What if a necessary medication is not covered by Medicare Part D?

Medicare Part D can be a lifesaver for seniors who cannot otherwise afford their medication, but what if a necessary medication is denied coverage? Read on for some valuable tips.

The single most important thing you can do is understand your Medicare Part D plan’s coverage policies. While Medicare Part D is a government sponsored program, coverage is implemented through a number of insurance companies. There are, however, rules all Medicare Part D providers must follow. For instance, all providers must give their members a copy of the plan’s formulary (a listing of medications covered by the plan) and must give 60 days notice for any changes to that formulary.

Alternate medications

If Medicare Part D will not cover your necessary medication, grab a copy of your plan’s formulary and go over it with your physician. Medications belong to ‘classes’ – bactrim and penicillin, for example, are in the Antibiotic class while Cymbalta and fluoxetine are in the Antidepressant class. There are often dozens of covered medications in any given class and it’s quite possible one of them can serve as a viable alternative to the medication Medicare Part D would not cover.

“Prior approval”

If there are no alternatives, the necessary medication stands a good chance of coverage through “prior approval”. Your physician will attest to the lack of any viable alternative for the necessary medication, then send the documentation off to your Medicare Part D provider. Once the paperwork is received, the provider must, by law, make its decision within 72 hours (24 hours if you request an expedited claim). Some plans will even cover a 30 day supply of the medication during the prior approval process. If a prior approval claim is approved, the medication will be covered as if it were part of the formulary.

Related posts

1. What Prescription Drugs Are Covered Under Medicare Part D?
2. How Do I Know What Prescription Drugs Are Covered Under Medicare Part D?
3. How To Pick A Medicare Part D Plan?
4. What Happens If I Do Not Enroll In A Medicare Part D Plan?
5. What Is Medicare Complete?

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