By Marcus A, Brummett  –  June 13, 2017

Part D Plan Won’t Cover My Prescription

There are many reasons why Medicare Part D beneficiaries have difficulty getting their Part D Plan to cover prescriptions they feel should be covered.  If you are prescribed a medication that is not on your Medicare Part D Plan’s formulary, then you’re prescription will not be covered, and you will be required to pay the full retail cost of the drug. The drug may cost more than you think it should.  You may have a prior authorization requirement before you can fill your prescription at the pharmacy. The plan can also choose to not cover a prescription because it does not agree that you need it.  Below I have written a list of steps to take if someone finds their way into this mess.  This is not a list to be done in order. Each item is a seperate way to address this issue.  As you read, know that I am happy to help anyone with each of these steps by answering questions or assisting with forms where I am able.

Compare Prescriptions on Your Plan’s Formulary:

Find out if your insurance company covers other drugs for the same issue. If so, contact your doctor and see if those will be acceptable replacements. Some people are unwilling to ignore their doctor’s initial suggestion. That’s understandable.

Appeals Process:

Begin the Appeals process. This does not mean run straight to Medicare. You must first have dialog with the insurance company by calling and asking them to cover this drug directly. They may make you have your doctor call them or send them a request form. Most of the time, Prior Authorization issues are solved this way. However, after this process they may still reject your and your doctor’s request, particularly if the drug you are seeking is not on their formulary. WHAT! Yes, this happens. Now the actual appeals process can begin. This can be a difficult process. It has many stages including a RE-review by your insurance company. Many give up early. Those who stick with it aren’t necessarily wasting time, about half of those who get to the end are successful. Also, if you win, then the plan only has to cover it for the remaining calendar year. So if your plan doesn’t cover the prescription next year and you don’t change plans, this same process would begin again.

Assistance programs and discounts:

Address income benefits. Even if you make a decent retirement, you may qualify for certain non-government discount programs through manufacturers and other sources. It’s also worth it to look into low income subsidy for Part D Plans. This is a big benefit not only because it will discount the prescriptions covered by your plan, but it also allows you to immediately change to a plan that may cover the drug not covered under your current plan. You must to be careful if you are on a Medicare Advantage plan though, because this could cause you to lose coverage if your healthcare and Part D are issued by the same policy. In this case, you would need to search for another MAPD, or address the possibility of a Supplement instead of an Advantage plan. Most of these benefits are available to anyone on Medicare who meet the income requirements, regardless of age.

Compare Plans Each Year:

Make sure that you compare Part D plans during the Annual Election Period from October 15th through December 7th to insure that all of your prescriptions that can be covered are so. Most states have over 20 participating Part D plans and Medicare Advantage + Prescription Plans and they all can change what drugs they cover, and their costs from calendar year to year.

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