Medicare Prescription Drug Benefit: If Your Medication Isn't Covered

Linda Wells, Aging and Disability Services Planner

If your drug isn't covered by your prescription drug plan, what can you do?

First, find out why not. Talk to your pharmacist or contact your Medicare Prescription Drug Plan to ask. There are some things you can do to get the medicine you need, but first you have to see why the plan will not pay for the prescription.

If the reason is this:

Your drug is not on the "formulary" for your Prescription Drug Plan.

Then try doing this:

• See if your doctor thinks another drug on the formulary will work just as well for you.
• See if you can change to another plan that does cover your drug, effective next month.
• If you just got this plan, call the plan and ask if they will cover your drug for a "transition period." For example, will they give you the medicine for one month while you talk to your doctor about switching drugs?
• If your doctor thinks the drug you are taking is the best one for you and you cannot or do not want to change plans, ask for an "exception." If you still do not get the drug, you can appeal. (See next month's Seniors Digest for more about requesting an exception.)

If the reason is this:

Your Prescription Drug Plan wants you to try another drug first.

Then try doing this:

• Talk to your doctor about whether you could safely try the other drug first.
• If the doctor does not think it is safe for you to try it, you can ask the plan for an "exception."
• If the plan still will not cover a drug that both you and your doctor agree you need, you can appeal. 

If the reason is this:

Your Prescription Drug Plan requires your doctor to get "prior authorization."

Then try doing this:

• Ask your doctor if he or she has asked the plan for approval.
• If the doctor has gone through the plan's procedures and the plan still will not cover a drug that both you and your doctor agree you need, you can appeal. 

If the reason is this:

The drug is not covered by Medicare.

Then try doing this:

• A few drugs are not covered by Medicare but are covered by Medicaid. If you have a Medicaid card, show that to your pharmacist and see if Medicaid will pay for the drug.
• If you do not have Medicaid and Medicare does not cover a drug, you may have to pay for the drug yourself. Talk to your doctor and other people who help you to see if any other government programs, organizations, or charities can help you get the medicine you need.