Medicare Drug Coverage and Your Rights  

You have the right to ask for a coverage determination from your Medicare drug plan to provide or pay for a drug you think should be covered, provided, or continued. You also have the right to ask for a special type of coverage determination called an “exception” if you:

 Need a drug that’s not on your plan’s list of covered drugs 

Believe a coverage rule (like prior authorization or a quantity limit) shouldn’t apply to you for medical reasons 

Need to take a non-preferred drug and you want the plan to cover the drug at a preferred drug price 

How to ask for a coverage determination 

To ask for a coverage determination, you or your prescriber can call your Medicare drug plan’s toll-free phone number on the back of your plan membership card, or go to your plan’s website. 

You can ask for an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. 

Be ready to tell your Medicare drug plan: The name of the prescription drug, including dose and strength (if known) 

The name of the pharmacy that tried to fill the prescription 

The date you tried to fill the prescription

 If you ask for an exception, your prescriber will need to explain why you need the off-formulary or non-preferred drug, or why a coverage rule shouldn’t apply to you 

Your Medicare drug plan will send you a written decision. If coverage isn’t approved and you disagree with this decision, you have the right to appeal. The plan’s notice will explain why coverage was denied and how to ask for an appeal. 

Get help and more information Look at your plan materials or call 1-800-MEDICARE (1-800-633-4227) for more information about how to ask for a coverage determination. TTY users can call 1-877-486-2048. For help contacting your plan, call 1-800-MEDICARE