Here is a dilemma many Medicare beneficiaries face:
My physician ordered a new medication to treat a longstanding medical problem. The pharmacist said my drug plan doesn’t cover this drug. I really need to take it. What can I do?
This is not a rare event. Yet, many beneficiaries are surprised to discover that an essential drug is not covered by their Part D plan. They believe the plan should cover their medications, so what’s the problem? Understanding what drug plans can and cannot cover is a good place to start.
Drugs that a plan cannot cover
The list of drugs that a plan cannot cover includes:
- Drugs to treat anorexia, weight loss or weight gain, cold or cough symptoms, erectile dysfunction, or fertility problems
- Drugs for cosmetic purposes or hair growth
- Prescription vitamins and minerals, and
- Over-the-counter drugs (purchased without a prescription).
(There can be medically necessary exemptions to this list in which case a drug plan may cover the medication.)
Plans cannot cover drugs that are not approved by the FDA. For example, dessciated thyroid is an unapproved drug and a Part D plan cannot cover it.
If Medicare Part A, hospital insurance, or Part B, medical insurance, covers a medication, a Part D drug plan cannot. Flu vaccinations and IV chemotherapy medications are two examples.
Drugs a plan must cover
Every Part D plan must cover all medications in “protected” drug classes. (A class or category is a group of drugs that have similar effects on the body or treat the same symptoms.)
These are the “protected classes:”
- Immunosuppressant (organ transplant)
- Antiretroviral (HIV/AIDS)
- Antidepressant
- Antipsychotic
- Anticonvulsant (seizures), and
- Antineoplastic (cancer)
Drugs a plan can choose to cover
Drug plans must cover at least two drugs from the other categories and that is where many noncoverage situations begin. Beta blockers is one category of drugs. In this category, a plan might cover atenolol and propranolol, but not metoprolol.
What you can do
Except if there is a medically necessary exception, you will not get approval for your plan to cover drugs on the “cannot cover list.” There is always the option to purchase medications outside of the prescription drug plan with a coupon or discount card. You could not process this through your Part D plan.
For drugs a plan chooses not to cover, you have options.
- If the noncovered prescription drug is a brand-name medication, ask your doctor whether a generic equivalent might work.
- Find out whether there are any other prescription drugs in your plan’s formulary that would be effective.
- Your physician can try a formulary exception, a request to obtain a Part D drug that is not included on a plan’s formulary. The physician’s statement must prove that the noncovered drug is necessary to treat the medical condition and no alternatives on the plan’s formulary would work. If the plan denies the request, there is an appeals process.
- Finally, during the Open Enrollment Period, October 15-December 7, check out the plans available to you. You might find one that would work.