It’s one of the most common complaints about Medicare drug plans: A patient goes to the drugstore to pick up a prescription, only to find out the drug plan won’t cover it. Here’s what to do if it happens to you.
By law Part D plans won’t pay for certain types of drugs, period. These include medications for baldness, erectile dysfunction, obesity, wrinkles, and infertility. For those, you’ll have to pay out of pocket. Use GoodRx.com to find the best prices.
For any other rejection, the drugstore is supposed to hand you a standardized notice saying it can’t fill your prescription and to contact your plan and/or prescribing doctor for more information. However, according to the Medicare Rights Center, a nonprofit consumer advocacy group, almost none of the people who’ve contacted them about prescription denials have any recollection of ever getting this piece of paper.
Call Part D customer service
Whether or not you get the notice, you should immediately call the customer service number on your Part D plan’s membership card, advises Casey Schwarz, Medicare Rights Center’s senior counsel for federal policy and education.
“They should be able to tell you why you were denied,” she says. “But in any case, request something called a ‘coverage determination,’ which is the formal decision the plan has made about your coverage.” It is a standardized form that gives the specific reason that the drug plan denied your prescription and instructions on how to file an appeal. Without this document, your appeal can’t proceed.
How to proceed next depends on why your prescription got turned down.
• If the plan requires prior authorization before it will cover the drug, ask your doctor to request it.
• If you’ve been taking a brand-name drug and a generic version is introduced partway through the year, the plan is allowed to reject the branded prescription, Schwarz says. Unless your doctor has a specific reason why the new generic is not appropriate for you, it’s best to give it a try.
The plan may require “step therapy,” meaning that you must first try a different, less expensive drug for your condition and only move to the more costly medication if the cheaper one doesn’t work.
Or the drug you were prescribed might not be on your plan’s formulary, or list of approved drugs, at all. In either case, if there are medical reasons why you can’t attempt step therapy or take an alternative medication—for instance, you’ve already tried it and it hasn’t worked—ask your doctor to give supporting details on the appeals form.
How to find more help
Medicare actually provides for several levels of appeal of drug denials. Win one appeal, and the drug should be covered for the rest of the year.
And if a delay in filling the prescription could jeopardize your health, there’s even an expedited appeals process that’s supposed to turn around within 24 hours.
If all this sounds daunting and bureaucratic, well, it is. For help and hand-holding, don’t hesitate to contact your State Health Insurance Assistance Program. This service provides free individualized counseling and advice to anyone on Medicare.
Nancy Metcalf is an award-winning independent journalist specializing in health topics. A senior writer and editor for Consumer Reports for more than 25 years, she is a nationally recognized expert on health insurance and health reform.