Medicare Part D

Medicare Part D covers self-administered prescription drugs (oral medications, self-injectable drugs). Part D is administered through private insurance companies (PDPs and MA-PDs) that each have their own formulary, but must cover at least two drugs in each therapeutic class and all drugs in six protected classes (including cancer and HIV/AIDS drugs).

Common Denial Patterns

• •Drug not on plan formulary — formularies vary by Part D plan
• •Prior authorization required — not obtained before prescription fill
• •Step therapy not completed per plan requirements
• •Quantity limits exceeded
• •Coverage gap (donut hole) — patient reaches out-of-pocket threshold

Step Therapy Approach

Part D plans set their own step therapy requirements within CMS guidelines. Six protected classes (anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, immunosuppressants for transplant rejection) have restrictions on step therapy and prior authorization. For non-protected classes, step therapy varies by plan.

Appeal Process

Part D uses a specific coverage determination and appeal process: (1) Coverage determination by plan, (2) Redetermination, (3) IRE reconsideration, (4) ALJ hearing, (5) Medicare Appeals Council. Standard determinations within 72 hours; expedited within 24 hours. Prescriber can request exceptions.

Tips for Appealing Medicare Part D Denials

1. 1.Check whether your drug falls into a Protected Class — if so, the plan has limited ability to deny
2. 2.Request a formulary exception if your drug is non-formulary — the plan must respond within 72 hours
3. 3.For Part D, the prescriber can request a coverage determination exception citing medical necessity
4. 4.Consider the Extra Help (Low-Income Subsidy) program if cost is a barrier — it significantly reduces copays
5. 5.Part D plans can change formularies annually — re-check coverage at the start of each plan year