Are you facing challenges with getting your prescribed medication covered at the pharmacy?

Not being able to access your medication can be very stressful. Here are a few steps you can take to identify the issue and ensure uninterrupted access to your medication in the future: 

Know your coverage: 

• Call your plan and check for any applicable coverage restrictions. You must follow these rules before your plan covers your drug.
• Call Medicare to learn about which part of Medicare should cover your drug.
• Check to ensure your Part D drugs are on your plan’s formulary, or list of covered medications.

Make sure your pharmacist submits claims properly: 

• Your pharmacist might be billing your prescription to the incorrect section of Medicare or failing to provide necessary documentation. This could clarify a drug coverage denial or the difficulties your pharmacist is encountering with your plan.
• If your provider doesn’t know how to submit these claims, they can ask your plan or Medicare for help.

Make sure your provider or pharmacist has the documentation they need: 

• This is helpful for drugs that are covered differently depending on the situation.
• For example, many biologic medications, like Enbrel, Humira, Cosentyx, Taltz, and Rinvoq, are used to treat spondyloarthritis and are often covered by Medicare Part D. However, some may be on a higher cost tier or require prior authorization.

Know your right to appeal:   

• You have the right to appeal a denial from either Medicare or your plan.
• Ask your doctor to help prove your drug is medically necessary and that you meet the coverage criteria.

For more information about working with your Medicare Plan, visit The Medicare Rights Center.

For further details on what to do if your treatment is denied, click here.