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What Can I Do If Medicare Doesn’t Cover a Drug I Need?


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You can get Medicare prescription drug coverage through a Medicare Advantage Prescription Drug plan (MAPD) or a stand-alone Medicare Part D Prescription Drug Plan, which works alongside your Original Medicare coverage. However, the specific prescription drugs covered may vary by plan, so it’s possible that certain prescription drugs you need may not be covered by your Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan. Prescription drugs can be expensive, especially if you have to pay the full cost out of pocket.

Find out what you can do if your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan doesn’t cover a medication you need.

Learn whether Medicare Part A or Part B covers your medication

If your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan doesn’t cover a prescription drug you need, you should start by figuring out whether that medication is covered by Medicare under a different “part” (such as Part A or Part B) – or not at all. For example, vaccines, cancer drugs, and other medications you can’t give yourself (such as infusion or injectable prescription drugs) aren’t covered under Medicare Part D, so a stand-alone Medicare Prescription Drug Plan will not pay for the costs for these medications. However, you can get coverage for these prescription drugs under Medicare Part B or Medicare Advantage plan if you get them in an outpatient setting, such as a doctor’s office.

Then there are certain medications that simply aren’t covered under the Medicare program. Medicare doesn’t cover medications that:

  • Are non-prescription (sold over-the-counter).
  • Are not approved by the Food and Drug Administration.
  • Are sold or used outside of the United States.
  • Are not used for a medically accepted purpose.

Some examples of medications that may not be covered by Medicare include:

  • Weight loss or weight gain drugs
  • Medications used to treat cold or cough symptoms
  • Fertility drugs
  • Vitamins and minerals (with the exception of prenatal vitamins or fluoride preparation products)
  • Medications used for hair growth or cosmetic reasons
  • Medications used to treat sexual dysfunction (unless used to treat a condition other than sexual dysfunction)

Ask your doctor about substitutes

If the non-covered prescription drug is a brand-name drug, ask your doctor if there are any generic equivalents that would work as well as the non-covered drug. You can also ask your doctor if there are any other prescription drugs your Medicare plan does cover that would be effective for treating your health condition.

Request a formulary exception

If you or your physician believe that the non-covered medication would be the most effective for treating your condition, the next thing you can do is to request a formulary exception. A formulary is a list of prescription drugs covered by the Medicare plan. Every Medicare Prescription Drug Plan and Medicare Advantage Prescription Drug plan has one, although the specific medications included by each plan’s formulary will vary. Formularies may change at any time; you’ll be notified by your Medicare plan if necessary.

A formulary exception can be granted if your doctor and/or Medicare plan determines that the prescription drug you requested is medically necessary for your health, so you will need a written statement from your doctor or health-care provider to support your case. (In some cases, your doctor can also make an oral statement to your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan.) Once your Medicare plan has received the statement from the prescribing physician, it will make a determination whether or not to cover the non-formulary medication. For a standard formulary exception request, your plan will make its decision and notify you within 72 hours of receiving the prescribing doctor’s statement.

If waiting 72 hours for a decision could endanger your health, you also have the right to ask for an expedited formulary exception request. If you submit an expedited request, your Medicare plan must respond within 24 hours with its decision.

File an appeal

If your Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan denies your request for a formulary exception, you can file a request for redetermination, which is the first of five levels of appeal (a new decision on the rejection) with the Medicare plan. If that decision is unfavorable as well, you can appeal the decision with an independent review entity, which is the second level of the appeals process. If you disagree with the decision made at any level of the appeals process, you can move on to the next level if it meets certain criteria established by Medicare. At each level, you’ll receive information on how to move to the next level of appeal if you disagree with the decision.

Change your Medicare Part D coverage

If your request for a formulary exception is denied, you may want to switch to a different Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan. Of course, before you switch plans, make sure the new Medicare plan covers the medications you need by checking the plan’s formulary.

You can switch Medicare plans and make changes to your coverage during the Annual Election Period (AEP), which runs from October 15 to December 7 each year. During this period, you can:

  • Enroll in a Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan for the first time.
  • Switch from one Medicare Part D Prescription Drug Plan to another.
  • Disenroll from your Medicare Part D Prescription Drug Plan.
  • Switch from one Medicare Advantage Prescription Drug plan to another.
  • Disenroll from your Medicare Advantage Prescription Drug plan and go back to Original Medicare. You can then add on a stand-alone Medicare Part D Prescription Drug Plan.

If you use the Medicare Advantage Disenrollment Period (January 1 to February 14) to leave your Medicare Advantage plan and return to Original Medicare, you can also use this period to enroll in a stand-alone Medicare Prescription Drug Plan. These are the only changes you can make during this period. You can’t use this period to enroll in a different Medicare Advantage Prescription Drug plan or switch from one Medicare Prescription Drug Plan to another.

You generally must make changes to your Medicare coverage during one of the above periods unless you qualify for a Special Election Period, which can occur at any time that you have a qualifying situation. Your plan’s denial of coverage for a prescription drug generally doesn’t qualify you for a Special Election Period. However, you may qualify for a Special Election Period based on other criteria. For example, if you move out of your Medicare plan’s service area, live in a nursing home, or lose your Medicaid eligibility, you could be eligible to make changes to your Medicare Part D coverage outside of the regular periods.

In most cases, if you switch Medicare plans, you don’t need to tell your current Medicare plan that you’re leaving. Instead, you’ll be automatically disenrolled from your current plan if you enroll in a new Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan during one of the above periods.

Paying for your prescription drugs

If you prefer to remain with the same Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan and your request for a formulary exception was denied, you may have to pay full price for your prescription drug, instead of the usual copayment or coinsurance. Choosing a generic drug instead of a brand-name drug may be your best option if your doctor decides that could work for your health condition.

Some drug manufacturers offer payment assistance programs, especially for newer or expensive drugs. You would need to contact the drug manufacturer on your own to explore this possibility.

Do you have questions about your options if your Medicare plan doesn’t cover a medication you need? If you’d like assistance finding Medicare Part D coverage that may cover your prescription drugs, feel free to contact eHealth to speak with a licensed insurance agent. We’re here to help.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

 

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