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Medicare Prescription Drug Coverage and Your Rights

Your Medicare Rights

You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an exception if you believe:

  • You need a drug that is not on your drug plan’s list of covered drugs (the list of covered drugs is called a formulary);
  • A coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
  • You need to take a nonpreferred drug and you want the plan to cover the drug at the preferred drug

What You Need to Do

You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber can request an expedited (24-hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:

  1. The name of the prescription drug that was not filled. Include the dose and strength, if
  2. The name of the pharmacy that attempted to fill your
  3. The date you attempted to fill your
  4. If you ask for an exception, your prescriber will need to provide your drug plan with a statement explaining why you need the off-formulary or nonpreferred drug or why a coverage rule should not apply to

Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.

Refer to your plan materials or call 1-800-MEDICARE (1-800-633-4227) for more information.

Download the Medicare Prescription Drug Coverage form.