Q1Medicare.com Brings Medicare Part D Prescription Drug Plan Exceptions, Appeals, and Grievance Section Online

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Medicare beneficiaries have the right to request that their Medicare Part D plan make certain changes to their prescription drug plan coverage in the form of a Formulary Exception or Coverage Determination. If a Medicare beneficiary’s Formulary Exception is denied, then they have the right to appeal their Medicare Part D plan’s decision. In certain situations, Medicare beneficiaries also have the right to file a complaint or grievance with their Medicare Part D plan. In order to help Medicare beneficiaries navigate these somewhat complicated topics, Q1Medicare.com now has added a Medicare Part D Exceptions, Appeals and Grievance section providing guidance and tips that walks Medicare beneficiaries through these processes.

We are hoping that our new section will help Medicare beneficiaries understand more about Exceptions, Appeals, and Grievances and realize that these procedures have been put into place to insure their access to appropriate health care.

Q1Medicare.com has now added an online section to help Medicare beneficiaries and caregivers understand the processes involved with Medicare Part D Exceptions, Appeals, and Grievances.

All members of Medicare Part D prescription drug plans have the right to request a Formulary Exception or Coverage Determination from their Medicare Part D plan. A Formulary Exception is a request for a specific change in plan coverage and can be made for several reasons. For instance, a Medicare beneficiary may request that a non-formulary medication be covered by their drug plan or a person may ask that their medication be moved to a lower cost-sharing tier or they could request a change to a specific utilization management restriction. However, not all exceptions are allowed. For instance, a person cannot ask that their Medicare Part D plan cover a medication that is specifically excluded from the Medicare Part D program.

Usually a person, their physician or their appointed representative, can file an exception. However, a Formulary Exception is usually not successful without some assistance from the physician or the medication prescriber. If a person’s health is at risk, they can also ask that their exception be given an expedited or faster review. Generic forms to file a written exception can be downloaded at: Q1Medicare.com/ExceptionForms, although some plans may require the use of their own exception forms.

Medicare Part D plans do not automatically grant a request for a Formulary Exception or Coverage Determination. If a request for a Formulary Exception is denied, the Medicare beneficiary can challenge their plan’s decision through five different appeal levels, starting with the Medicare Part D plan itself and ending with a Federal Court. A chart showing the different levels of appeal can be viewed at: Q1Medicare.com/AppealsChart.

A Medicare beneficiary also has the right to file a complaint or grievance with their Medicare Part D plan. For instance, if a Medicare Part D plan does not respond to a request for an exception or an appeal on a timely basis, the Medicare beneficiary can telephone their plan and file a grievance. A list of other common grievances can be viewed at: Q1Medicare.com/Grievance.

“We hear from many people who are still unaware that they can request changes to their Medicare Part D coverage or they are simply intimidated at the thought of challenging their plan’s decision,” notes Dr. Susan Johnson, Technical Director and co-founder of Q1Group LLC. “We are hoping that our new section will help Medicare beneficiaries understand more about Exceptions, Appeals, and Grievances and realize that these procedures have been put into place to insure their access to appropriate health care.”

About the Q1Medicare.com Website
Q1Medicare.com is one of the largest independent online resources for Medicare Part D prescription drug plan and Medicare Advantage plan information. Q1Medicare offers a comprehensive section of Frequently Asked Questions, online tools, and a free Medicare Part D Newsletter all designed to help Medicare beneficiaries, caregivers, advocates, advisors, and insurance agents better understand the Medicare Part D and Medicare Advantage programs. Q1Medicare.com is operated by Q1Group LLC (Saint Augustine, Florida).

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Lynnea Christner

Susan Johnson MS-MIS, MBA, PhD
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