Medicare Prescription Coverage Rules
Your prescription plan’s drug plan coverage rules determine whether or not your prescriptions are covered. Due to these rules, there may sometimes be delays getting your prescriptions filled. Contact your Medicare drug plan to find out the specific drug coverage rules for your plan. For prescriptions covered by Medicare Part B, contact your physician. Part B prescriptions, such as injectable and infused drugs or vaccinations, are provided in a physician’s office.
Potential Issues and Coverage Rules
There are several reasons your pharmacy might be unable to fill a prescription for you under your health plan:
Your new plan is still processing
You haven't met step therapy requirements
You exceeded quantity limit restrictions
There’s a prior authorization or pre-certification for the prescription
Formulary changes occurred
You're using an out-of-network pharmacy
Your coverage lapsed
Formulary
A formulary is a list of prescription drugs covered by a plan offering prescription drug benefits. Also called a drug list. Contact your insurance carrier for questions about its formulary.
Prior Authorization
You or your prescriber must contact your plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it. Plans may also use prior authorization when they cover a drug only for certain medical conditions but not others. When this occurs, plans will likely have alternative drugs on their list of covered drugs (formulary) for the other medical conditions the drug is approved to treat.
Your insurance carrier can tell you what’s needed before filling your prescription. The phone number to contact your carrier is generally on the back of your Insurance ID card.
If you’re currently unable to fill a prescription due to a prior authorization or pre-certification requirement, your physician might be able to request an exception from your insurance carrier.
Step therapy
Step therapy is a type of prior authorization. In most cases, you must first try a certain, less expensive drug on the plan’s formulary that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, some plans may require you first try a generic drug (if available), then a less expensive brand-name drug on their drug list before you can get a similar, more expensive, brand-name drug covered.
However, if your prescriber believes that because of your medical condition it’s medically necessary for you to be on a more expensive step therapy drug without trying the less expensive drug first, you or your prescriber can contact the plan to request an exception.
Quantity limits
For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain period of time. For example, most people prescribed heartburn medication take one tablet per day for four weeks. Therefore, a plan may cover only an initial one month supply of the heartburn medication.
If your prescriber believes that, because of your medical condition, a quantity limit isn’t medically appropriate (for example, your doctor believes you need a higher dosage of two tablets per day), you or your prescriber can contact the plan to ask for an exception.
In-Network Pharmacies
The most cost-effective way to fill your prescriptions is to use a preferred, in-network pharmacy (retail or mail order). Standard in-network pharmacies are available, but you may have a higher copay or coinsurance amount than at a preferred pharmacy. If you use an out-of-network pharmacy, you have to pay the retail price of the drug.
The licensed benefit advisor* you speak with during your enrollment call can tell you which pharmacies are in network for the health plans you're considering.
If you're already enrolled in a health plan, contact your insurance carrier or visit its website for a list of preferred and standard, in-network pharmacies (retail and mail order). The insurance carrier's phone number is generally located on the back of your Insurance ID card.
*Our licensed benefit advisors specialize in health insurance for retirees. They go through annual training and certification to ensure they can help you make an informed and confident decision.
Additional Assistance
Contact the carrier for your prescription drug plan for information on filling your prescriptions using mail order. The phone number to contact your carrier is generally on the back of your Insurance ID card.
Please contact us for assistance if you’re having trouble reaching your carrier or need additional assistance.
For assistance shopping for a prescription drug plan on our website, read Shop and Enroll in Medicare Plans on the Website.