Getting my Medicare private drug plan to cover my drugs

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Make sure to follow your Medicare private drug plan’s rules

  • Before you go to the pharmacy, find out if your drug is on your plan’s formulary. Your plan’s formulary is its list of covered drugs. When your doctor writes your prescription, ask him or her to check for you. If your doctor does not have time, call your plan yourself or check your plan's website. Also find out whether there are any restrictions on coverage, such as:
    • Prior Authorization, which requires you to get permission from the plan before a drug will be covered;
    • Step Therapy, which requires you to try a less expensive drug before a more expensive one will be covered; or;   
    • Quantity Limits, which limit how much of a drug will be covered.
  • If your drug is not covered or is covered with restrictions, you have several options which are listed below.
  • If your drug is covered, make sure to use a preferred, in-network pharmacy. Many drug plan pharmacy networks include both preferred and non-preferred pharmacies. At preferred pharmacies, you typically pay less for your prescriptions than at non-preferred pharmacies. 
  • You may also be able to request a tiering exception. This is when you ask your plan to cover the drug at a lower cost.

 If your drugs are not covered or are covered with restrictions  

  • You should talk to your doctor first about changing your prescription to a drug on your plan’s formulary. See if there are any generic or lower-cost alternatives would work for you.
  • If only the prescribed drug will work for you, then you must ask the plan for an exception to its formulary. Your doctor should provide medical support in writing that the drugs covered by your plan would not be as effective as the prescribed drug or may be harmful to you.
    • Starting Jan. 1, 2012, plans must accept verbal statements from doctors asking for an exception to its formulary. However, it may require that those verbal statements are followed up by a written statement.
  • If your drug is covered, but it has a restriction, you should have your doctor ask the plan to override the restriction. In order to get an override, your doctor will need to ask your plan for an exception to its formulary. Your doctor should provide medical support that other drugs on your plan’s formulary would not be as effective as the prescribed drug or may be harmful to you.

In the mean time, ask your pharmacist to give you a temporary supply of the prescription through your plan's transition policy for new and existing members.

Drug transition policies

  • Every drug plan must have a transition policy to ensure that new members have uninterrupted access to drugs they were already taking before they joined.  
    • Your plan's transition policy must cover at least one temporary 30-day supply of drugs not on the formulary and not apply any plan restrictions (such as prior authorization and step therapy). This policy is in place for the first 90 days you are enrolled in the plan. The pharmacist may need to ask the plan for its override code in order to bill correctly. 
    • If you live in a nursing home, your plan must cover a 31-day supply of your medication during the first 90 days that you join a new Medicare private drug plan. Multiple refills are allowed as necessary. 
      • Starting Jan. 1, 2012, plans must provide nursing home residents a temporary supply of non-formulary drugs (or those with prior authorization or subject to step therapy) for at least 91 days (and up to 98 days).

  • If you take a drug that your plan intends to remove from its formulary in the next calendar year, or add restrictions such as step therapy, it must do one of the following. The plan must either:
    • Help you switch to a different drug that is covered,
    • Complete an exception request before the changes take place on January 1, or
    • Provide a transition process for current enrollees consistent with the transition process required for new enrollees.

If the plan provides a 30-day transition fill or overrides the restriction, they must send you a transition notice within 3 business days of your getting the prescription filled. Your plan does not have to give you a transition fill if the drug is taken off their formulary for safety recalls.

Transition fills are temporary

Take action immediately and have your doctor change your prescription to a drug covered by your plan or ask your plan for an exception. This way you will ensure that you continue getting the drugs you need after your transition period has ended.

You can also look at resources outside your Medicare private drug plan to get coverage for your prescription.

If you’re unhappy with your plan, you may want to change plans. Remember you can usually only change plans once a year during the Fall Open Enrollment.

Note: If you were misled into joining your plan because a plan representative or insurance agent told you a medication would be covered without restrictions, and it is not, you should be able to switch to another plan at any time during the year. You should also file a complaint or grievance with your plan for misleading you.


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