Medicare doesn't cover all drugs

5 Options for Medications Not Covered by Medicare

courtesy of DailyCaring.com


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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 change constantly. A new medication your senior's doctor prescribes might not be covered or a drug they've been taking for years could suddenly be dropped from the formulary.

If your older adult's medication isn't covered, use these 5 options to get the drugs they need 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 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 for your senior 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 senior'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. There are a total of 5 levels of appeal. Scroll to the bottom of this page to see the levels.

5 Options for Medications Not Covered by Medicare

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. However, you can only change plans during the Open Enrollment period, from October 15 to December 7.

Pro tip: When you're choosing a new drug plan, ask the doctor which of your senior's medications must be a specific brand and which are okay as generics or substitutes (some drugs types are more sensitive than others). That gives you more flexibility to find a plan that covers all the medications your senior needs.

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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. Be prepared for sticker shock. Paying out of pocket 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.

If your older adult qualifies, the Medicare Extra Help program also helps pay for prescription medication.


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