Beginning April 1, the Centers for Medicare & Medicaid Services (CMS) will begin enforcing a requirement in Part D that a beneficiary who goes to one of their plan’s network pharmacies and whose prescription is denied at the point-of_service (POS), which usually means at the pharmacy window, will get a written notice about the denial. This notice is titled “MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS” and is Form No. CMS-10147.
The notice tells you only that your drug is not covered, and gives you some instructions on how to proceed. Basically, you’ll need to call your prescription drug plan and ask why the drug in question was not covered. You Plan then has to give you a coverage determination (a formal denial and the reason for the denial). If you or your doctor still thinks you should get the drug, you can make an exception request. The instructions in the notice will give you some details on this, and it’s also spelled out beginning on page 206 of Managing Your Medicare. Too, your doctor’s office probably has some experience with these (you almost certainly will have to get them involved), and you can also call your State Health Insurance Assistance Program (SHIP). Their number is on the back of your Medicare & You booklet; they are often quite skilled at dealing with drug denials.
You should note that you will not always get this notice. For example, if you were prescribed an over-the counter (OTC) drug (these are not covered by Part D), or if it isn’t yet time to refill your prescription, you will not get this formal notice.
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