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Use Your Plan: Troubleshooting

Problem #2: Your prescription drug plan (PDP) does not pay for the medicine you were prescribed.

It may be that the medicine prescribed by your health care provider is not covered by your PDP—or is not on the formulary, the list of medicines covered by the plan. You can usually find the list of covered medicines on your plan's Web site or by calling the member services phone number on the back of your pharmacy benefit ID card. If this happens the first time you try to get a refill for a medication you are already using under a new Medicare drug plan, you, your pharmacist or your health care provider should contact the plan immediately and ask for a transitional supply.

Plans are supposed to have special "transition benefits" to accommodate new enrollees. This one-time 30-day supply gives you time to work with your health care provider to either switch to a medication that is covered by the new plan, or to decide if you want to take steps to request coverage of your existing medication. But it is important that you use that 30-day opportunity to take action, otherwise you may not be able to get your medication covered when you go for your next refill.

If this happens the first time you try to fill a new prescription, you can either pay for the medicine yourself or ask your health care provider if a different medicine—one your insurance will pay for—will work for you. If not, you or your health care provider can ask your PDP for a formulary exception to get the medicine covered.

PDPs are required to approve coverage of a non-formulary medication when you request a formulary exception if the PDP determines that it is medically necessary for you to have that particular medication based on the information your health care provider gives to the plan. If that fails, you can begin the appeal process.

You will receive instructions from the PDP on how to start the Medicare appeal process if the PDP denies your formulary exception request. It is important to remember that if you pay for a medicine that is not on the plan's formulary yourself, the cost of the medicine will not count toward the out-of-pocket threshold. It makes sense to seek a formulary exception if you really need a particular medicine. If you need the medication right away, you can pay for it yourself and then request a formulary exception for the PDP to pay you back.