What is a Medicare Part D Coverage Determination?
A coverage determination is the first decision made by a Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... 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 exceptionIn a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... to a plan rule when you request it
If the drug plan doesn’t give a prompt decision and the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. 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 appealAn appeal is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare Part D plan..