What if a Medicare Part D plan denies a prior authorization or an exception request?
A person can appeal a drug plan’s unfavorable exception or prior authorization decision. The first level appeal is made to the plan, generally done in writing by the enrollee or an appointed representative. Expedited appeals take only a few days. Plans must provide this information to beneficiaries upon enrollment. CMS describes this process in the “Physician Part D Resource Fact Sheet”, which explains the exception and appeal process and provides a glossary of terms to help enrollees, providers and pharmacists better understand this process.
