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I’ve just been prescribed a new drug and was told Medicare won’t cover it. What can I do?

Medicare covers most out-patient drugs through the Part D drug benefit. To get coverage, you must join a Medicare drug plan.

There a few reasons Medicare may not cover your drug:

  • The drug is excluded by law from coverage,
  • The drug is not on your plan’s list of covered drugs, also called the formulary, or
  • The plan may have special rules or set limits on how you get your drugs.

If your current plan does not cover a drug you are taking, there a few things you can do:

  • Ask your pharmacy: Your pharmacy should give you a notice that explains why your prescription could not be filled and how to contact your plan.
  • Ask your plan why the drug is not covered: Call your plan. Look at your plan membership card or other materials for the toll free number.
  • Talk with your doctor: See if your doctor (or other prescriber) can switch you to a similar drug on your plan’s formulary. If not, ask your doctor to give you free samples of the drug.
  • Request an “exception”: If the drug is covered by Medicare but not by your plan, ask your plan to cover it. This is called an “exception.” You will need your doctor who prescribed the drug to tell the plan why you need the specific drug. Contact your doctor and ask if he can help you request an “exception” from your drug plan.
  • Prescription Assistance Programs: See if any local prescription assistance programs in your area may offer this drug at a discount.
  • Review other drug plans: If you cannot get an exception from your plan and there is not an alternative drug, review other drug plans available in your area. Medicare’s coverage of prescription drugs varies from plan to plan. There may be another drug plan that does cover it. Use our QuickCheck tool to get help to compare plans.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: drug, Part D, prescription

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