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What if my medication is covered yet the claim denied? Skip to content

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My Medicare Part D drug plan won’t cover my drug, although it’s on the plan’s list of covered drugs. Why is this happening?

En español | There are several reasons a Part D plan may deny coverage for a drug that it normally covers: 

  • You may be in the “deductible” phase of coverage and must meet your plan’s deductible (by paying out of pocket for your drugs) before coverage can begin.
  • You may have filled your prescription at a pharmacy that is not in your plan’s pharmacy network.
  • Your plan may have set a “restriction” on your drug, in one of three categories:  
  1. Prior authorization: This means that you must ask the plan’s permission (with your doctor’s help) before it will cover the drug. It may be because the drug is a powerful one that poses safety concerns, or that this drug is sometimes covered under Part B and the plan needs to find out from your doctor why it was prescribed, to decide whether it should be covered under Part B or Part D.
  2.  Step therapy: This means that your plan wants you to try a similar but lower-cost drug before it will cover the more expensive one your doctor prescribed. To avoid this, your doctor must show that you have already tried lower-cost drugs that didn’t work as well for your medical condition. 
  3. Quantity limits: This means that your doctor has prescribed a dosage or quantity that is higher than the plan considers normal to treat your condition. The plan won’t cover the drug unless your doctor shows that the prescribed amount is necessary to treat you effectively.  

In order to reduce fraud, Medicare requires that a doctor who writes prescriptions for medications must have either formally enrolled in Medicare or formally opted out — otherwise, your Part D plan may not provide coverage.


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