Man ConcernedKenneth Buss had taken a blood thinner, for over a year when his mail-order pharmacy refused a request to refill his prescription. He immediately contacted his physician who urged his Medicare plan insurer to approve the medication. 

The request was denied. But Buss, 79, did not let the matter drop. Without coverage, a 90-day supply of Xarelto costs about $1,300 at a local pharmacy — more than 10 times what Buss had been paying.

“That killed me,” said Buss, who remembers phoning his Medicare plan and saying, “Excuse me, are you saying my doctor is wrong and you know better?”

With his physician’s help, this determined Arizona resident persuaded his plan to renew his prescription. But many similarly frustrated older adults are not sure how to appeal Medicare drug plan denials.

“A lot of cases fall through the cracks,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. “People simply do not know exactly how to proceed or they try to go through the process; but it’s complicated, time-consuming and people just give up.”

Concerns about Medicare drug coverage are common: More seniors call the Medicare Rights Center’s national hotline (800-333-4114) about this topic each year than any other Medicare organization.

Here is some essential information about the appeals process:

The Basics

Nearly 41 million Medicare beneficiaries receive drug coverage through stand-alone drug plans or privately run Medicare Advantage plans — Kenneth’s type of coverage.

Some rules apply across the board. Notably, plans must cover substantially all drugs in six categories: HIV/AIDS treatments, antidepressants, antipsychotic medications, anti-convulsive treatments for seizures, immunosuppressive medications and treatments for cancer. In other categories, at least two medications from each class must be offered.

Plans are not allowed to cover such drugs as those for weight loss, coughs and colds, fertility, cosmetic purposes, sexual difficulties and non-prescription medications, among others.

Beyond these generalities, Medicare drug plans have considerable flexibility in choosing which drugs to cover (their formularies), capping the amount filled per prescription (quantity limits), requiring preapproval before a medication is supplied (prior authorization), asking people to try other lower-cost treatments first (step therapy) and assigning medications to different classes with different costs attached (cost-sharing tiers).

A failure to meet any of these requirements may result in a denial. In Buss’ case, his plan requires annual prior authorization of Xarelto. Although his doctor submitted the proper request, as he did in 2016, this time the plan deemed his rationale for prescribing the medication as insufficient.

Persistent Problems

The latest government audit of Medicare’s drug program confirms that plans often impose limits on drug coverage without advance approval from the Centers for Medicare & Medicaid Services (CMS), as required.

Notably, 64 percent of plans applied quantity limits that had not been approved by CMS, while 41 percent improperly dealt with requests for prior authorization or exceptions to plan requirements.

Also, insurance plan representatives were deficient in communicating with members and providers: 70 percent of denial notices did not offer adequate explanations for the actions taken, were incorrect or were written in a manner that was difficult for most people to understand.

About 45 percent of the insurance plans did not reach out to Medicare members or physicians to acquire the necessary additional information to make a coverage decision.

The takeaway for seniors: You must take the initiative in supplying relevant materials. Your chances are best if your physician clearly and comprehensively states, in writing, why you must take a particular medication and the likely harm of not doing so while referring to your particular medical circumstances.

Appeals Process

Seniors tend to think that when they are unable to get a medication at a pharmacy, they have grounds to appeal. But that is not true.

Another step awaits: An individual needs to request a formal “coverage determination” from the Medicare drug plan before the appeals process can start. Included should be an “exceptions request” asking that a plan’s rules be waived so a senior can obtain a medication or pay less for a drug.

Once a coverage determination is issued, there are five steps to the appeals process: a “redetermination” by the drug plan; a “reconsideration” by an independent review entity (MAXIMUS Federal Services serves this purpose across the U.S.); a hearing before an administrative law judge; a review by the Medicare Appeals Council; and a review by a federal district court.

Breakdowns in the process can occur right at the start: Individuals are supposed to get a notice from the pharmacy informing them of their right to appeal when a prescription cannot be filled, but much of the time this does not happen, said Casey Schwarz, senior counsel at the Medicare Rights Center.

Appeals can be processed on an expedited, fast-track timetable or at the standard, slower pace. But even expedited appeals can drag on, as plans and other entities miss decision-making deadlines.

Tips For Seniors

Older adults can become discouraged as they go through the early steps of this process, but “we encourage them not to give up — people are often successful at higher levels of appeal,” Schwarz said.

In 2015, the latest year for which data are available, independent reviewer MAXIMUS reversed drug plan decisions 30 percent of the time. That year, appeals to MAXIMUS climbed 47 percent over 2014 levels.

Some other tips from advocates: Keep careful records of every person you have spoken with and what they told you. Work closely with your physician’s office. Keep a record of any out-of-pocket drug expenses; these can be recovered later if your appeal is successful. Be persistent.

For help, call the Medicare Rights Center national hotline (800-333-4114).

“The complexity is awful, but hang in there if you can,” said Buss, who hopes he will not face similar difficulties when it’s time to renew his Xarelto prescription next year.