Make sure to follow your Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. plan’s coverage rules when getting prescription A prescription is an order for a health care service or drug written by a qualified health care professional. drugs covered. This is the best way to avoid additional expenses and other issues.
Part D plan coverage rules
- Before you go to the pharmacy, find out if your drug is on your plan’s formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. . 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:
- : you must get prior approval from the plan before it will cover a specific drug
- Step Therapy Step therapy is a restriction placed on drug coverage by Part D plans and Medicare Advantage Plans. Before your plan will cover a drug, you must first try a different or less expensive drug that treats your condition to see if it will be effective for you. : 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 In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. 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 (1-800-633-4227) if a representative from your plan told you that your drugs would be on the formulary or covered without restrictions.