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Drug Coverage Determinations

Medicare Prescription Drug Coverage and Your Rights

You have the right to get a written explanation from your Medicare drug plan if:

  • Your Doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor.

  • You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.

The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.

You also have the right to ask your Medicare drug plan for 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;” or

  • You believe you should get a drug you need at a lower cost-sharing amount.

What you need to do:

  • Contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.

  • Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan.

  • When you contact your Medicare drug plan, be ready to tell them:

    1. The prescription drug(s) that you believe you need.

    2. The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.

    3. The date you were told that the prescription drug(s) is not covered.



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