Navigating Prescription Coverage Determinations

If your doctor or pharmacist tells you a prescription drug isn't covered, you can ask for an exception, a coverage determination, or an appeal. You can also ask for help finding a different drug.

A standard request has a 72-hour turnaround time. You can also ask for a faster turnaround time of 24 hours.

Types of Coverage Determinations

Your doctor can ask to appeal an initial decision about a coverage determination, also called a request for "redetermination." Incluya cualquier información que pueda ser útil en su solicitud de redeterminación.

• Ask for your appeal within 60 calendar days after the date of the denial notice.
• Podemos darle más tiempo si tiene un buen motivo para haberse excedido de la fecha límite.
• You, your prescriber, or your appointed representative may ask for a standard or an expedited (faster) appeal.

You may request a prescription drug appeal by phone, fax or mail. Visite nuestro Comuníquese con nosotros para encontrar más información.

• Formulario de solicitud de determinación de cobertura de medicamentos con receta
• Formulario en línea de solicitud de determinación de cobertura 
• Formulario de solicitud de redeterminación de cobertura de medicamentos con receta
• Formulario en línea de solicitud de redeterminación de cobertura

A grievance is a complaint about the quality of care or other services from a Medicare provider. No es una queja sobre la falta de cobertura o pago de un determinado medicamento. En esos casos, use el proceso de determinación explicado más arriba.

Expedited Filing: If you asked for an expedited (fast) coverage determination or redetermination that was denied and you have not yet gotten the drug in dispute, you may file an expedited grievance. File your grievance by phone or fax, and we’ll tell you about our decision within 24 hours of getting your complaint.

You may choose someone to file an appeal or grievance for you. This is called an "appointment of representative."

• Esta persona puede ser un familiar, amigo, patrocinador, abogado o médico.
• Un tribunal también puede nombrar a alguien.
• You and the person you choose must complete, date, and sign a representative statement.
• The notice or request can also be made in a written letter. If you're legally not of sound mind or incapacitated, the representative can complete and sign the statement.
• The representative needs to have the correct legal papers or legal authority to sign for you.
• Si usted elige a un abogado, solo usted deberá firmar la declaración de representatividad.
• La declaración de representatividad debe incluir su nombre y el número de reclamación de Medicare.

If you have an issue related to what is covered for pharmacy services, or if you or your appointed representative wish to file a grievance, please call us. Visite nuestras Comuníquese con nosotros page. You may also file a grievance by fax or mail. 

Forms to Appointment a Representative

• CMS Appointment of Representative form 
• Social Security Administration form

You can contact Medicare for more information about benefits and services. This includes basic information about Medicare Advantage Prescription Drug coverage.

To learn about decisions related to medical care, visit Apelaciones e inconformidades médicas.