Enrollee Rights: Requesting Coverage Determinations and Appealing Decisions
•Part D Plan Sponsors must provide access via a secure website or secure e-mail address on the website for enrollees to quickly request a determination of whether the plan will cover a drug (a coverage determination) or appeal a coverage decision.
Enrollees may appeal coverage determinations, decisions on exceptions, or requests concerning tiering or formularies.
•Plan Sponsors must also require network pharmacies to provide enrollees with a printed notice with the plan’s toll-free number and website for requesting a coverage determination.
Enrollee Rights: Requesting Exceptions for Drugs
•Enrollees have the right to request coverage of a drug that is not on the Part D plan’s formulary or to request exceptions from plan rules such as prior authorization, step therapy, or quantity limits. Such requests are known as formulary exception requests.
•Enrollees also have a right to request coverage of formulary drugs at a less costly formulary tier. This is known as a tiering exception.
•Exception requests must be accompanied by a supporting statement by a physician or other prescriber explaining why the exception is necessary.
•A standard form is available on Part D plan websites for enrollees to request a coverage determination, including a formulary or tiering exception. A physician or other prescriber may also request a tiering or formulary exception.
Enrollee Rights: Filing Grievances
•Beneficiaries may also file complaints about their Part D plan or their pharmacies. These complaints are known as grievances.
•Grievances include complaints about issues such as pharmacy wait times, a plan’s failure to mail a beneficiary requested material, or the length of hold time on the plan customer service line. Grievances do not include complaints about a Part D sponsor’s refusal to cover a drug or
•approve an exception request. Beneficiaries must resolve such issues through the appeals process.
