Presumably, if you have a Medicare Part D Plan or a Medicare Advantage Plan (Part C) that includes Part D drug coverage, you looked at its formulary before you made the decision to enroll in the plan. Perhaps since then, however, you have developed a need for another medication which is not covered by your health plan. What can you do in this circumstance? You have several options.
Consult Your Doctor
The first step is to consult your doctor. Your health plan’s formulary is the list of drugs it will cover. If your plan does not cover the medication you need, perhaps there is another similar drug in the formulary, which your doctor should know about. In some cases there are other factors involved:
- The drug you need may require prior authorization. This means that your doctor must notify the plan that for you this drug is medically necessary.
- Your plan may require step therapy. This means that before your more expensive drug is authorized, you need to try a less-expensive one or perhaps a generic drug first.
- The drug may have quantity limits. This means that it may have been authorized for a specific period of time.
Request a Coverage Determination
If the drug is still denied, or it’s still too expensive, you can request a coverage determination. To do this:
- You can download and fill out a form online; afterwards you can either send it by mail or e-mail.
- Include a statement from your doctor explaining why you need this drug and should be granted an exception.
- Once your plan receives your request they must respond within 72 hours. If you or your doctor asks it be expedited due to life and death emergency they will respond within 24 hours.
How to Appeal
If you disagree with your plan’s decision there are several ways you can appeal.
- You can request a re-determination. This normally takes longer than the first determination, but it will be expedited if your health is at risk.
- You can request a review from an Independent Review Entity (IRE). This too can be either standard or expedited.
- If you disagree with the IRE ruling, you can request an Administrative Law Judge hearing.
- If this doesn’t work you can ask a Medicare Appeals Council to review your case.
- Finally, you can ask for a review by a Federal court.
All of these appeals, of course, would take a considerable amount of time. In the end, it might be far more simple to look for another plan that would meet your needs.
There is one more option that’s worth exploring. Most pharmaceutical companies have patient assistance programs that provide aide to patients that need their medications but can’t afford to pay the retail price. You can Google patient assistance program (PAP) and the name of your medications (e.g., “abilify patient assistance program”) to find the program information page. Another good resource is www.needymeds.org.
In conclusion, it is important that you ask yourself these questions now, before the next Open Enrollment Period, when you have the opportunity to make any needed changes.