Top three reasons why your Medicare prescription plan will not cover your drugs

Right around February is when we get a slew of calls from concerned individuals with the statement “why doesn’t my plan pay for my drugs?”  Some say it nicer than others.

Here are the top three reasons why your plan doesn’t cover your prescriptions (anymore):


1.    Formulary change

Plans can change what prescriptions they cover each year.  Often times, changes go into effective January 1st.  It’s important to review available options each year from October 15 to December 7th to make sure your plan will continue to cover your prescriptions.

What to do:  If you’ve missed this deadline, see if you qualify for a special election period to switch plans during the year.  If not, you can call your plan to see if they will grant you a “formulary exception” – meaning they will cover your prescription for the year.


2.    Prior authorization

Your plan may cover your prescriptions with prior authorization.  This means that your prescribing physician has to send in a prior authorization to the insurance company in order for your prescriptions to be covered.

What to do: if your prescription requires a prior authorization, coordinate the documentation by calling your prescribing physician.


3.    Plan error

Your insurance company may have made a mistake.  Sometimes things are printed incorrectly or details fall through the cracks – especially with prescriptions containing numerous delivery methods and dosages.

What to do: gather documentation stating that your prescriptions are supposed to be covered at a certain amount (online via, visiting the plan’s site and downloading the formulary, or calling the plan to request a formulary).   Call into your insurance company’s customer service line to state your case.  Often times, your insurance company will review the error and decide whether to cover your prescription at the rate you were expecting.

Johnny Luo M.D.Comment