Medicare Your Coverage Options

If your Medicare drug plan refuses to cover your medications, take these five simple steps

Written by Diane Archer

Too often, pharmacists are unable to fill prescriptions for people with Medicare because their Part D plan says the drugs are not covered. If you need the medications, you should appeal. The drug plan may improperly believe that a less costly medication will meet your needs.  Or, the drug plan might apply inappropriate limits on your medication or not implement proper Medicare policy. Here are three things to think about when choosing a Medicare Part D drug plan.

Almost four out of five people who appeal get their drugs covered. To file an appeal, you will need to follow a five-step process, whether you have a stand-alone Part D plan or you get your drug coverage through a private Medicare Advantage plan. Along the way, the drug plan might agree to cover your drug.

  1. If your pharmacist tells you that your Medicare Part D drug plan will not cover a drug you need, you will get a “Medicare Prescription Drug Coverage and Your Rights Notice.”
  2. Call the Part D plan and find out the reason for the denial. Unfortunately, the pharmacy cannot tell you the reason for denial. If it’s because the drug prescribed is not on the drug plan’s list of covered drugs, its “formulary,” ask your doctor if there’s another drug you can take that is on the formulary. If it’s because you must first try another drug or meet some other requirement, speak with your doctor.
  3. If you need the drug prescribed, you will need a denial letter from the drug plan. You can only appeal the drug plan’s refusal to cover a prescription if you have this letter. To get the letter, file a request for drug coverage, an exception request (or an expedited exception request if you need the drug urgently), along with the letter from your doctor explaining the need for the drug, with your Part D plan. Your Part D plan will let you know how to file this request. And, the drug plan might decide to cover your drug after it receives your exception request.
  4. If your Part D plan denies your exception request, it will send you a Notice of Denial of Medicare Prescription Drug Coverage. The Part D drug plan’s denial letter should explain the reason for denial. Get your doctor to explain in writing why the drug prescribed is medically reasonable and necessary and why no other drug will meet your needs. In a 2013 audit, CMS found that more than half of the health plans audited had issued inappropriate denials.
  5. If necessary, file an appeal with the Part D plan, including the letter from your doctor; file an expedited appeal if you need your drug immediately.

So long as your drug is medically necessary, you are very likely to win the appeal. The delay you might face in getting needed medications is a problem that the Center for Medicare and Medicaid Services is now looking to address.

Of course, even with drug coverage your out-of-pocket costs can be sky high since Congress allows the drug companies to charge whatever they want and they often have the power to set prices. And the health plans simply raise copays to offset rising costs.  They have no ability to rein in prices. It’s no surprise that 576,000 Americans had drug bills over $50,000 in 2014.

For more information on Medicare Part D appeals, visit Medicare Interactive.

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  • My problem with Medicare – D is that they keep bouncing generic drugs to higher tiers. So one month my medicine might cost $5 and the next month the same medicine may cost $50. I am with AARP-United Health Care and they have local suppliers but prefer that you use OptumRx. OptumRx is extremely slow and since many of my meds are not for long term illnesses but meds that I need to start immediately I have chosen to use a local pharmacy – still accepted by UHC but at a higher cost. And my local pharmacy makes sure that my meds don’t have a bad reaction with other meds that I am taking.

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