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Frequently Asked Questions

Q1. I really need the medication prescribed by my doctor (or other prescriber). My plan has denied my request. Can my prescriber help me with my appeal?

Q2. Is there an advantage to having my prescriber appeal instead of me?

Q3. What information do I need to include when I file a drug appeal with MAXIMUS Federal? 

Q4. I really need my medication. How long will it take MAXIMUS Federal to make a decision on my appeal? Is there a way to ask for a quicker decision?

Q5. How do I get a “quick” decision?

Q6. The plan denied my request for the drug my prescriber wants me to use, stating that the drug was being used for an off-label indication. Does it really matter what condition my prescriber is treating me for?

Q7. Before the Medicare Part D Prescription program, I used to get certain drugs under Medicare Part B. Do I need to request coverage through Medicare Part B before seeking coverage under Medicare Part D?

Q8. Sometimes my doctor will have the pharmacist compound a special prescription for me. Does Medicare Part D cover drugs that are compounded?

Q9. Are there specific drugs or uses of drugs that are not covered under Medicare Part D? Where can I get some more specific information on this?

Q10. I recently received a decision from MAXIMUS Federal that denied the drug that my prescriber wants me to use. I would like to appeal this decision. Can you provide information on how I can appeal your decision?

Q11. I was happy to receive a decision from MAXIMUS Federal that granted my request for an exception to my plan’s formulary. Am I going to have to request this exception every year from the plan?

Q12. MAXIMUS Federal made a decision last month that the plan needed to cover the drug I requested. When I go to the pharmacy, the plan is still denying coverage for the drug. What can I do?

Q13. I have been told by my plan that I owe a penalty for enrolling late in the Medicare Prescription Drug Program. I do not think that this is correct. How do I file an appeal?

Q14. Why did the Part D QIC apply a Late Enrollment Penalty to my monthly premium?

Q15. I received a decision letter from MAXIMUS Federal telling me that I did not owe a penalty but my plan is still charging me a penalty. What should I do?

Q16. I recently filed a Late Enrollment Penalty appeal with MAXIMUS Federal but I have not received a decision letter yet. Can you tell me when I can expect a decision?

Q17. I received a decision from MAXIMUS Federal telling me that I still owe a Late Enrollment Penalty. I do not believe that this is correct. Can I appeal to another level?

Q18. I was eligible for Part D coverage but did not take any medications until this year. Since I did not need Part D coverage, why do I have to pay a penalty now that I enrolled with Part D?

Q19. What is creditable prescription drug coverage?

Q20. I had a Medicare Supplemental Insurance (Medigap) Policy. Is that considered creditable prescription drug coverage?

Q21. I have been using a drug discount card/patient assistance program. Is this considered creditable prescription drug coverage?




Q1. I really need the medication prescribed by my doctor (or other prescriber). My plan has denied my request. Can my prescriber help me with my appeal?

Answer:

Your prescriber’s office can help you. However, your prescriber cannot appeal to MAXIMUS Federal without your written permission. This permission requires specific information. Please click here for the Appointment of Representative form that may be used to appeal, and closely follow the instructions for completion. An incomplete form cannot be accepted and will delay processing of the appeal.



Q2. Is there an advantage to having my prescriber appeal instead of me?

Answer:

The outcome of the decision is not affected by who asks for the appeal. Regardless of who appeals, a statement from your prescriber is needed to support an exception to the Plan’s rules. You or your prescriber can send in the prescriber’s statement when you ask for an appeal. If additional information is needed, MAXIMUS Federal will contact your prescriber by phone or fax.



Q3. What information do I need to include when I file a drug appeal with MAXIMUS Federal?

Answer:

You may request a standard or expedited (fast) appeal by sending a signed written request to MAXIMUS Federal Services. You can use the “Request for Reconsideration” form. We will accept any other written document as long as it is signed and includes the following:

1.      Enrollee’s name;

2.      Enrollee’s Medicare Claim Number;

3.      Identification of the item that is being appealed, e.g., the prescription drug, including dose and quantity;

4.      Name of your authorized representative, if applicable, and documentation of valid appointment; and

5.      Name of the Part D plan that denied coverage.

A note from your prescriber is needed to support an exception to the Plan’s rules. You or your prescriber can send in the prescriber’s statement when you ask for an appeal. If your prescriber thinks this is an urgent matter, he or she should include the words “urgent” or “expedited” on the statement.

You must ask for the appeal within 60 calendar days from the date of the notice of your plan’s redetermination, unless the time frame is extended by MAXIMUS Federal for good cause.



