Medicare drug coverage for outpatient self-administered prescription drugs is an important benefit available to those covered by Medicare. It’s crucial to understand how to maximize your benefits and use your Medicare prescription drug coverage effectively to reduce out-of-pocket costs.
Your Doctor Prescribed You a Medication: Now What?
To take full advantage of your Medicare plan’s prescription drug benefits, the first thing you need to do when your doctor prescribes medication(s) for you is confirm if your plan covers the prescribed medication. Performing a formulary search to identify your medication or an equivalent with your pharmacist prior to filling any prescription is a good practice. Failure to check an inclusion in the formulary could leave you exposed to higher costs. Here are the ways you can check to see if your medication is covered:
- Call your Medicare Part C or D drug plan provider directly.
- Check your plan’s formulary. A formulary is a comprehensive list of drugs that your Medicare Advantage or Medicare Part D plan will cover. This can be found on your plan provider’s website in either a PDF or searchable database.
All participating Part C and D plans are required to have at least two medications to resolve over 1,000 medical conditions identified by the Centers for Medicare and Medicaid (CMS) and Health and Human Services (HHS). Each plan can have more than two medications per identified condition, but not less, and they can be brand name or generic. Furthermore, each provider has the freedom to openly identify and negotiate which pharmaceutical companies they work with to provide the actual medications.
As mentioned, each plan’s formulary will list the names of drugs and what tier they fall into. Per CMS design, each plan must categorize medications into a specific tier, ranging from Tier 1 preferred generics to Tier 5 specialty medications. Providers have the freedom to determine the copay or coinsurance for each tier of their plan. To remain compliant, they must adhere to the guidelines established by the Centers for Medicare and Medicaid Services. For plan-specific information, reference your plan’s evidence of coverage and formulary to determine any changes in your medications, benefits and costs.
Steps to Take If Your Prescription Is Covered
Once you have confirmed your prescription(s) are on the formulary, be aware that there can be restrictions placed on your medications by your plan provider. These are featured on all plans and each provider will determine what medications will include any or all of these limitations. These restrictions are put in place oftentimes to protect the beneficiary from various side effects or other medical concerns with the prescribed medication. These limiting factors can include:
- Quantity limits. In some cases, your plan provider may cap the medication you can receive in a set timeframe, either by limiting the amount or refill duration.
- Prior authorization. For drugs that require prior authorization, you or your prescriber must call your plan provider, prove that the prescription is a medical necessity and ask them to approve the drug before it qualifies for coverage under your plan.
- Step therapy. For drugs that fall under this limitation, your provider will ask you to use a generic or less expensive version of the prescribed drug first. If you do not get results with the less expensive drug, they may approve a more expensive version.
As you see, it is vitally important to stay updated on any changes to your plan’s formulary, tiers and drug plan coverage rules. Remaining vigilant will allow you to maximize your benefits and obtain the prescribed medications you need while staying healthy and within budget.
Steps To Follow When Your Medication Is Not Covered
An important step of your Part D plan search is identifying the plan that provides access to your medications at the lowest costs from your preferred pharmacy. While researching your options based on your current medications is beneficial, life happens and adding prescriptions during the plan year can present challenges. Occasionally, a situation could arise where a newly prescribed medication is not on the formulary of your current plan. Here’s what to do if your prescription drug is not covered, and you’re not able to switch your coverage in the near future.
The best thing to do is discuss with your healthcare professional and identify alternative medications on your formulary, such as a different brand, less expensive alternative or generic version of the medication you need. Another option would be to invoke step-therapy and try to identify a lower cost medication that resolves your condition safely. Lastly, if these options do not resolve your situation, you have the right to appeal to your plan for an exception to add a non-formulary medication to your list of approved medications. You can request such an exception with a letter from your doctor detailing the need and reasoning for coverage of the specific medication. There is no guarantee that your appeal will be granted, but it is your right to make the request should you need help from your plan.
If you are unhappy with your plan, you can change your coverage each year during the Annual Enrollment Period (October 15 – December 7), but significant changes to your medication needs or a plan’s formulary can occur at any time. As we age, it is not uncommon for our health to change, which could result in adding or changing medications. Should this happen to you, you now know what to do if your medications are or aren’t covered, and also understand the importance of preparation.
To summarize, it’s important you pay attention to the details of your benefits, stay updated on your plan’s formulary and tiers and reassess your drug coverage each year to determine the best fit. Get assistance from a local Medicare insurance agent if you have questions about comparing your Medicare prescription drug coverage options. Contact us at Medicare Portal today!
