Aging Options

Medicare Won’t Cover Your Prescribed Drug? Fight Back!

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An interesting article on the popular financial website talks about a troublesome trend affecting a growing number of retirees. You get to the pharmacy counter and ask to fill a prescription, only to be told that your Medicare drug plan won’t cover that particular drug. You walk away confused and empty handed.

Do you have any recourse? The answer is yes. Click here to read this important and helpful article that describes how to fight back when coverage of your prescription is denied.

According to Kiplinger, “More and more seniors are finding themselves in this confusing and potentially dangerous situation.”  The article states that questions about pharmacy-counter denials of coverage – and what to do next – are among the most common questions brought to the attention of the Medicare Rights Center’s national helpline. Unless seniors know how to fight back, they may end up paying out of pocket unnecessarily, or going without medication entirely.

But here’s the statistic that most surprised us: according to the U.S. Center for Medicare and Medicaid Services, in 2013 nearly 80% of drug denials that were appealed were subsequently approved. In other words, persistence pays off!

So what’s going on? Why are drug denials on the rise? The simple answer, says Kiplinger, is cost control. Medicare drug plans are imposing what are called “utilization management restrictions” on a growing number of drugs, forcing patients to try cheaper alternatives and in some cases limiting quantities the patient can get at any one time. Kiplinger quotes the Kaiser Family Foundation who reports that, in 2015, almost 40 percent of drugs listed in the Medicare formulary had such restrictions, more than double the percentage from 2007.

We won’t go into the details here, but the Kiplinger article includes a series of helpful steps to follow and key terms you’ll need to know if and when you decide to appeal a drug coverage denial.          First, if your drug is denied, you are usually entitled to a “transition refill” to get you through at least 30 days of use. Then you should contact your plan and ask for a “coverage determination” which provides a written explanation of the reasons behind the decision to deny coverage. You’re supposed to get a reply within 72 hours, but you can request an expedited decision in an emergency. The article goes on to explain how to ask for an “exception,” and, if needed, a “redetermination.” Sound frustrating? It certainly can be. But remember, if you persist, the odds are in your favor that you’ll get the coverage you need. That’s what happened eight out of ten times.

What does the government have to say about appealing prescription drug denials? Here’s a link to the appropriate page on the Medicare website ( and it pretty much matches the Kiplinger article, only in more detail.  According to the website, you have plenty of recourse if coverage of a drug is denied. You should start by talking to your doctor (or whoever wrote the prescription) to see if your plan has any special coverage rules that might qualify you for an exemption. See if a generic is available, one that Medicare might cover. If there are still no good options, ask for a coverage determination from your Medicare drug plan. A coverage determination explains:

  • Whether a certain drug is covered
  • Whether you have met the requirements to get a requested drug
  • How much you pay for a drug
  • The rules for making an exception to a plan rule when you request it.

It also explains when and how to ask for an exception. If you’re trying to get your prescription covered and Medicare is saying no, this web page is a good place to start fighting back.

Persistence and planning are two of the key elements we emphasize with our clients here at AgingOptions. When we put together a personalized retirement blueprint, called a LifePlan, we help our clients work through all aspects of a carefully thought-out plan tailored just for them. We help you answer a host of key retirement questions: Will you have adequate medical coverage? Where and how will you want to live? Do you have all your legal affairs in order? Is your family fully informed of your wishes so there will be no unpleasant surprises or “family feuds”? And finally, do you have a sufficient financial plan to make sure you won’t outlive your assets?

That may sound complicated, but with the right assistance it doesn’t have to be. Let us guide you through the process of developing your own LifePlan. Sign up today to join Rajiv Nagaich at one of our free, information-packed AgingOptions LifePlanning Seminars. You’ll find a complete listing of dates, times and locations here on our Upcoming Events page. Space is limited, so register now, and we’ll look forward to working with you to help you chart a course for a fruitful and secure retirement future.

(originally reported at

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