Q4. I really need my medication. How long will it take MAXIMUS Federal to make a decision on my appeal? Is there a way to ask for a quicker decision?

Answer:

Decisions for a valid expedited (fast) appeal are generally communicated by MAXIMUS Federal within 72 hours by phone, followed by mailing or faxing of the decision letter. Decisions for a standard appeal are generally mailed or faxed within 7 calendar days. An appeal is not valid if it is missing an appointment of representative form or an adequate prescriber statement. Processing may take longer while MAXIMUS Federal attempts to obtain this missing information.



Q5. How do I get a “quick” decision?

Answer:

A note from your prescriber is needed to support an exception to the Plan’s rules. You or your prescriber can send in the prescriber’s statement with your written appeal request. If your prescriber thinks this is an urgent matter, he or she should include the words “urgent” or “expedited” on the statement.

 


Q6. The plan denied my request for the drug my prescriber wants me to use, stating that the drug was being used for an off-label indication. Does it really matter what condition my prescriber is treating me for?

Answer:

Yes, it does matter what condition the drug is being used to treat. However, many drugs that are being used “off-label” are covered by Part D. We review these appeals on a case by case basis by checking with the Medicare-approved references.


Q7. Before the Medicare Part D Prescription program, I used to get certain drugs under Medicare Part B. Do I need to request coverage through Medicare Part B before seeking coverage under Medicare Part D?

Answer:

Drug plans may not require enrollees to provide proof that a drug will not be paid for under Part B before requesting coverage under Part D. However, drug plans may have prior authorization requirements in place to help determine whether a drug should be covered under Part B or Part D.


Q8. Sometimes my doctor will have the pharmacist compound a special prescription for me. Does Medicare Part D cover drugs that are compounded?

Answer:

This depends on the components of the compounded medication. In addition, a compounded drug must also be prescribed for a "medically accepted indication". Reimbursement is limited to FDA approved component(s) of the compounded medication. Most compounded drugs are made from bulk powders, which are not FDA approved, and are not covered under Part D.


Q9. Are there specific drugs or uses of drugs that are not covered under Medicare Part D? Where can I get some more specific information on this?

Answer:

Medicare Part D excludes certain drugs, classes of drugs or drugs prescribed for certain medical uses. The following is a list of drugs that are excluded from coverage under Medicare Part D. There are some exceptions to the exclusions listed below:  

  • Drugs used for anorexia, weight loss or weight gain;
  • Drugs used to promote fertility;
  • Drugs used for cosmetic purposes or hair growth;
  • Drugs used for the symptomatic relief of cough or cold;
  • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations);
  • Nonprescription drugs;
  • Drugs subject to a manufacturer tying arrangement;
  • Barbiturates;
  • Benzodiazepines;
  • Drugs used to treat sexual or erectile dysfunction
A Part D Plan may provide supplemental coverage for excluded drugs, classes of drugs or drug uses if the Plan has contractually agreed to provide such coverage. This information should be in your subscriber materials such as the Evidence of Coverage.

For more information about Part D exclusions, go to Appendix B in the Medicare Prescription Benefit Manual, Chapter 6, which provides additional information on Part D coverage and exclusions.


Q10. I recently received a decision from MAXIMUS Federal that denied the drug that my prescriber wants me to use. I would like to appeal this decision. Can you provide information on how I can appeal your decision?

Answer:

Information regarding how to appeal our decision was included in the Reconsideration decision letter issued for your appeal. As indicated in our letter, the next level of appeal is with an Administrative Law Judge (ALJ). If you received an unfavorable decision (or partially favorable decision) from MAXIMUS Federal (Part D QIC), you or your representative may request a hearing with an ALJ from the Office of Medicare Hearings and Appeals (OMHA). To request an ALJ hearing, you or representative must make a request in writing within 60 days of the date of our Reconsideration decision letter. The request must be sent directly to the OMHA office that is identified in the decision letter.

For more information, please refer to the OMHA website.


Q11. I was happy to receive a decision from MAXIMUS Federal that granted my request for an exception to my plan’s formulary. Am I going to have to request this exception every year from the plan?

Answer:

This depends on the plan and on the circumstances of your exception. For example, if the decision was made near the end of a plan year, your plan may require you to file a new exception request when the new plan year begins. If your plan decides not to continue coverage for a specific drug into the next plan year, the plan generally is required to send you a written notice at least 60 days prior to the end of the plan year.


Q12. MAXIMUS Federal made a decision last month that the plan needed to cover the drug I requested. When I go to the pharmacy, the plan is still denying coverage for the drug. What can I do?

