Did You Know: Drug Not Covered

There are several reasons why a drug might not be covered by Medicare Part D:

  1. Excluded by Law: Certain types of drugs are excluded from Medicare coverage by law. These include drugs for weight loss or gain, fertility, cosmetic purposes, hair growth, and over-the-counter medications. 
  2. Not on the Formulary: Each Part D plan has a list of covered drugs, known as a formulary. If a drug is not on this list, it won't be covered.
  3. Prior Authorization: Some drugs require prior authorization, meaning your doctor must get approval from the plan before the drug is covered. 
  4. Off-Label Use: If a drug is prescribed for a use that is not approved by the FDA or not listed in Medicare-approved drug compendia, it may not be covered.
  5. Less-than-Effective DESI Drugs: Drugs that have been evaluated and found to be less effective by the Drug Efficacy Study Implementation (DESI) are excluded from coverage. 

If your medication isn't covered by Medicare Part D, here are some steps you can take:

  1. Check for Alternatives: Ask your doctor if there is a similar medication that is covered by your plan. 
  2. Request a Formulary Exception: You can ask your Part D plan to make an exception and cover your medication. Your doctor will need to provide a statement explaining why the drug is medically necessary.
  3. File an Appeal: If your request for an exception is denied, you have the right to appeal the decision. This process involves several levels of review. 
  4. Explore Patient Assistance Programs: Some pharmaceutical companies offer programs to help cover the cost of medications for those who qualify.
  5. Switch Plans: During the Medicare Open Enrollment Period (October 15 to December 7), you can switch to a different Part D plan that covers your medication. 
  6. Check Other Medicare Parts: Sometimes, medications might be covered under Medicare Part B if they are administered in a doctor's office or hospital.

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