Social Security & Medicare Questions: Prescription Is Not Covered

Social Security & Medicare Questions: Prescription Is Not Covered

Q: My doctor recently changed one of my prescriptions because a similar drug was causing troublesome side effects. At the pharmacy I had to pay the full cost of the new prescription even though I'm enrolled in a good Part D plan. When I called my drug plan I learned that my new drug isn't covered. Is there anything I can do? 

A: You may be surprised by how relatively easy it is to get an exception to your drug plan's formulary when medically necessary. Carefully following the procedures could save you a bundle in out-of-pocket costs, and help is available at no charge if you need it.

When your doctor prescribes a drug that's medically necessary, but not on the list of drugs covered by your drug plan, or formulary, you, your doctor, a family member, or other person you appoint, such as a counselor with your State Health Insurance Assistance Program (SHIP), can call your plan or write a letter requesting that the plan cover the prescription you need. This is called a "coverage determination." Once your drug plan receives the request, it has 24 or 72 hours to notify you of its decision, depending on whether you requested an expedited or standard request.

You will need to request an "exception." This is a specific type of coverage determination that requires a supporting statement from your doctor explaining why you need the drug you are requesting. In general, exception requests must be granted if the plan determines that the medication is medically necessary, and the prescribing doctor says that none of the drugs on your plan's formulary would be as effective as the non-formulary drug, or that any other drug would have adverse effects. Your doctor, no doubt, is familiar with handling this type of request.

Once the exception is granted, it remains effective through the calendar year, as long as your doctor continues the prescription. During the Medicare Open Enrollment period that runs from October 15 to December 7, be sure to carefully check all your other drug coverage options, and make a decision about whether you want to switch to another drug plan for 2014. You should do so if your overall costs, premiums, as well as total out-of-pocket cost for all the drugs you take, would be lower if you do so. If you opt to keep your same Medicare drug plan, you may need to submit a new exception request.

To get help at no charge from a Medicare counselor, call your local Area Agency on Aging, or find a counselor at