What if I can’t afford a higher tier drug?

If your doctor strongly feels that you need a higher tier drug as opposed to a similar drug in a lower tier, an exception by the plan may be granted to have a lower copayment for the higher tier drug. You or your doctor will need to contact the plan to request the exception. A current formulary may be obtained by contacting your plan.

 

An “Explanation of Benefits” (EOB) notice is mailed out to you each month that you fill a prescription.

 

Each month that you fill a prescription, your drug plan mails you an “Explanation of Benefits” (EOB) notice.  It is important that you examine your notice to make sure that it is accurate. Often, drug providers will make mistakes and bill Medicare for the wrong drug, and/or even for prescriptions which were never filled or administered. Once you review your EOB, if you feel that it has errors, call the Medicare Drug Integrity Contractor (MEDIC) at 1-877-772-3379.

 

Plans may have certain coverage rules which must be adhered to. Here are just a few:

  • Certain prescriptions require an authorization before they can be filled. You or your prescriber must contact your drug plan to obtain that authorization. In order for the plan to issue the authorization, you or your prescriber may have to provide proof that the prescription is medically necessary.

  • Plans may limit the amount of medication that you may obtain at a time. This limit can be a 30- day supply, 90-day supply, or other.

  • Lower cost drugs must be tried before a plan will authorize the more expensive drugs. This is referred to as step therapy.

 

There are exceptions to the rules, or course. If you or your doctor feel that one or more rules should not apply, you can always ask the plan for an exception.

 

To have your prescriptions covered by any Medicare drug plan, practically all your prescribers need to be enrolled in Medicare or have an opt-out request on file. This ruling is effective as of 2017. A 90-day supply may still be issued even if your prescriber does not meet the above requirement. This 90-day period allows your doctor/prescriber time to enroll or opt out. It also gives you time to find a new doctor/prescriber if your current one does not wish to enroll or opt out.

 
Frequently Asked Questions (FAQs)