By: Sara Duris
Q. I’ve always had great prescription drug coverage but my doctor put me on something new and it isn’t covered by my insurance. What can I do?
A. First contact your drug plan and find out why this drug isn’t covered and what the plan recommends. There might be an alternative drug on the plan’s formulary (their list of covered drugs) that can work just as well. If the drug is newer and more expensive, your plan might require step-therapy before approving coverage of the newer drug. This is where a medical condition is treated with the safest but most cost-effective drugs first and progresses to the more expensive drugs only if necessary. Work with your physician to see if any of the covered drugs are appropriate for your condition.
If switching to another drug is not an option, you can choose to appeal. First, you will need to file an exception request with your plan. Contact your plan to learn how to file the exception request. You will need a doctor’s letter of support to accompany your request. If your exception request is approved, your drug will be covered. If your exception request is denied, your plan will send you a Notice of Denial of Medicare Prescription Drug Coverage.
You have 60 days from the date listed on the Notice of Denial to begin the formal appeal process. Follow the directions on the Notice to file an appeal with your plan. Again, it is important to have a letter of support from your doctor addressing all the plan’s reasons for not covering the needed drug. If your plan approves the appeal, your drug will be covered. If your appeal is denied, you can choose to move to the next level of appeal (there are four levels after initial appeal.) At each level, be sure to follow all the instructions and deadlines carefully. For assistance with any of the steps in the appeal process, you can contact your area Michigan Medicare/Medicaid Assistance Program (MMAP) counselors by calling 800-803-7174.
Q. I have heard if I am over 65 but still working, I can still qualify for a Medigap plan when I retire, is this accurate?
A. It is accurate to an extent. There are two stipulations that must be met. Under federal law, a Medicare beneficiary who is over 65 and still working and delays enrollment into Medicare Part B, because they have coverage through their current Employer Group Health Plan that pays primary to Medicare, will have the usual six-month Medigap Open Enrollment Period that starts when they enroll in Part B. So, restated, you must not be enrolled in Part B and you must have coverage through your employee health insurance in order to still qualify for the Open Enrollment Period, which allows individuals to buy supplemental coverage even if they have pre-existing health problems. For more information, you can go to www.Medicare.gov or contact the MMAP hotline noted above.