What Can I do If My Medicare Plan Doesn’t Cover My Prescription Drug?

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 10/04/2018

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If you have Medicare Part D coverage for prescription drugs, either as a stand-alone Medicare Part D Prescription Drug Plan or through a Medicare Advantage plan with Part D prescription drug coverage, your plan might cover medications your doctor believes are medically necessary for your care.

Every Medicare Prescription Drug Plan has its own formulary, which is a list of covered prescription medications. The formulary may change from time to time but the plan must inform you when it does. In some cases, a doctor might prescribe a drug for you that’s not in your plan’s formulary and therefore won’t be covered. Often, the doctor may be able to substitute a different medication that your plan will cover to treat your health condition.

However, there may be times when your Medicare drug coverage refuses to pay for a certain prescription drug that your doctor determines necessary to treat your condition. Here’s what you can do if that happens to you or someone you love.

What should I know about Medicare prescription drug coverage?

Medicare Part D prescription drug coverage is offered by private insurance companies authorized by Medicare, and each plan may have different coverage requirements and out-of-pocket costs. Before you fill your prescription, you might want to ask your doctor if there is a generic medication or other cheaper equivalent that he or she can prescribe to treat your condition.

Medicare Part D coverage generally favors generic medications. You may pay less out-of-pocket for generic prescription drugs (as opposed to brand-name drugs). As mentioned above, each prescription drug plan has a formulary, or a list of covered prescription medications. Formularies can change at any time, but the plan must inform you in writing when then do.

If this is the first time you’re filling a prescription for a particular medication, you can also ask your plan for a coverage determination, which will tell you:

  • If the medication is covered and what you’ll pay for it.
  • Whether there are any special requirements you must meet before your benefits apply. For example, some plans require step therapy before they cover a particular prescription drug, which means that your doctor must try less expensive prescription medications to see if you respond before the plan pays for a more expensive one.

If your plan says your prescription drug coverage won’t pay for a particular medication, you may also ask for an exception. Your Medicare prescription drug coverage may approve an exception if:

  • Your doctor thinks it is medically necessary for you to get a prescription medication that isn’t on your plan’s formulary.
  • Your doctor orders a more expensive medication because she doesn’t think a lower-priced alternative would be as effective for you. In this case, your plan may let you pay less for the higher-priced prescription medication.

Either you or your health-care provider can request a coverage determination or an exception from your plan.

What if my Medicare Prescription Drug Plan still won’t pay for my medication?

If you still can’t convince the plan through which you receive your Medicare prescription drug coverage to pay for a prescription medication your doctor ordered, you can begin the appeals process. There are five levels of appeal.

  • Level 1: RedeterminationYou, your doctor, or an appointed representative can send a written request for a redetermination from your plan. Your plan has 7 days to respond, or 72 hours if you ask for an expedited decision. If your plan denies coverage, you move to the next step.
  • Level 2: Reconsideration by an Independent Review Entity (IRE). Your plan will send you a redetermination notice which includes information on how to request reconsideration if they refuse your request. The IRE has 7 days to respond, or 72 hours if it’s an expedited request. If you are denied, you can escalate to level 3. For this level and above, only you or your appointed representative can initiate the appeal.
  • Level 3: Administrative Law Judge hearingIf the medication costs more than $160 in 2018, you may request a decision from an administrative law judge (ALJ). Hearings are usually conducted over the phone or by video conference, although you can also request a decision without a hearing. Follow the instructions on your reconsideration notice to start the process. If the judge denies your request, you can move to level 4.
  • Level 4: Medicare Appeals CouncilYou can submit a written request for an appeal with the Medicare Appeals Council following the instructions on your decision notification from the ALJ. Call 1-800-MEDICARE TTY users 1-877-486-2048; 24 hours a day, 7 days a week if you’d like more information about the Appeals Council process. If you still aren’t happy with the decision, you can escalate to level 5.
  • Level 5: Federal District Court reviewYour claim must be at least $1,600 in 2018 to qualify for a Federal Court Review of your Medicare drug coverage The instructions for requesting this level of appeal are included in your decision notice from the Appeals Council.

Do you need more information about Medicare prescription drug coverage? I am happy to give you more information and answer your questions. If you prefer, you can schedule a phone call or request an email by clicking on the buttons below. You can also find out about Medicare plan options in your area by clicking the Compare Plans button.

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