Answer:

You should probably contact the plan first. If you still are not receiving coverage, you should contact the CMS Regional Office listed in our Reconsideration decision letter. The CMS Regional Office will follow up with your Part D plan.


Q13. I have been told by my plan that I owe a penalty for enrolling late in the Medicare Prescription Drug Program. I do not think that this is correct. How do I file an appeal?

Answer:

If you are being charged a Late Enrollment Penalty (LEP), you may request an LEP Reconsideration appeal with MAXIMUS Federal Services, the Part D Qualified Independent Contractor. Your Part D Plan is responsible for supplying a Reconsideration Request Form. If you have not received a Reconsideration Request Form, please call the Part D plan to request one or click here for more information.


Q14. Why did the Part D QIC apply a Late Enrollment Penalty to my monthly premium?

Answer:

Your Part D Plan and Medicare are the entities that process and apply the actual LEP charges. If you did not have prior creditable prescription drug coverage when you were first eligible to enroll in Part D, and you went 63 or more days without having creditable prescription drug coverage when you were eligible for Part D, the Part D plan and Medicare will likely charge you a Late Enrollment Penalty. The Part D QIC only processes Late Enrollment Penalty appeals, and is not responsible for charging, assessing or administering Late Enrollment Penalty amounts.


Q15. I received a decision letter from MAXIMUS Federal telling me that I did not owe a penalty but my plan is still charging me a penalty. What should I do?

Answer:

If more than 90 days have elapsed from the date of the LEP Reconsideration decision letter and you are still being charged an LEP, you will need to contact the CMS Regional Office listed in the LEP Reconsideration decision letter sent by the Part D QIC. The Part D plan and Medicare are the entities that will make sure the Part D QICs final decision is followed. The Part D QIC cannot provide reimbursement or remove the Late Enrollment Penalty.


Q16. I recently filed a Late Enrollment Penalty appeal with MAXIMUS Federal but I have not received a decision letter yet. Can you tell me when I can expect a decision?

Answer:

The Part D QIC has 90 days to make a decision on a Late Enrollment Penalty appeal. You will generally receive an LEP Reconsideration decision letter within 90 days of submitting your appeal request.


Q17. I received a decision from MAXIMUS Federal telling me that I still owe a Late Enrollment Penalty. I do not believe that this is correct. Can I appeal to another level?

Answer:

The Reconsideration decision issued by the Part D QIC is final and not subject to further appeal. However, if you believe there was an error or you have new information that might change the Part D QIC’s decision, and that information had not been available before, you may request reopening of the LEP Reconsideration decision. You should submit a detailed written request for reopening within 180 days from the date of the LEP Reconsideration decision letter.


Q18. I was eligible for Part D coverage but did not take any medications until this year. Since I did not need Part D coverage, why do I have to pay a penalty now that I enrolled with Part D?

Answer:

CMS may impose an LEP if at any time after your Initial Enrollment Period is over, there is a break of 63 days or more when you did not have creditable prescription drug coverage. For more information, please refer to the Medicare & You Handbook.


Q19. What is creditable prescription drug coverage?

Answer:

Creditable prescription drug coverage is coverage for prescription drugs that is as good as Medicare’s. Prescription drug coverage provided through the Federal Employee Health Benefits (FEHB) Program, Department of Veterans Affairs (VA), TRICARE, and Indian Health Services is considered creditable prescription drug coverage. Prescription drug coverage provided by an employer or union may be considered creditable prescription drug coverage. Contact your insurance plan to ask if your drug coverage is considered creditable. For more information, please refer to the Medicare & You Handbook.


Q20. I had a Medicare Supplemental Insurance (Medigap) Policy. Is that considered creditable prescription drug coverage?

Answer:

As of January 1, 2006, Medigap drug coverage is not considered creditable and you may be subject to an LEP if you decide to join a Part D Plan later. Medigap policies (H, I, J) that provided prescription drug coverage can no longer be sold or issued. If you have a current Medigap policy with prescription drug coverage you may keep it. If you decide to join a Part D Plan, your Medigap insurer must remove the drug coverage from your Medigap policy and adjust your premium. For more information, please refer to the Medicare & You Handbook.


Q21. I have been using a drug discount card/patient assistance program. Is this considered creditable prescription drug coverage?

Answer:

Medicare guidance indicates that prescription drug discount cards, patient assistance programs, free clinics, or drug discount websites are not insurance and do not meet Medicare’s minimum standards of what is determined to be creditable prescription drug coverage. Generally, drug discount card programs and drug discount websites will indicate that their product/program is not considered insurance. For more information, please refer to the Medicare & You Handbook.


For information about the availability of auxiliary aids and services, please visit:
http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

Frequently Asked Questions