Coverage determination (Part D)

What is Coverage determination (Part D)?

Coverage determination (Part D) meaning

The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:

  • Whether a particular drug is covered
  • Whether you have met all the requirements for getting a requested drug
  • How much you’re required to pay for a drug
  • Whether to make an exception to a plan rule when you request it

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests).  If you disagree with the plan’s coverage determination, the next step is an appeal.

 

reference: Glossary of Medicare program

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