24 msfocusmagazine.org Are there resources outside of my doctor’s office that can help? Ifyou're covered bya job-based health plan, contact the Employee Benefits Security Administration, U.S. Department of Labor, online at askebsa.dol.govorcall 866-444-3272. Your employer’s human resource department may also offer assistance. The nonprofit PatientAdvocate Foundation offers free healthcare appeal assistance to individuals who meet certain criteria. Call Case Management toll-free at 800-532-5274 or fill out an application online at www. patientadvocate.org. How do I appeal a drug coverage denial if I get my health insurance through federal and state programs? For details, forms, and assistance regarding all Medicare/Medicaid appeals contact: • The Center for Medicare and Medicaid Services at cms.gov or call toll-free 800- MEDICARE (633-4227). If needed, ask how to appoint a representative to act on your behalf. Your representative can be a family member, friend, advocate, attorney, doctor, or someone else. • The government website for Medicare at medicare.gov. • The State Health Insurance Assistance Program at www.shiptacenter.org or call toll-free 877-839-2675. SHIP provides free, in depth, one-on-one insurance counseling and assistance to Medicare and Medicaid beneficiaries. The following summaries cover the basics in the Medicare/Medicaid appeal process: Original Medicare Original Medicare includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Part B covers most drugs that can’t be self-administered (such as infusions at a medical clinic). If you’ve been denied access to a drug under Part B, look for information about your appeal rights in the Medicare Summary Notice mailed to you every three months. If you decide to appeal, ask your doctor for supporting information that may help your case. Keep a copy of everything you send to Medicare as part ofyourappeal and document all correspondence. The appeals process has five progressive levels, but approval can be granted at any level. MedicareAdvantagewithPrescriptionDrug Coverage (Part C) and Medicare Prescription Drug Coverage (Part D) To obtain a drug not included on a plan sponsor's formulary, or to obtain a formulary drug that involves requirements you need to bypass (such as step therapy, prior authorization, and quantity limit) start by requesting a formulary exception. So you don’t have to repeat the process next year, ask the plan to approve coverage for as long as you’re in the plan. Your prescriber must submit a supporting statement to the plan sponsor, explaining whythe requested drug is medicallynecessary for you or why you should be permitted to bypass the requirements. The statement must also indicate the nonformulary drug is necessary for treating your condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects. If relevant, the statement can also include: • Why the number of doses under a dose restriction has been or is likely to be less effective. Hot Topics