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Drug Coverage Denied – Here’s What You Can Do

Drug Coverage Denied – Here’s What You Can Do

Medicare Part D is an excellent way to offset the rising cost of prescription drugs. It’s a great way for a Medicare enrollee to get the medications that they need without breaking their bank every month, but every day some people are having their drug coverage denied, and it can be a frustrating process deciding what you should do next. Not having the coverage that you need could leave you with massive out-of-pocket expenses.

When you go to the pharmacy, you can provide the pharmacist with all of your drug coverage, and hopefully you will never hear those dreaded words, “your coverage doesn’t pay for these medications,” but if you ever run into this problem, don’t panic, there are a few steps that you can take to hopefully protect yourself from having to pay for those medications yourself.

Medicare Part D

Part D is additional coverage that you can buy to supplement your primary coverage that is offered through Parts A and B, neither of which will offset the costs of medications. Part D is sold by private insurance companies, which means that every plan is going to be different and will offer coverage for different lists of drugs.

Before you enroll in Part D, you’ll need to check to ensure that your medications are covered under the plan that you’re buying, but you may already find yourself in a situation where you need a drug that isn’t covered. You’re not sure why, but you’ve been told that your Part D isn’t going to help pay for your prescriptions. You can either pay for the whole thing yourself, or you can leave without any medications. What should you do next?

Sadly, this is becoming more and more common. In fact, being denied prescription coverage is one of the leading questions that the Medicare Rights Center’s Helpline deals with the most. The Center’s president explains some of the things that he’s seen, “The problem of pharmacy denials and people being confused by Part D prescription-drug coverage is a growing trend,” and more than likely, it’s going to continue to get worse every year.

Denied? Here’s What To Do!

The first thing that you should know if you’ve been denied is that there are some steps that you can take. The pharmacist doesn’t have any control over the coverage (which means getting mad at them will do you little to no good), but their “no” doesn’t mean that you can’t get help paying for those medications. After you’ve left the pharmacy, the first thing that you should do is take a note of the prescription name and the dosage that you are going to be taking. You should also take note of the pharmacy that you’re trying to get the medications filled at.

After that, you’ll need to call your plan provider and ask them for a “coverage determination,” which is a written explanation of the coverage decision. This will show you why your medications weren’t included in the coverage. Once you ask, they have 72 hours to respond, but if you need it faster, you can request that they make it an expedited decision, which shortens the response to 24 hours.

If they tell you that the drug is not on their formulary or that it’s one of the coverage restriction, then you can ask for an exception to the coverage. If this happens, you’ll need to have your primary physician write a statement which explains while only this medication will be effective. The goal of the statement is to show the drug coverage company that this medication is the only option for treating whatever your medical condition is, and if your doctor can do this, then the company will grant you an exception to the coverage.

If the company decide that they still will not cover the drug, you’ll have 60 days from that point to ask for a “redetermination,” which is the first level of the appeals process. Most applicants will only reach this level, but there are several other appeal procedures that you can go through if you continue to be denied coverage. The more levels of appeal that you go through, the longer the process is going to take and the more expensive that it can become.

Part D And Getting Declined

As Medicare coverage continues to change and prescription costs continue to rise, we expect that there are going to be more and more enrollees that are facing the challenge of being rejected for coverage, which could lead to massive out-of-pocket expenses. We know that getting Part D to reconsider the coverage can be a complicated process, especially for anyone that has no experience in the insurance industry.

If you have any questions about Part D coverage or about being declined for drug coverage, please contact one of our experienced agents today. We would be happy to answer those questions and ensure that you’re getting the quality drug coverage that you will need.

One of the most important things that you should note is that regardless of being declined for coverage, it’s important that you don’t skip taking any medications because of coverage. There are several other ways that you can offset expensive drugs. Your health is one of the most important things that you should consider during the process, and don’t sacrifice it for the money.


MedicareWallet.com is an unbiased, online resource for individuals turning 65 or already on Medicare. Our utmost goal is to provide information in a way that is user-focused, informative and ethical. With a combined 40 years of experience in the Medicare market, we can answer any questions about Medicare and Medigap insurance. Feel free to reach out to us at 800.376.0824 or by email atinfo@medicarewallet.com.

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