WASHINGTON – Some patients and doctors are facing a new problem with the fledgling Medicare prescription drug benefit: Medications they once received without question from other plans are being denied by the private insurers running the Medicare plan.

When they appeal the coverage denials, the patients and their physicians face confusing forms, time-consuming demands for personal medical information and long delays.

In some cases, the private plans won’t cover the full dosage called for in a prescription or try to steer patients to drugs other than those prescribed by their doctors.

When disputes arise, doctors are asked to justify their prescribing decisions in writing, sometimes with patients’ medical histories or test results as supporting evidence. Some plans even ask for doctors’ notes or for peer-reviewed articles that justify their decisions.

“Whether intended or not, it’s a process that nobody can navigate in an efficient way. It’s a major problem right now,” said Sam Muszynski, head of health care systems and financing at the American Psychiatric Institute.

And many fear things will worsen in April when tens of thousands of elderly and disabled patients must formally petition the plans to get refills on medications that were provided on a temporary emergency basis.

“The system is going to melt down, and I think it’s going to require some emergency legislation,” said Dr. Holly Leeds, a general practitioner in Auburn, Calif.

Amid widespread complaints about coverage lapses following the January launch of the Medicare drug benefit, federal officials told plans to pay for drugs that they wouldn’t normally cover until March 31. Meanwhile, patients were urged to either switch to medications that were covered or file appeals to have the plans pay for their preferred drugs.

Many of those who petitioned the plans say the appeals process is often a poorly managed, highly subjective nightmare. Doctors say phone delays frequently leave their staff on hold with the plans for hours.

Some plans don’t meet mandatory time requirements to resolve appeals. Dr. Elizabeth Delesante, a psychiatrist in Brainerd, Minn., said she still hasn’t heard from anyone at the Humana plan she filed two appeals with in January.

Delesante gives her patients free samples to ensure that they get their medication while the cases are pending. “If it weren’t for that, these people would be in trouble,” she said. Officials at Humana said they have contacted Delesante and will work to resolve her complaints.

Doctors also say it’s hard getting the proper forms from the Medicare plans. “And none of these are standardized forms. Every company uses a different one, which is ridiculous,” said Dr. Rosemary Deleo of Kingston, N.Y.

Mohit Ghose, a spokesman for America’s Health Insurance Plans, a trade association, acknowledged that the process has problems. He said the plans are working with Medicare and physician groups to develop standardized appeals forms to simplify the process.

The plans also will soon offer a messaging system that gives pharmacists a list of alternative medications that patients can use when a plan denies a prescription request.

“I can assure you that the processes are getting better and they are getting streamlined,” Ghose said.

Medicare administrator Mark McClellan said the agency will monitor complaints about the appeals process and could levy fines and penalties if widespread problems persist.

To avoid further complications, Medicare is urging the plans to alert members whose medications will no longer be covered in April. Medicare officials also want the plans to increase telephone staffing for the expected rush of appeals and to extend drug coverage for people who haven’t resolved appeals by March 31.

But many worry that patients who lose their appeals could be forced to take less effective alternative medicines or, at worst, drugs that could endanger their health.


Don Riley of Danville, Ohio, is a 72-year-old retired truck driver. A diabetic stroke victim with heart problems and failing kidneys, Riley takes 12 medications a day, including Norvasc for high blood pressure.

Riley has used Norvasc since 2004, but after his drug coverage shifted from Medicaid to Medicare in January, he ran into problems. Riley’s Medicare plan from United Healthcare won’t pay for the drug in the amount prescribed by his doctors – two 10mg tablets a day.

The plan would cover only one 10mg tablet a day. To continue the higher dosages, the plan wanted a written explanation and supporting documents from his doctors. One doctor complied. Another refused, unwilling to spend untold hours on the phone chasing plan representatives, said Riley’s daughter-in-law, Paula Riley.

After Riley was denied twice by the plan, Paula Riley started working with attorneys from the Medicare Rights Center, a national patient advocacy group, to appeal the case to a mediator that’s contracted by Medicare. Until his case is resolved, Riley is taking only half his Norvasc dosage, and his blood pressure is creeping up.

The plan said he can switch to a new medication that’s fully covered, but his family is reluctant because neuropathy has diminished his ability to feel what’s going on in his body.

“If he changes medicines and has a side effect, he can’t feel it or tell you what it is,” Paula Riley said. “The only way we can detect it is by having him on a monitor or watching him. And I don’t have 24 hours a day to watch this man. So I don’t want to change what’s working. I don’t feel I should have to.”

Neither does Dr. Larry Fields, president of the American Academy of Family Physicians. He said that if a doctor thinks a higher dose is needed, the drug plan should stay out of it.

“That’s a doctor’s decision. The doctor is taking the responsibility to give a different dose and that should not be something that the plan’s involved in,” Fields said. “Their job is to supply drugs for the patients. … It’s not their job to decide which drug and it’s not their job to decide how much.”

Because of privacy laws, United Healthcare officials couldn’t comment directly on Riley’s case. But they said U.S. Food and Drug Administration guidelines set the maximum dosage level for Norvasc at 10mg per day. Federal rules require Medicare drug plans to follow these guidelines and other medically accepted practices when covering drugs under the Medicare benefit, said United Healthcare spokeswoman Joyce Larkin.

While doctors often exceed FDA-recommended dosing levels and sometimes prescribe drugs for ailments they weren’t designed to treat, these practices require strict review by Medicare plans to determine their medical appropriateness and eligibility for program coverage.


If a Medicare drug plan denies a prescription request, the patient or doctor can call the plan to seek a coverage exception. Plans are required to respond within 72 hours or within 24 hours if a doctor makes an expedited request for a patient whose health is in danger.

If the plan denies the request, the patient can seek a second review by the plan. Second reviews must be decided within seven days or 72 hours for an expedited appeal. Leeds said that most plans don’t meet the time requirements, even on the expedited requests. “If I’m lucky it might happen, but more often than not, it doesn’t,” she said.

If a patient still isn’t satisfied, he or she can appeal the case to an independent review agency contracted by Medicare, the Maximus Center for Health Dispute Resolution. So far, the company has received nearly 1,000 requests for appeals, McClellan said.

Additional appeals can then go to an administrative law judge, to the Medicare Appeals Council and even to federal court.

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