What To Do When Medicare Won’t Pay For Prescribed Medicine

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 they change constantly.

A new medication you or your older adult’s doctor prescribes might not be covered. Or, a drug they’ve been taking for years could suddenly be dropped from the formulary.

If the medication isn’t covered, use these options to get the needed drugs at the lowest cost possible:

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 different medications that could also be used to treat their health condition.

2. Ask the insurance company for a formulary exception

If you or 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 as a special exception. A formulary exception may be granted if the doctor provides a written statement saying that the drug is medically necessary for your older adult’s health. Ask the insurance company for the required forms.

3. File an appeal if the formulary exception is denied

If the drug plan denies the request for a formulary exception, you can file a request for a new decision on the initial rejection.

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. Reach out to a SHIIP volunteer in your community for FREE help with this task ( Senior Health Insurance Information Program). Keep in mind that you can only change programs during  the annual Open Enrollment period, from October 15 to December 7.

When you’re choosing a new drug plan, ask the doctor which of your or your older adult’s medications must be a specific brand and which are OK as generics or substitutes. That gives you more flexibility to find a plan that covers all the medications 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. It’s not always as expensive as you think it may be, but be prepared for sticker shock – paying out of pocket might means paying full price, which is usually a lot more than the insurance co-pay. 

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

Some other Pharmaceutical resources that might be helpful include: 

Prescription Hope: $50 per month drug prescriptions: 877-296-4673

RXassist.org

SingleCare.com

SearchRx.com 

GoodRX.com: 1-855- 426- 4465

RxSaver.com: 855-569-6337 

Novartis PatientAssistance: 800-277-2254 

PillPack.com.  (Amazon)

The Rx Advocates: 844- 609-4612

Publix Supermarket offers $7.50 prescriptions

AstraZeneca.com: Prescription Savings Program: 800-292-6363

People with limited income may qualify for “Extra Help” to pay for their  prescription drug costs, annual deductibles, and coinsurance. To see if you qualify, call 800-MEDICARE (800-633-4227);  TTY Users should call 877-486-2048.   Additionally, ask Medicare about the Low Income Subsidy Assistance program. You can also call your state the Medicaid Office to see if you’re eligible for such assistance