5 Steps to Take When Medications Are Not Covered by Medicare

medications are not covered by medicare

Medicare doesn’t cover all drugs

Most older adults get prescription drug coverage through a Medicare Part D plan or a Medicare Advantage plan. Each plan has a list of drugs that the plan will pay for, called a formulary.

A big problem is that these formularies don’t cover everything and change constantly. A new medication your senior’s doctor prescribes might not be covered. Or, a drug they’ve been taking for years could suddenly be dropped from the formulary.

If your senior’s medication isn’t covered by their prescription drug plan, there are 5 steps you can take to get the drugs they need.


5 steps to take when medications are not covered by Medicare

1. Ask the doctor about generics or substitutes
Multiple medications can often have similar effects. If the brand drug isn’t covered, ask the doctor if there are any generic medications that would work just as well. Or, ask if there are other medications that could also treat their health condition.


2. Ask the insurance company for a formulary exception
If your older adult must have a specific drug, you can ask the insurance company for a formulary exception. That means they’ll cover that medication for your senior as a special exception.

A formulary exception may be given if the doctor provides a written statement saying that the drug is medically necessary for your senior’s health. Ask the drug plan company for the required forms.


3. If the formulary exception is denied, you can file an appeal
If the drug plan denies the request for a formulary exception, you can file a request for a new decision on the initial rejection. There are a total of 5 levels of appeal – scroll to the bottom of this page to see the levels.


4. Switch to a different Medicare prescription drug plan
If you can’t get the formulary exception, you might want to switch to another prescription drug plan that does cover your older adult’s necessary medications. However, you can only change plans during the Open Enrollment period, from October 15 to December 7.

DailyCaring tip: To help you choose a new drug plan, ask the doctor which of your senior’s medications must be a specific brand and which are OK as generics or substitutes (some drugs types are more sensitive than others). That will give you more flexibility to find a plan that covers everything your senior needs.


5. Pay out of pocket
If the formulary exception is denied, it’s not Open Enrollment time, and the doctor says your senior needs that specific drug, your last resort is to pay for the medication out of pocket. Watch out for sticker shock – paying out of pocket means paying full price, which is usually a lot more than the co-pay you’re used to.

To help with those costs, some drug manufacturers have payment assistance programs, especially for newer or expensive drugs. Contact the drug manufacturer or check their website to see if they offer this type of program.

And if your older adult is low income, they may qualify for help paying for prescriptions under the Medicare Extra Help program.  


Next Step  Find out about 7 ways to save money on prescription drugs


You might also like:
Seniors Can Get Help Paying for Prescription Drugs
7 Ways to Save Money on Prescription Drugs
Check Medications for Dangerous Drug Interactions


By DailyCaring Editorial Staff
Image: PBS

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