What if the Pharmacy Doesn’t Fill Medicare-Covered Prescription Drugs?
This article was updated on: 12/06/2016
You may have a Medicare plan that includes prescription drug coverage. However, there may be times when a pharmacy can’t fill your prescription drugs. Here are some reasons why pharmacies won’t fill Medicare-covered prescription drugs and your options for handling the situation.
First, please note the two ways to receive Medicare prescription drug coverage: either through a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan. Original Medicare, Part A and Part B, includes only limited prescription drug coverage and usually doesn’t cover medications you take at home.
You went out of network or outside your plan’s service area to fill your prescription drug
Often, a prescription drug won’t be filled because the pharmacy is not within the network of your plan. Many stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans use a local network of pharmacies. Make sure to verify that your pharmacy is within the network–if not, you may have to go to a pharmacy that is in the network, or pay the full price.
Depending on your plan, you may have access to a national network of participating pharmacies available away from home. Call the customer service number on the back of your member ID card, or check the plan’s website for help locating a participating pharmacy.
You’ve reached the quantity limit for your prescription drug
Some Medicare plans with prescription drug coverage use cost-control and quality measures such as quantity limits. If your plan has placed a quantity limit on your prescription drug, Medicare will only cover a certain number of doses over a particular period.
If you reach a quantity limit and your plan refuses to cover your medication you may try the following:
- You or your doctor can contact the plan and ask for an exception. The request must include a statement from your doctor that gives a medical reason for more medication. Your pharmacist should show you a notice that explains how to do this and whom to call. Exception requests can be made in writing, unless your plan accepts requests over the phone. Your plan has 72 hours to make a standard determination, or 24 hours for an expedited request.
You may need to pay the full cost of your medication yourself if valid refills remain on your prescription drug.
Your prescription drug isn’t listed on your plan’s formulary
All Medicare prescription drug coverage, whether it’s a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, relies on a formulary. A formulary is a list of approved prescription drugs that determines coverage benefits. Your doctor may be familiar with your plan’s formulary requirements and prescribe medications that are covered. However, a plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Occasionally, your health-care provider may order a medication that isn’t included on your plan’s formulary, and your pharmacy will refuse to fill it. When that happens, you have the following options:
- Ask the pharmacist to call your doctor to ask for a different medication that’s covered. Often, there will be a comparable substitute.
- If the doctor believes there is a medical reason why you need a particular prescription drug that’s not covered, you or your prescriber can request an exception. Follow the instructions on the notice provided by your pharmacist. Remember, your doctor can request an expedited decision if he or she believes a delay could jeopardize your health.
- You can fill the prescription drug and pay the full cost yourself.
Keep in mind that plans will occasionally remove a prescription drug from their formulary that was previously covered. You’ll receive a written notice from your plan at least 60 days before the change takes effect (unless the Food and Drug Administration pulls the prescription drug for safety reasons, in which case, no advance notice will be given). If it’s a medication you take regularly, you’re entitled to receive a 60-day supply under the old plan rules.
Your pharmacy has run out of your Medicare-covered prescription drug
Sometimes your pharmacy may run out of a commonly prescribed medication. Then, you have two options:
- You can find out when the next delivery is expected. If you don’t need the prescription drug right away, you may be able to wait until your regular pharmacy can fill it.
- Since most prescription drugs are managed electronically, you can ask your prescriber to send your prescription drug to another network pharmacy (you may want to first call the pharmacy to make sure it has an adequate supply).
If neither of these situations applies and your pharmacy still can’t fill your Medicare-covered prescription drug, ask the pharmacist to give you the specific reason why. Depending on the pharmacist’s response, you may need to follow up with your doctor or your plan to resolve the situation.
Do you have questions about Medicare plans with prescription drug coverage? I’m available to help. If you’d like to schedule a phone call or receive information via email, click the corresponding link below. To see some plans in your area you may qualify for, click the Compare Plans button. Find out more about me by clicking the “View profile” link below. For immediate assistance, please call me or another licensed insurance agent at 1-844-847-2660 (TTY users can call 711) Monday through Friday, 8AM to 8PM ET.
For more information, please see:
“How Medicare Prescription Drug Plans & Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) Use Pharmacies, Formularies, & Common Coverage Rules,” Centers for Medicare & Medicaid (CMS), last modified October 2015, https://www.medicare.gov/Pubs/pdf/11136.pdf
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