Appeals and Exceptions for Medicare Beneficiaries

Appeals and Exceptions for Medicare Beneficiaries

Medicare denying your medical food prescription?
Learn about appeals and exceptions.

Medical foods are not covered under Medicare Part D, so it’s important to file for an exception. For a Medicare exception, your doctor must provide a statement of medical necessity about why the medication needs to be approved. Medicare beneficiaries and their doctors can request an exception by phone or in writing when a medication is not on a Part D plan’s formulary. To get started, you can do one of the following for a standard request.

To start the process, follow these steps:

  1. Call your plan
  2. Write your plan letter
  3. Complete a “Model Coverage Determination Request” form and send it to your plan to ask for an exception

Medicare prescription drug plans must respond to a standard request within 72 hours.

If you are in urgent need of your medical food, where going without it will cause you harm, you or your doctor can ask your plan by phone or in writing for an expedited request. Both of the following criteria apply to urgent requests:

  • You haven’t received the prescription
  • Your plan determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function

Your plan has 24 hours to notify you of its decision once it receives the expedited request. You will receive a written disposition. If your plan denies the exception, you have the right to appeal. Medicare has five levels of appeals. The decision to reverse your prescription drug plan’s denial and cover your prescription medical food can happen at any of these levels:

Level 1: Redetermination from your plan

Level 2: Review by an Independent Review Entity (IRE)

Level 3: Hearing before an Administrative Law Judge (ALJ)

Level 4: Review by the Medicare Appeals Council (Appeals Council)

Level 5: Judicial review by a federal district court

For more information about filing an exception with a Medicare Part D plan, visit Medicare.gov, and email your congressman and senators to demand that Medicare cover your medical foods. 

 

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