Coverage Determination

by David Bynon, last updated

What is a Medicare Part D Coverage Determination?

A coverage determination is the first decision made by a Medicare Part D plan (not the pharmacy) about a plan member’s drug benefits, including the following:

  • Whether a particular drug is covered
  • Whether you’ve met all the requirements for getting a requested drug
  • How much you’re required to pay for a drug
  • Whether to make an exception to a plan rule when you request it

If the drug plan doesn’t give a prompt decision and the beneficiary can show that the delay would affect their health, the plan’s failure to act is considered to be a coverage determination. If a beneficiary does not agree with the coverage determination, the next step is an appeal.

Was this article helpful?

Related Articles