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.
Q. What is creditable drug coverage with Medicare?
As defined by Medicare, creditable drug coverage is prescription drug coverage that is at least as good as or better than the Medicare drug benefit. It could be from your employer or union, Veterans’ benefits, TRICARE, Indian Health Service, or Federal Employee Health Benefits. After becoming Medicare eligible, individuals run the risk of accruing a Late Enrollment Penalty (LEP) for each month they are not enrolled in a plan providing creditable coverage. If you have creditable coverage, you can delay signing up for Medicare without any penalty.
Each fall, health plans are required to provide notice to their enrollees regarding whether their prescription drug coverage is “creditable” under Medicare standards. Enrollees can also request this information at any time during the year.
A new wrinkle that enrollees with current creditable coverage will face in the future involves the passage and implementation of the Inflation Reduction Act (IRA.) As a result of the IRA, the out-of-pocket maximum under all Medicare Part D plans will be capped at $2,000 per year starting January 1, 2025. While this significant change gives current Part D enrollees peace of mind when it comes to budgeting for their medical expenses, an unintended consequence may fall on those Medicare-eligible individuals enrolled in employer or other non-Medicare plans.
According to a recent Kiplinger article, Centers for Medicare and Medicaid Services (CMS) says it is evaluating the impact of the IRA on creditable coverage determinations and will not disqualify private plans that are considered creditable, for now. So, if a health plan’s prescription drug benefit was determined to be creditable in 2024, it should continue to be considered creditable in 2025, “as long as it continues to meet the criteria.” CMS added that it will be evaluating the issue more this coming year. In short, CMS is aware of the issue and there are no steps Medicare-eligible individuals need to take other than to pay close attention to mail received from their plans. Concerned enrollees can always contact their plans for more information.
For additional help with Medicare questions, contact the Michigan Medicare Assistance Program (MMAP) at 800-803-7174.
Sara Duris is community information liaison of Region IV Area Agency on Aging in Southwest Michigan. Questions on age or independence services? Call the Info-Line for Aging & Disability at 800-654-2810 or visit areaagencyonaging.org. The Generations column appears each weekend in The Herald-Palladium.