Doctor With a Medicare Touch Screen IconAs Elder Law attorneys who help seniors protect their assets, pay for long-term care, and provide for the next generation, we sometimes get questions about other issues that affect seniors, such as Social Security and Medicare. We are happy to help our clients and neighbors in any way we can, so we provide some guidance here about paying for prescription medications when you are on Medicare.

What Does Medicare Cover?

The first thing to understand is that Original Medicare does not cover the cost of most prescriptions. There are a few exceptions, including medications you can’t give to yourself, such as infusions and injectable drugs. This is usually made clear when you enroll in Medicare, but some people are surprised to find it out later. Original Medicare Part A covers hospital stays, skilled nursing facility care for a limited amount of time, short-term nursing home care, hospice care, and in-home care. Medicare Part B covers doctor visits, lab services, durable medical equipment, and preventative health services. However, you can choose to pay for Medicare Part D, which provides prescription drug coverage. On Original Medicare, there are co-pays for most services.

Another option many people choose is a Medicare Advantage Plan. These are offered by private insurance companies, and most do include prescription coverage. The biggest downside of these plans is that they usually limit you to certain doctors, hospitals, and pharmacies. As long as you are in-network, however, you often get more coverage for less money than with Original Medicare. If you are denied prescription coverage under a Medicare Advantage Plan, it could be because you went to an out-of-network pharmacy.

Why Would a Particular Prescription Be Denied?

If you have some kind of prescription coverage and you discover that a drug prescribed by your physician is not covered, it could be for a couple of reasons. Every insurance company—including Medicare—has a list of medications that they do not cover. A medication might be on the list because the drug is new, hasn’t been FDA-approved for a certain use, is available over the counter, or it’s not considered to be medically necessary. Some companies will not cover brand-name drugs if a generic version is available. If your insurance company does not cover the drug, that doesn’t mean you can’t have it; it just means they want you to pay out of pocket. However, that could be prohibitively expensive.

What to Do If Your Prescription Is Not Covered

If you go to the pharmacy to pick up a new prescription and they tell you that coverage was denied, you do not have to pay for the medication just because the pharmacy filled it. Ask them why it was denied and make some calls before panicking. Your options include:

  • Talking to your doctor about a substitute. If the insurance company only covers the generic version, your doctor might have to write a new prescription that allows a generic alternative. If a drug is denied, but the company covers a similar drug, your doctor could write a prescription for the covered drug.
  • Requesting a formulary exception. With the help of your doctor, you can request special coverage for a medication that is not on the Medicare Part D or your Medicare Advantage Prescription Drug plan. This is known as a formulary exception and can be successful if your doctor can convince them that the drug is medically necessary. Decisions are usually made within 72 hours of receiving your doctor’s statement.
  • Filing an appeal. If your request for a formulary exception is denied, you can file an appeal. There are five levels of appeal in the Medicare system, so this can become a burdensome process.
  • Switching your prescription coverage. You always have the option of switching to a prescription plan that covers the medications you need. You will have to do this during Medicare’s Annual Election Period from October 15 to December 7.

In our experience, healthcare providers are more than happy to help their patients get the prescription medication they need. Always start by talking to your doctor.

Are You Looking for a Medicaid Planning Attorney in Texarkana, TX?

If you are hoping to qualify for Medicaid to cover prescriptions and to pay for nursing home care, you need to speak with an experienced Medicaid Planning attorney as soon as possible. Contact us online or call our Texarkana office directly at 903.223.5653. We also have offices in Tyler, Paris, and Longview, as well as Magnolia, AR!


Ben King
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Ben King helps clients in TX and AR with estate planning, asset protection, probate, and medicaid planning.