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.
