How to Ensure You Get Your Prescriptions on Medicare Plan D

By Patricia Barry

Copyright © 2015 AARP. All rights reserved.

Medicare’s message to people in Part D plans is plain: “Don’t leave the pharmacy without your medicines.” What it means by this advice is that the system has certain built-in mechanisms that ensure you get your drugs — if you know how to use these rules.

What if your pharmacist can’t confirm your plan membership, says that your plan doesn’t cover one of your drugs, or indicates that you need to get permission from the plan before it will cover a drug? What if he asks you to pay more for your drugs than you think you should? Or says that your doctor isn’t allowed to prescribe drugs for Part D? Any of these what-ifs can happen.

If the pharmacist can’t confirm your enrollment in a plan

Getting details of new enrollees into the computer system takes time — especially in early January, when many people have just switched plans. If you have no proof of coverage and the pharmacist can’t verify your enrollment by calling the plan, here are your options:

  • Pay for your drugs (at full price), keep the receipts, and send copies to the plan. The plan then refunds you any money that’s due. However, if your enrollment is denied, the plan won’t cover these bills.

    Can your enrollment in a Part D plan be denied? Yes, in certain specific circumstances: Your enrollment period has expired, you don’t live in the plan’s service area, your eligibility for Medicare can’t be confirmed in the official records, and so on. So if the pharmacist tells you the system has no record of your enrollment, you need to contact the plan to find out why.

  • If you can’t afford the prescriptions, ask the pharmacist to call Medicare’s dedicated pharmacy hot line, which is used for dealing with this situation.

If the pharmacist says the plan won’t pay for one of your meds

The pharmacist will probably tell you if your plan doesn’t cover a drug you’ve been prescribed or if the med comes with restrictions requiring the plan’s consent before you can get it. In any event, call the plan to find out what you need to do.

If you’re newly enrolled in the plan and you’ve already been taking this drug, you have the legal right to a 30-day supply so that your treatment isn’t interrupted. Ask the pharmacist to fill the prescription under your plan’s transition or first-fill policy. If he’s reluctant to do so, ask him to contact your plan for approval. (This 30-day rule also applies if you’ve been in a Part D plan but have just switched to another.) But note that this work-around is only a temporary solution. You must take immediate steps to change to a drug your plan does cover or work with your doctor to get the restriction lifted.

If the pharmacist charges you more than you think is correct

The most-common explanations for being asked to pay more than you think you should at the pharmacy are these:

  • Your plan has a deductible. In this case, you must pay the full cost of your drugs until you’ve met the amount of the deductible — either at the beginning of the year or partway through the year if that’s when you first join a plan. People don’t always realize their plan has a deductible — especially if it didn’t charge one the previous year but does now. Plans make this decision each year.

  • Your plan has changed its co-pay for your drug. Plans can make these changes every calendar year too.

  • The pharmacy isn’t in your plan’s network. In this case, you’re probably required to pay full price.

  • You qualify for Extra Help, but the pharmacist can’t confirm it immediately through the system. If you have Medicaid coverage, show your card. If you’re receiving Supplementary Security Income (SSI) or your state pays your Medicare premium, tell the pharmacist; in all these situations, you automatically qualify for Extra Help. If you applied for Extra Help, bring the letter from Social Security that says you qualify. Either way, you should be charged only small co-pays for your drugs.

  • You’ve applied for Extra Help but haven’t yet heard whether you qualify. In this situation, you have two options:

    • Pay the plan’s normal co-pays and keep your receipts. After Social Security has confirmed your eligibility, the plan must refund you the difference between what you paid and what you would’ve paid under Extra Help — dating back to the time you applied for it.

    • If you can’t afford to pay the usual co-pays upfront, tell the pharmacist, who has the discretion to help you under Medicare rules. At the very least, if you have less than a three-day supply of your meds left, the pharmacist must allow you an emergency supply. Don’t be too shy or proud to ask, and — just like the Medicare honchos say — don’t leave the pharmacy without your meds.

If the pharmacist says your doctor isn’t an approved Medicare prescriber

Starting January 1, 2016, Medicare requires doctors who write prescriptions to be either formally enrolled in Medicare or formally opted out — otherwise, your Part D drug plan may not provide coverage. This new rule is part of an effort to prevent fraud and illegal prescribing.