Dear Marci,
I started taking immunosuppressant drugs after an organ transplant that I had several years ago. I have recently been running into a lot of trouble getting them covered. How does Medicare cover immunosuppressants, and what can I do about my problems getting them covered?
-Maya (Spartanburg, SC)
Dear Maya,
Immunosuppressants are drugs that you take following a transplant to prevent your body from rejecting the donor organ. The way Medicare covers your immunosuppressant medication depends on the circumstances of your transplant.
Medicare Part B covers your immunosuppressants if you meet all of the following requirements:
- You received your transplant in a Medicare-approved facility
- You had Medicare Part A at the time of your transplant
- You have Medicare Part B when getting your prescription filled
If you have Original Medicare, Part B will cover your immunosuppressant medication at 80% of the Medicare-approved amount, meaning that you will be responsible for a 20% coinsurance charge. If you have a Medicare Advantage Plan, contact your plan to learn about its costs and coverage rules for immunosuppressants.
Part D covers your immunosuppressants if you did not have Part A at the time of your transplant or you did not have your transplant in a Medicare-approved facility. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to in-network pharmacies for your drugs.
All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once you are stabilized on your immunosuppressant drug. However, prior authorization can apply. This means that your plan may need to verify that Part B will not cover your drugs before providing coverage. Be sure to look for plans that have the fewest coverage restrictions and that have your pharmacy in the preferred network.
If you are experiencing issues accessing your medication, first become familiar with the rules around its coverage, including whether it is supposed to be covered by Medicare Part B or Part D.
Then, ask your pharmacist to submit claims to the correct part of Medicare. If your pharmacist is having trouble billing, or if you are being denied coverage for a drug, it is possible that the medication is being billed incorrectly. If your provider is unsure how to submit these claims, tell them who they can reach out to for assistance:
- For a Part D-covered drug, they should contact your Part D plan.
- For a Part B-covered drug, they should contact the Medicare Administrative Contractor for your region if you have Original Medicare or your private health plan if you have Medicare Advantage.
If payment is denied, appeal the denial. You have the right to appeal a denial by Original Medicare or your plan. Ask your doctor to help you prove that the medication is medically necessary for you and that you meet the coverage criteria. If you need help appealing a denial of coverage, contact your State Health Insurance Assistance Program (SHIP) by calling 877-839-2675 or visiting www.shiptacenter.org.
-Marci