Dr. Katy’s tips on how to get Medicare to cover your prescription drugs.
What to Do When Medicare Doesn’t Cover Your Prescription Drug
By Kate Ashford, CSA®, April 14, 2023
Specific drug coverage varies by plan, and you may not be able to switch to a plan that covers your drug immediately, or you may find that no plans cover it.
"The problems are the more expensive brand name medications," says Katy Votava, who holds a doctorate in health economics and nursing and is president and founder of Goodcare, a consulting firm focused on the economics of Medicare. "That can be difficult for people, and they're often based on medical necessity anyway, and prior authorization is typically required."
If you find that a medication you've been prescribed isn't covered by your Medicare plan, here are some options to consider.
Check the Medicare landscape
First, is this a medicine that Medicare ever covers — just not your plan? Does Medicare cover it under Part B because it's administered in-office? Or does Medicare never cover this drug? "Knowing the reason, so why it isn't being covered, is important," says Justin Lalor, an attorney at the Center for Medicare Advocacy.
For instance, some drugs are never covered by Medicare, including things like weight loss drugs, drugs used for cosmetic purposes, and cough and cold medications.
"So that first step is seeing, does Part D ever cover these?" Lalor says. If the answer is yes, he says the second step is noting if any Part D plans cover the drug.
Talk to your doctor
"Discuss with your doctor if there is a similar medication that is covered by Medicare or Medicare Advantage, or if there are any other treatment options available," says Jeremy Duboys, president of medication discount card company RxGo.
If there aren't any comparable drugs, your doctor will have to support your need to be on the drug in question since you'll need their help to file one of the appeals listed below.
"They're the ones that have to state that it's medically necessary," Lalor says.
Request a formulary exception
A formulary exception is a request to add your drug to your plan's formulary or list of covered drugs.
“The formulary exception is a medical necessity thing where your physician signs off on why you need it,” Votava says. “Written properly, most of the time, that works. But you have to get your providers to do it.”
The request also might have to be submitted more than once. If you call the insurance company, Votava says, they might give you the specific language you should be using to have your request granted.
Request a tiering exception
If your Medicare plan covers your drug but places it in a high tier that results in a high price tag, you or your provider can request a tiering exception. Higher tiers generally mean you share a greater percentage of the price, and if you can get a plan to cover a drug in a lower tier, you’ll pay less.