Why is my Medicare drug plan refusing to cover a drug that is on its list of covered drugs (formulary)?

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There are two possible reasons. To make sure you take the correct action, you should make sure you know why your plan is denying you coverage and get the reason in writing.

1. Coverage restrictions

Your plan may deny coverage for a drug that is on its list of covered drugs (formulary) if it has placed any of the following restrictions on that drug.

  • Prior Authorization: Your plan requires that you ask for special permission before it will consider covering the drug.
  • Quantity Limits: Your plan will only cover a certain amount of a prescription. If your doctor is prescribing more than the amount approved on the formulary, the prescription may be denied.
  • Step Therapy: Your doctor must show that you tried a less expensive medication before your plan will cover a more expensive one.

If your plan is denying your medication because of coverage restrictions, first work with your doctor to see if an unrestricted covered medication will work for you. If not, you can make a formal request to your plan to cover the medication for you (request an exception). You will need to make a formal request to override coverage restrictions. This way you will be able to get your prescription filled for the rest of the year without making any other requests.


2. Off-label use

If your doctor prescribes a medication on the formulary for a reason other than the use approved by the U.S. Food and Drug Administration your drug will probably not be covered unless the use is listed in one of three Medicare-approved drug compendia (medical encyclopedias of drug uses). You can ask for an exception, but these requests are rarely granted.

As of January 1, 2009, Medicare began accepting indications of drug use for anticancer chemotherapeutic regimens from additional compendia and other peer-review medical literature.


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Medicare.gov - Drug Plan Comparison

State Health Insurance Assistance Program (SHIP) Directory

 
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