This section describes your Part D prescription plan rights including grievances, coverage determinations, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.
By law, certain types of drugs or categories of drugs are not covered under Medicare Part D. In those cases, Medicare exempts the drugs or drug categories from the exception and appeal processes. These drugs or categories are called "exclusions." They include:
Non-prescription drugs (also called over-the-counter drugs)
Drugs when used to promote fertility
Drugs when used for the relief of cough or cold symptoms
Drugs when used for cosmetic purposes or to promote hair growth
Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
Drugs when used for treatment of anorexia, weight loss, or weight gain
Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
However, in some cases you may use the coverage determination process to argue that a medication is not statutorily excluded, is not statutorily excluded from a specific indication, or is covered by the plan as a supplemental benefit. If you are not disputing that a drug is excluded, but have a question or general complaint about an excluded drug not being covered by your Medicare Part D plan, your question or complaint will be processed as an inquiry or a grievance.