- Coverage determination is a decision made by Medicare Part D PDP about whether a specific drug is covered under a beneficiary’s plan and, if so, under what circumstances. Coverage determinations are made when the beneficiary or their healthcare provider request coverage for a prescription drug that is not included on the plan’s formulary, or when the beneficiary requests an exception to a formulary rule, such as a request for a
higher dosage of a covered drug. - If a beneficiary has a Medicare Part D PDP and they have been prescribed a drug that is not covered under their plan, or if a beneficiary has been denied coverage for a drug due to a formulary rule, they have the right to request a coverage determination. To request a coverage determination, the beneficiary or their healthcare provider will need to submit a request to the plan, along with any relevant medical documentation.
- Medicare Part D plan is required to decide on the beneficiary’s coverage determination request within a certain timeframe, which is specified by Medicare. If the plan denies the beneficiary’s request for coverage, they have the right to appeal the decision through the Medicare Part D appeal process.
- It is important to note that coverage determinations can be complex, and it is recommended that the beneficiary seek the assistance of a healthcare professional or advocate if they are considering requesting a coverage determination or appealing a decision.