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:
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:
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
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