicians in applying for
exceptions and prior authorizations on behalf of Medicare beneficiaries enrolled in Medicare drug plans.  This form allows for a simplified process for physicians to apply for coverage determinations on behalf of all of their Medicare patients, regardless of which Part D plan the beneficiary is enrolled in.

Part D Exceptions and Appeals Contacts

Pharmacists and physicians should follow the routine procedures of each Part D plan provided on line at the point of sale, including the contact information provided when seeking prior authorization or a formulary exception.  This is usual practice.
In the event the provider is seeking prior authorization or a formulary exception and the plan’s routine protocol fails or the contacts are being made after normal business hours, then the exceptions number provided in the Downloads area below may be used (see Exception Contacts.

If the provider is appealing a Part D plan determination, the plan’s Part D appeals protocol should be followed. Beneficiaries are provided this information, and plans can make it available to providers.  The Part D appeals number in the Downloads area below may be used to contact the plan for the purpose of appealing a determination (see Appeal Contacts).

Problem Reporting

If you wish to communicate with CMS directly, please contact CMS Region 9 Office Part D Mailbox:
Email:  CMS

Handling Medicare Prescription Drug Plan Complaints.