Medicare won’t cover a prescription I need—what now?Posted by Medicare Made Clear
You’ve successfully navigated the waters of Medicare prescription drug coverage. You have a standalone Part D prescription drug plan or a Medicare Advantage plan with prescription drug coverage built in. But you’ve hit a roadblock: Medicare won’t cover one of your prescriptions. Here are 4 things to consider if this happens to you or a loved one.
1. Have you looked at your plan’s formulary lately?
A formulary is the list of drugs your plan will cover. Put simply, you won’t get help with the cost of a drug that is not covered by your plan. For example, a plan may cover only certain cholesterol-reducing drugs. If the specific drug you take isn’t covered by a plan, the plan won’t help you with the cost of that drug. However, your plan may cover a similar drug. Talk to your doctor to find out more. Remember that formularies can change from year-to-year, as well.
Some drugs also have special requirements that must be met before the plan will cover them. Be sure you understand terms like Prior Authorization, Quantity Limits and Step Therapy. If you don’t get approval from your plan for a drug with a requirement or limit before using it, you may have to pay the full cost of the drug. Many of these terms go hand-in-hand with the term “tier.” Briefly, the drug tiers in your plan’s formulary generally refer to how expensive they are. Tier 1 includes the least expensive drugs, while Tier 5 has unique and/or very high-cost drugs.
2. Should you request a coverage determination?
You’ve looked at your plan formulary. You’ve talked to your doctor about other drugs that might work for you. If you still think your drug should be covered by your plan, it might be time for a coverage determination. Basically, if you’re looking for a coverage determination, you and your doctor will need to give your plan more information so the plan can determine if your drug will be covered. For example, your plan might need to know how a drug will be used. Another type of coverage determination, called an exception, might be the way to go if you think your drug should be covered but it isn’t. Be sure to read your plan materials carefully to find out the specific rules for coverage determinations and exceptions. Look for things like:
- Any contact information you need to include when you contact your plan. This might include you, your doctor and/or your representative.
- Whether you need to request or download special forms to include with your request.
- Whether you need a written statement from your doctor to support your request.
- Whether or not you can complete your request online.
3. Do I have the right to an appeal?
If the results of your request for a coverage determination weren’t what you were hoping for, you can ask your plan to look at their decision again. This is called an appeal or plan “redetermination.” Check your plan materials for more information on the steps you need to take to make an appeal. Make sure you pay attention to details like whether or not you need to submit your appeal in writing, and if there are special forms you need to request or download. You might be under a time limit to file your appeal, so be sure to check this, too.
And what if your plan still says “no”? Most plans have a follow-up appeals process. Check your plan materials to see what this might be.
4. How do I know if I need to file a grievance?
What if your request wasn’t handled well? Then it might be worth your while to file a grievance. One example might be if your plan didn’t get back to you within the required time frame. Each plan handles grievances a bit differently, so check your plan materials to see what your plan requires. Is there a special phone number for grievances, or can you submit a formal complaint in the mail?
It’s all about information.
Your Part D prescription drug coverage has rules and requirements for which drugs it covers and why. It is important that you know these rules so you can understand why your plan might not cover the prescriptions you need. Not only will this help you understand your coverage better, but it can also help you decide if you need to look at different coverage that better meets your needs.
For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.
MedicareMadeClear: Understanding Medicare Part D
Medicare.gov publication (PDF) How Medicare Uses Pharmacies, Formularies and Common Coverage Rules
Medicare.gov Medicare Appeals and Grievances
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