Inefficient Medicare Part D Appeals Process Can Result in Dangerous Medication Delays

Lindsey CopelandMedicare WatchLeave a Comment

The Medicare Rights Center applauds Senators Ben Cardin (D-MD) and John Cornyn (R-TX) for introducing the bipartisan Streamlining Part D Appeals Process Act (S. 1861).

The bill would eliminate unnecessary steps in the Medicare Part D appeals process, making the system less burdensome for people with Medicare, providers, and plans. Specifically, the Cardin-Cornyn bill would simplify the process for Part D enrollees who experience medication denials at the pharmacy counter.

Currently, when beneficiaries are told at the pharmacy counter that their Part D plan will not cover a prescription, they must then work with their prescribing physician to file an exception request with the plan. Only upon receipt of a written denial in response to this request—called a “coverage determination”—may the beneficiary request a formal appeal from the plan.

This multi-step process is overly onerous for all involved. It requires people with Medicare to correspond with both their plan and their prescriber on multiple occasions, which may involve many phone calls and long wait times, often up to several days. For many older adults and people with disabilities, this is dangerously too long to go without needed medication.

The Cardin-Cornyn bill would streamline this process—limiting delays in beneficiary access to needed therapies and reducing administrative requirements for plans and prescribers—by allowing a denial at the pharmacy counter to qualify as a coverage determination.

The Medicare Rights Center strongly supports this legislation.

Year after year, questions concerning access to affordable prescription drugs are a top trend on Medicare Rights’ National Consumer Helpline. We consistently observe that many Part D enrollees struggle to navigate the highly complex appeals process—resulting in delays in access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs.

The Streamlining Part D Appeals Process Act’s sensible efficiencies would help address these challenges. We thank Senators Cardin and Cornyn for their leadership and urge lawmakers to pass this bill without delay.

Read the bill text.

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