It is likely an all-too-familiar story for many seniors on Medicare – you go to the local pharmacy to pick up your monthly prescription as you always do, and suddenly you are told that your prescription drug plan through Medicare is no longer covering that medication. You can’t go without your blood thinner pills, but without coverage, it would cost you an estimated $1,300 out-of-pocket for a 90-day supply. So, what can you do when prescription drug plans for seniors deny coverage?
Prescription Drug Plans for Seniors: Navigating Payment
The most important thing to remember if you get denied coverage by prescription drug plans for seniors is to fight it! Although it can be a lengthy and complicated process to appeal Medicare’s decision, do not let it go. In most cases, you literally can’t afford to.
Understanding the Basics of Prescription Drug Plans for Seniors
There are some things that apply across the board when it comes to prescription drug plans for seniors. For example, plans essentially have to cover all drugs in six categories: HIV/AIDS treatments, antidepressants, antipsychotic medications, anti-convulsive treatments for seizures, immunosuppressive medications and treatments for cancer. Prescription drug plans for seniors are not allowed to cover drugs for things like weight loss, colds, or anything that’s cosmetic. Beyond that, there’s a lot of flexibility when it comes to what they will and will not cover, which is why things can get messy.
You’re not Alone.
You’re not the only person struggling with getting your prescription medication covered. In a recent government audit of Medicare’s drug program, it found that plans are often limiting drug coverage without approval from the Centers for Medicare and Medicaid Services, as plans are supposed to do. The audit also found that plans are bad at communicating with members and physicians. So, what does that mean for you? It means you have to do some work – supply relevant materials, such as a written statement from your physician that tells Medicare why you need the medicine.
Appealing the Denial
Before you jump in and file an appeal, you need to request a form for “coverage determination” from the drug plan. This basically asks them to make an exception and pay for the drug. From there, there are additional steps to take before you reach the appeals process – Medicare reviews your request, an independent review company will review the request, then the case moves through the courts. Be prepared – many times this process can drag on.
Additional Tips for Seniors
Right now, you’re reading this and feeling a little overwhelmed and helpless, right? The good news is that the drug plan’s decision is being reversed about 30 percent of the time. Although that’s not the best odds for you, it does show that there’s a chance you could win the appeal. Advocates also provide additional tips for seniors: As you move through the process, keep records of everybody you talk to and what they tell you, and keep your physician involved. Also, keep a record of any out-of-pocket drug expenses you accumulate so that they can be recovered later on if you win. Above all else, be persistent!
