When Your Client Cannot Get Prescription Medications: Flowchart of Part D Appea

Executive Summary

This flowchart developed by NHeLP and the National Senior Citizens Law Center guides advocates through the appeals, exceptions and grievances processes for problems their clients may have encountered with the Medicare Part D prescription drug benefit.

The Medicare prescription drug coverage program has several different tracks for clients to follow in order to obtain coverage for their prescriptions. 
The first stages of the appeals and grievance processes largely involve paper reviews, rather than hearings at which advocates can represent their clients at in-person settings. Nevertheless, advocates? assistance, along with cooperation from the client?s physician, will be crucial to getting clients the medications that they need. Besides the federal laws and regulations, advocates should look to the CMS Prescription Drug Manual, Chapter 18 (available at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PartDManualAppeals_11.30.05.pdf for guidance on appeals and 
grievances. References on the charts are to Title 42 of the Code of Federal Regulations unless otherwise noted. 
First steps: 
  • Ensure that your client has Medicare and is enrolled in a Medicare prescription drug plan (PDP) or a Medicare Advantage drug plan (MA-PD). With the client?s consent and identifying information, an advocate should be able to confirm this at www.medicare.gov or by calling 1-800-MEDICARE. These resources should also be able to tell whether your client is enrolled in the low-income subsidy (?extra help.?) 
  • Make sure that the medication is not among the types of medications excluded from Medicare Part D coverage. These medications include: benzodiazepines, barbiturates, drugs for anorexia, weight loss or weight gain, fertility drugs, drugs for cosmetic purposes or hair growth, medications for cough and cold symptoms, over-the-counter medications, and vitamins and mineral products (unless prescribed for prenatal purposes.) If the client also has Medi-Cal coverage, most of these medications continue to be covered by Medi-Cal. 
  • Obtain the client?s consent to his/her medical information with a HIPAA-compliant consent form. You will likely need to speak to the client?s prescribing physician and perhaps to other medical professionals that the client sees. Because the physician?s willingness to cooperate in the appeal process will be crucial, you should contact the physician early on to gauge the physician?s willingness to help and to find out whether the most expedient way to ensure your client?s health actually may be to obtain a prescription for another drug which the client?s PDP or MA-PD will cover without problems. You may also need to view the client?s medical history to document his/her need for the medication. You will also need CMS form CMS-1696 (or its equivalent) from the CMS Web site to communicate with the PDP. 
  • Find out from the client what s/he was told at the pharmacy. Was the client told that the particular medication is not on the PDP?s formulary? Was the client told that the pharmacy is not in the PDP?s network? Was the client told that s/he cannot get the quantity requested? Finding out what happened at the pharmacy will be crucial to deciding which track you should follow. 

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