“I’m sorry, your insurance doesn’t cover this prescription.”

Have you ever heard your pharmacist say those words?

It’s January. You just made it through the Christmas season splurging on gifts for your grandkids like you do every year. This is the time of year when you realize you need to tighten up the budget a bit and start playing a little catch-up with your finances.

The first thing that comes to mind is, “Well, how much is this going to cost me? I need this prescription.”

Then you start to wonder what happened. Your drug plan covered this prescription last year.

Or, maybe you’re new to Medicare and Part D altogether. You signed up for your drug plan by just filling out an application from one of those colorful brochures you’d been getting in the mail for months leading up to your 65th birthday. It’s the plan your brother is on, and it’s been working for him. But you didn’t check to see if it covered all your drugs. Then again, why wouldn’t it?

Whatever the reason is that you find yourself without coverage for one (or more) of your drugs, let’s figure out what your options are to get covered if you find yourself in this spot…


Switch to a Similar Drug

Every Medicare drug plan is required to cover at least two medications in each class of drugs used to treat a certain medical condition. Said another way, if your drug plan doesn’t cover your prescription, there are at least two other drugs that you can switch to that are covered by your plan to treat your issue. Now, they may not work as well as what you’re currently on, or they may have some negative side effects for you, but you do have some alternatives.

To give yourself some time to figure out what you want to do, you can…

Get a Transitional Refill

If your drug plan stops covering your prescription from year-to-year, or the plan you enroll in once you’re new to Medicare doesn’t cover one of your current prescriptions, you have the right to a transitional refill for this drug. You can get a 30-day supply of this drug sometime in the first 90 day period where you’re drug isn’t covered, as long as your situation meets Medicare’s criteria.

There are some exceptions to this transitional right. A couple of them are:

  • This drug has to be a Medicare-covered drug. Some examples of drugs that are not Medicare-covered are drugs used for weight loss, or for sexual dysfunction.
  • This drug has to be one that you’ve been taking, and not one that’s new

There may be other exceptions, but usually you can get this 30-day supply to buy yourself some time to talk to your doctor about finding another drug that will work for you. Or you can…

Apply for a Formulary Exception

All Part D plans have a formulary. A formulary is just a list of prescriptions that a certain drug plan covers. Now each formulary has hundreds of drugs that it covers, but no formulary covers every single drug. If the plan you’re on doesn’t cover the one specific drug you need, you can apply for a “formulary exception”. This is simply asking your plan if they can make an exception and cover your drug.

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When you apply for this exception, you’ll need to get a note from your doctor saying why you need this specific drug. You have to have a legitimate reason, (for example: any other similar drug that is covered either wouldn’t be as effective, or would cause side effects). Your plan has to give you an answer within 72 hours. If they deny your request, you can always appeal this decision.

If your formulary exception gets denied, and you still need, or prefer, to take this drug, you have a couple other options…

Ask Your Doctor for Free Samples

Now this isn’t some fancy insurance loophole secret that I’m letting you in on. But, maybe you’ve never thought about simply asking your doctor for free samples. This might especially be the case if you’ve never gotten any free samples in the past.

Doctors and doctor’s offices usually have relationships with lots of different pharmaceutical sales reps, and they will often give free samples for their drugs. Sometimes my clients will tell me they can get free samples for several months, or even years, of some of their meds.

See if the Drug Maker has Savings Programs

One ninja trick that I like to share with folks is to go straight to the company who makes that drug. This drug manufacturer will often have some type of coupon that you can get for one or more fills of your prescription. Also, sometimes they will have pharmaceutical assistance programs where you can get ongoing financial help paying for your drug that they make if you qualify.

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Hopefully you can take one or more of these tips to help you if you ever come across this surprise situation. Remember, you can switch drug plans every year, so you only have to make due the rest of the calendar year until you can switch to a plan that actually covers your drug. This advice can help you in the meantime.