What Can You Do if Your Doctor Prescribes Drugs that Your Part D Plan Doesn't Cover?

Q. I selected a Medicare drug plan because it covered the generics I was taking. Now my doctor has switched me to two brand-name drugs that my plan doesn’t cover. Can I switch plans midyear for this reason? Or must I wait for the next enrollment period and pay the freight until then?

A. You can’t change your plan during the year just because your prescriptions changed. However, you don’t necessarily have to pay the freight until the end of the year either. There are several actions to consider:

• First ask your doctor to look at your plan’s formulary (the list of drugs it covers). There might be other drugs on it that are used to treat the same condition. (Every plan must cover at least two Medicare-approved drugs in each class of medications used to treat the same condition if more than one drug exists.) You can find your plan’s formulary in the materials the plan sent you for this year or on its website. Or call your plan and ask for the formulary.
• Ask your plan to cover your new drugs as an “exception” to its rules. To have any chance of success, you need your doctor to support your request by writing a statement explaining why these particular medications (instead of those on the plan’s formulary) are necessary for your health. Call the plan and ask it to send you a “coverage determination” form so that you can request an exception. Also ask for the form that the plan prefers doctors to use in these circumstances and give the form to your doctor. The plan must respond to this request (as long as it includes the doctor’s statement or completed form) within 72 hours—or, if your doctor requests a fast determination because your health is at risk, within 24 hours.
• After considering your request, the plan can either decide to cover your drugs or not. If it denies your request, you have the legal right to appeal. The letter you receive from the plan must tell you how you can go about appealing to higher levels. For more detailed (and easy to understand) information on this process, see the Part D Appeals Manual, a consumer guide provided by the Medicare Rights Center.

Note: You can’t request an exception for a drug that Medicare doesn’t cover. Among those excluded by law are medications for fertility, erectile dysfunction, weight problems and cosmetic uses, over-the-counter drugs and certain antianxiety treatments (barbiturates and benzodiazepines such as Valium and Xanax). However, if you’re prescribed one of these drugs for a specific reason that is approved by the Food and Drug Administration and allowed by Medicare, you can request that your plan cover it, again with your doctor’s written explanation that the drug is medically necessary. For example, Medicare will not cover an erectile dysfunction drug to treat sexual problems but does allow coverage when it’s prescribed for certain medical conditions. Similarly, prescription drugs used for cosmetic reasons are generally excluded from Medicare coverage but are allowed to treat skin conditions such as acne and psoriasis.

Patricia Barry is a senior editor at the AARP Bulletin.