I am enrolling in a Medicare Part D prescription drug plan soon, and I take several medications. I am concerned about what will happen if a drug is denied. Why would a prescription drug be denied by a Part D plan, and what can I do about it?
-Eugene (Boise, ID)
Dear Eugene,
There are several reasons that your drug could be denied by your Part D plan. If this happens, the best way to find out why is to call your Part D plan and ask. Some of the most common reasons for denial are:
Your drug is off-formulary: The drug is not on your plan’s list of covered drugs
Prior authorization: You must get prior approval from a plan before it will cover a specific drug.
Step therapy: Your plan requires you to try a different (usually less expensive) drug first.
Quantity limits: Your plan only covers a certain amount of a drug over a certain period (like 30 pills per month).
Once you know the reason your drug has been denied, you will be able to work with your doctor to communicate with the plan. Your doctor may need to submit additional evidence—for example, if your drug is denied because you have not met step therapy requirements, your doctor may need to submit additional documentation that you have tried the other, lower tier drugs, or that trying them would be dangerous or ineffective for you. If your doctor cannot resolve this issue with the plan, you and your doctor can appeal for your plan to cover the drug. For more information about the appeals process, click here.
There are other reasons that your drug may be denied, such as if it was prescribed for an off-label use or if it is excluded from coverage by Medicare law. In these situations, be aware that you can appeal for coverage, but you are less likely to receive a favorable decision.
Your drug has been prescribed for an off-label use: “Off label” is a term used to describe situations where a doctor has prescribed a drug for a reason other than the use(s) approved by the U.S. Food and Drug Administration (FDA) or listed in certain medial reference texts. If your doctor prescribes a medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug may not be covered. Some very limited exceptions for cancer drugs exist. If you are taking an off-label chemotherapy drug, the drug plan can also look to whether there is peer-reviewed medical literature support for the use when deciding whether to cover it.
Your drug is excluded from Medicare coverage: some drugs are excluded from Medicare coverage. These include:
Drugs used to treat anorexia, weight loss, or weight gain,
Note: Part D may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases.
Fertility drugs
Drugs used for cosmetic purposes or hair growth
Note: drugs used for the treatment of skin diseases or conditions like psoriasis, acne, rosacea, or vitiligo are not considered cosmetic drugs and may be covered under Part D.
Drugs that are only for the relief of cough or cold symptoms
Drugs used to treat erectile dysfunction
Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
Non-prescription drugs (over the counter drugs).
If the drug you are trying to access is an opiate, some additional restrictions may apply, including restrictions based on your personal history of opioid use. If this happens, talk to your pharmacist and doctor.