Every Part D plan has a formulary that, by law, must include both brand-name and generic drugs. They also must include choices within commonly prescribed drug categories and classes. However, you may one day find yourself disappointed at the pharmacist’s counter that your plan doesn’t cover a drug you believe it should.
You have the right to request a coverage determination, and your prescription drug plan may respond by changing the formulary to cover that drug.
What’s a Coverage Determination?
The simplest way to describe a coverage determination is a plan’s decision that defines an enrollee’s coverage. These determinations go much deeper than just what drugs your plan covers, however. A coverage determination can also be requested when there is a disagreement on:
- The tier a drug appears in;
- How much a plan requires an enrollee to pay for a drug;
- The limit or dosage on a drug;
- A requirement to try another drug before a requested drug;
- Whether an enrollee has satisfied a specific authorization or requirement;
In some cases, the Medicare program may find it necessary to enact a coverage determination across the country. When this happens, they create a National Coverage Determination (NCD). This NCD will act as guidelines for carriers and Medicare Administrative Contractors (MACs).
When CMS finds it necessary to enact a coverage determination across the country, they create a National Coverage Determination (NCD).
When there is no NCD or one needs further explanation, a MAC may work with the Centers for Medicare & Medicaid Services (CMS) to create a Local Coverage Determination (LCD). An LCD is only applicable in that MAC’s jurisdiction. If an LCD contradicts an NCD, the NCD takes precedence. CMS created search engines for both LCD and NCD, if you want to see which ones take effect in your area.
How Do You Request One?
If you disagree with your drug coverage, you can request a coverage determination. This request can be made by you, a representative, or your prescriber. You may ask for a normal or expedited coverage determination. In the case of a normal coverage determination, a decision must be made within 72 hours. An expedited coverage determination will be made within 24 hours.
One common type of coverage determination is an exception, which is generally made on an individual basis, unlike an NCD or LCD. There are two types of exceptions. A tiering exception is when you or your doctor believe that your plan should charge a lower-tier price for a higher-tiered drug. A formulary exception is when you or your doctor feel a drug that’s not covered by your plan’s formulary is medically necessary and should be covered. This can also be used to ask your plan to waive a coverage rule.
One common type of coverage determination is an exception, which is generally made on an individual basis, unlike an NCD or LCD.
You can find a model form for a coverage determination request on CMS’ Forms site, though your Part D plan may have its own specific form. CMS strongly suggests that for any coverage determination request to be considered, it should meet the following guidelines:
- The request must be in writing and not marked as a draft
- The request is clearly identified as “A Formal Request for a National Coverage Determination”
- The request must identify the statutorily-defined benefit category that you believe the item or service falls into and contain enough information for CMS to make their own benefit category decision
- The request is accompanied by documents providing sufficient and supporting evidence
- The information identified the item or service’s relevance, usefulness, or the medical benefits to Medicare enrollees
- The information explains the design, purpose, and method of using the requested item or service
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If your coverage determination fails to get the result you desired, don’t worry! Often, a coverage determination is the first step in the Medicare insurance appeals process. You can get help with this process through Medicare.gov. There, you can learn to how appoint a representative to guide you through the process.
Your Medicare Part D plan covers many of your prescription needs, but sometimes, that’s not enough. Thankfully, the coverage determination process is in place so that you have a say in your Medicare insurance coverage.