Q & A: November 2019

Q & A: November 2019

What to Do When Your Doctor Prescribes an Expensive Medication that Your Insurance Doesn’t Cover

Q:  My doctor prescribed a new drug but, when I tried to fill it the first time, I learned that my drug plan does not cover it.  The drug cost close to $600 dollars and I could not afford that!  What can I do?

A:  Thousands of prescriptions are abandoned at pharmacies each year, often due to high prices.  There are several things you can do to bring that cost down to a more manageable level.

  1. Ask your doctor for free samples of the new prescription.  While the supply may be limited, free samples help you and your doctor assess the effectiveness of a new medication.  You will be able to learn how well you respond to the medication and whether you experience any severe side effects.
  2. Learn if there’s an older, less expensive drug that you can try first.  If you have a copy of your drug plan’s formulary you may want to take that with you to the doctor’s office to assist with checking an alternate medication, and what you will pay out-of-pocket.
  3. Compare drug plans during the fall Medicare Open Enrollment Period which is going on now, through December 7.  If your drug plan does not cover an expensive drug, it’s time to find a better plan.  This does not have to be hard to do.  Free one-on-one counseling is available through your State Health Insurance Program (SHIP).  Many of these programs operate through your local area on aging, or senior center.  For contact information visit the SHIP website: https://www.shiptacenter.org.
  4. If you require a non-formulary drug, for which there is no acceptable alternative, your doctor can ask your Medicare drug plan for a Formulary Exception, a type of Coverage Determination that would add the drug to your Part D plan coverage.  If approved, you would be able to purchase your medication at the lower plan co-insurance and receive discounts if or when you reach the Part D doughnut hole.
  5. Since your new prescription is not covered by your drug plan, learn if there’s a pharmaceutical assistance program.  These programs provide heavily discounted medications to qualified applicants, but not every drug has such a program. Your doctor may be able to provide you with contact information for help to apply, or you can try contacting your local SHIP program, through your local area on aging or senior center.  For contact information visit the SHIP website: https://www.shiptacenter.org.
  6. Apply for Medicare “Extra Help”:  Medicare Extra Help is a program that helps to pay for Part D premiums, annual deductibles, and co-payments for your medications.  You apply online using the Social Security Administration website. For more information see this pdf from the Social Security Administration.