Johns Hopkins Medicine - Department of Psychiatry and Behavioral Sciences
MEDICARE PART D |
TALKING TO YOUR PATIENTS
ABOUT MEDICARE PART D
Chapter 4 - Using the Program
Please select a link below for quick reference:
| How will Medicare Part D affect the way medications are prescribed? Answer |
| Requesting a determination: Is the drug covered? Answer |
| If the drug is not covered, how do you request a coverage exception? Answer |
| If the coverage exception is denied, how do you file an appeal?Answer |
| If the appeal is denied, are there further options?Answer |
| What happens if the drug plan drops the medication from its formulary? Answer |
| RELEVANT LINKS/CONTACTS |
How will Medicare Part D affect the way medications are prescribed?
The prescribing process will be altered by this new program, and it will take time to adjust to the new system. The prescriber will need to be aware of the medications available to the patient through the specific drug program that the patient has chosen to use. Becoming aware of the specifics of each program will take time and effort. Patients will need to help with this process to the extent that they are able.
You will need to know the following pieces of information for each patient:
- Patient’s state of residence
- Name of the program
- Level of the program
- Telephone contact number for program
Requesting a determination: Is the drug covered?
Before prescribing a drug you will need to find out if the drug is covered. This process is called requesting a determination. To obtain this information you will need to call the member services number for the program (not the enrollment number). Please see the list of phone numbers for determinations. You will need to ask if there are any special rules that effect the specific medication you are prescribing:
- Tier
- Quantity limits
- Prior authorization required
- Step therapy restrictions
If the drug is not covered, how do you request a coverage exception?
If a medication is not covered by a patient’s formulary, a request may be made for a “coverage exception”. These requests are made directly to the program plan provider, not to Medicare. The patient will need to call the plan, and the physician will need to write a letter stating the reasons an exception is necessary. Letters from physicians should be faxed to the program. A standard exception request should take 72 hours. An expedited request can be done in 24 hours. Exceptions can also be requested for financial reasons.
Please click here to see the list of phone and fax numbers for drug exceptions. This list is subject to revision, and will be updated as needed.
If the coverage exception is denied, how do you file an appeal?
If the request for a coverage exception is denied, an appeal can be filed. The appeal process generally takes 7 days. An expedited appeal takes 72 hours. This is known as a fast appeal. The process for filing an appeal is similar to the process for requesting an exception.
Please click here to see the list of phone and fax numbers for appeals. This list is subject to revision, and will be updated as needed.
If the appeal is denied, are there further options?
Answer 5: The process does not end with a rejected appeal. There are further steps that can be taken.
What happens if the drug plan drops the medication from its formulary?
Answer 6: Prescription drug providers may change their formularies at any time during the year. They are required to give 60 days notice to their members of any formulary changes. These changes will be “posted” on their web sites. Individual members will receive notice of changes in medications they are already receiving. Physicians will need to try to keep up to date on formulary changes.
Janet A. Bachur LCSW-C
12/12/05
USING THE PROGRAM: RELEVANT LINKS and CONTACTS
Making the system work
Medicare Rights Organization: “Medicare Drug Coverage 101”
www.medicarerights.org/drughelp.html
“How does the Medicare drug benefit work?” Questions 62-74
Mental Health Part D:
www.mentalhealthpartd.org/physicians
“The 10 first things every practicing psychiatrist should know about the new Medicare drug benefit, Medicare Part D”
Medicare: “Prescription Drug Coverage Information for Providers”
www.cmh.hhs.gov/medlearn/drugcoverage.asp
Click here to see contact list of phone numbers for programs.
Exceptions and appeals
Medicare: “Your Guide to Prescription Drug Coverage”
www.medicare.gov/Publications/Pubs/pdf/11109.pdf
“Rights and Appeals” (pages 61-66)
“How to file a complaint, coverage determination, or appeal”
www.medicare.gov/Publications/pubs/pdf/11112.pdf
Medicare Rights Organization: “Medicare Drug Coverage 101”
www.medicarerights.org/drughelp.html
“Do I have any protections?” Questions 88-101
Click here to see contact list of phone numbers for programs.
