The dilemmas faced by many Medicare beneficiaries are:
My doctor ordered a new drug to treat a long-standing medical problem. The pharmacist said my drug plan did not cover this drug. I really need to take it. what can I do?
This is not uncommon. Still, many beneficiaries are surprised that essential medicines are not covered by the Part D plan. They believe the plan should cover their medication, so what’s the problem? Understanding what a drug plan can and cannot cover is a good place to start.
Drugs that cannot be covered by the plan
The following is a list of drugs that the plan cannot cover.
- Drugs to treat loss of appetite, weight loss or weight gain, cold or cough symptoms, erectile dysfunction, or childbirth problems
- Medications for beauty purposes or hair growth
- Prescription vitamins and minerals, and
- Over-the-counter drug (purchased without a prescription).
(This list may have medically required exemptions, in which case the medication plan may cover the medication.)
The plan cannot cover drugs that have not been approved by the FDA. For example, dry thyroid gland is an unapproved drug and Part D plans cannot cover it.
If Medicare Apartment A, Hospital Insurance, or Part B, Medical Insurance covers the drug, then Part D’s drug plan cannot be covered. Influenza vaccination and IV chemotherapeutic drugs are two examples.
Drugs that the plan must cover
All Part D plans should cover all medicines in the “protected” medicine class. (A class or category is a group of drugs that have similar effects on the body or treat the same symptoms.)
These are “protected classes”.
- Immunosuppressant (organ transplant)
- Antiretroviral drug (HIV / AIDS)
- Anticonvulsants (seizures), and
- Anti-tumor (cancer)
Drugs that the plan can choose to cover
Drug planning should cover at least two drugs from other categories, from which many uncovered situations begin. Beta blockers are a category of drugs. In this category, plans may cover atenololol and propranolol, but not metoprolol.
What you can do
Unless there are medically necessary exceptions, plans to cover drugs on the “uncoverable list” will not be approved. There is always an option to use a coupon or discount card to buy a drug other than a prescription drug plan. The Part D plan couldn’t handle this.
For drugs that the plan chooses not to cover, you have a choice.
- If the non-target prescription drug is a branded drug, consult your doctor to see if generics work.
- Find out if there are other effective prescription medications in your planned prescription collection.
- Doctors can try exceptions to the prescription book, that is, requests to obtain Part D medications that are not included in the planned prescription book. The doctor’s statement needs to prove that out-of-line medications are needed to treat the condition and that alternatives to the planned prescriptions do not work. If the plan rejects the request, there is an appeal process.
- Finally, check out the available plans during the open registration period from October 15th to December 7th. You may find something that works.