Make sure to follow your Part D plan’s coverage rules when getting prescription drugs covered. This is the best way to avoid additional expenses and other issues.
- Before you go to the pharmacy, find out if your drug is on your plan’s formulary. If possible, ask your doctor to check that your prescription is covered. Otherwise, call your plan directly or check your plan’s website.
- Find out whether your plan places any restrictions on coverage, such as:
- Prior authorization: you must get prior approval from the plan before it will cover a specific drug
- Step therapy: your plan requires you try a different or less expensive drug first
- Quantity limits: your plan only covers a certain amount of a drug over a certain period of time, such as 30 pills per month
- Use a preferred, in-network pharmacy to fill your prescriptions. Many pharmacy networks include both preferred and non-preferred pharmacies. You typically pay less for your prescriptions at preferred pharmacies.
If your drugs are not covered or are covered with high costs and/or restrictions:
- Make an exception request, which is when you ask your plan to cover your drug as an exception to its rules. One specific kind of exception is a tiering exception, when you ask your plan to cover the drug at a lower cost. Note that in most cases you cannot use the exception process if your prescription is excluded from Medicare coverage by law.
- Ask your doctor if there is a drug on your plan’s formulary that you can use instead (possibly a generic or other low-cost alternative).
- If there are no comparable options on your plan’s formulary, request an exception to your plan’s rules. Ask your doctor to write a letter of support explaining why you need the drug and, if possible, how other medications to treat the same condition are dangerous or less effective for you.
- If your plan does not grant the exception request, file an appeal.
- If you qualify, ask your pharmacist to give you a temporary supply of your prescription through your plan’s transition refill policy. You can only do this if your drug was covered before you switched plans or before your plan changed its coverage rules.
- If you enrolled in a Part D plan after receiving misleading information from that plan, you may be able to disenroll and change plans. Call 1-800-MEDICARE if a representative from your plan told you that your drugs would be on the formulary or covered without restrictions.