Medicare Prescription Drug
Appeals & Grievances

This CMS section is of particular importance to beneficiaries receiving Part D drug benefits.

Additional CMS Resources:

• Quick Facts about Medicare’s Coverage for Prescription Drugs
• Understanding True Out-of-Pocket (TrOOP) Costs
• Bridging the Coverage Gap
• Part D Special Enrollment Periods: Who is Eligible?

Part D & Consumers

What is Medicare Part D and who does it affect?

Enrollment & Eligibility

How and when can people with Medicare enroll?  What are the special enrollment concerns for people with both Medicare and Medicaid?

Extra Help

What kind of subsidies will be available nationally and locally to help low-income individuals pay for the new Medicare prescription drug benefit?  How can you apply?

Costs for Consumers

What are patients’ responsibilities for premiums, deductibles, and co-payments?

Effect on Other Subsidy Assistance

Will the new benefit affect other assistance, such as food stamps and housing?

Prescription Drug Plan Formularies

Which medications will be covered?

Utilization Management

What are the protocols prescription drug plans will employ to manage access to specific drugs?

Coverage Determinations, Exceptions, & Appeals

What can you do if a prescription drug isn’t on the formulary, is subject to prior authorization, or is subject to higher co-payments?

Transition & Continuity of Care

What should be done now to help the transition go smoothly? How will people with both Medicare and Medicaid switch from their current prescription drug coverage to the new benefit? 

Long-Term Care Facilities

How does the new benefit affect residents of long-term care facilities which include nursing homes?

Current as of 9-26-2005