If you are experiencing issues accessing your medication, take these steps:
Become familiar with how your medication is covered: Use the information above or call 1-800-MEDICARE to learn about which part of Medicare should cover your medication. If it is a Part D drug, check that it is on your plan’s formulary and see if there are any coverage restrictions imposed by your plan.
Ask your pharmacist or provider to submit claims to the correct part of Medicare: If your pharmacist is having trouble billing to Medicare/your Part D plan, or if you are being denied coverage for a drug, it is possible that the medication is being billed incorrectly. If your provider is unsure of how to submit these claims, tell them they can reach out to your plan or to Medicare for assistance.
- If this is a Part D-covered drug, they should call your Part D plan.
- If it is a Part B-covered drug and you have a Medicare Advantage Plan, they should call your Medicare Advantage Plan.
- If it is a Part B-covered drug and you have Original Medicare, they should reach out to the Medicare Administrative Contractor for your region.
If the coverage of the drug depends on the circumstances in which you use it, make sure your provider or pharmacist has the documentation they need. For example, if your insulin should be covered by Part B because you use an infusion pump to take it, Medicare may need you to provide proof that you have an insulin pump (especially you purchased the pump before you were eligible for Medicare).
If payment is denied, appeal the denial. You have the right to appeal Medicare’s or your plan’s denial. Ask your doctor to help you prove that the medication is medically necessary for you and that you meet the coverage criteria. If you need help appealing a denial of coverage of your medication to Medicare or your Part D plan, contact your State Health Insurance Assistance Program (SHIP) by calling (877) 839-2675 or visiting www.shiptacenter.org.
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