October 6, 2016
As a Medicare beneficiary, you may one day be in a situation where your pharmacy can’t fill your Medicare-covered prescription. If you’re enrolled in either a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, there may be a number of ways to deal with this issue.
Medicare prescription drug coverage
Stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage plans with prescription drug coverage (also known as Medicare Advantage Prescription Drug plans) must offer the minimum standard of prescription drug coverage set by Medicare. Once you enroll in a Medicare Prescription Drug Plan, the insurance company might direct you to a list of pharmacies that are part of its network; this information may be on the plan’s website. In some cases, you may be required to go to one of these network pharmacies in order to fill your prescriptions.
Why can’t the pharmacy fill your Medicare-covered drug?
If a pharmacy won’t fill your medication:
- Make sure that the pharmacy belongs to your Prescription Drug Plan’s network (if your plan has this requirement). You may have selected a pharmacy that’s not approved by your specific plan. If it turns out that the pharmacy does not belong to your plan’s network, refer back to the plan’s pharmacy directory and choose a different pharmacy. You might be able to fill the prescription at an out-of-network pharmacy, but it might cost more than if you stayed in the plan’s network.
- Certain Medicare Prescription Drug Plans place limits on the amount of a medication you can get at one time. If you or your doctor believe that the quantity limit should be waived in your particular case, you should contact your health plan directly and ask for an exception.
- Sometimes a Medicare Prescription Drug Plan removes a drug from its formulary (a list of covered medications). A plan’s formulary may change at any time. You will receive notice from your plan when necessary. If the Food and Drug Administration has required that pharmacies pull a drug off the shelves for safety reasons, no advance notice is required.
- If the pharmacy has simply run out of your particular prescription drug, in many cases you can again refer to the plan’s pharmacy directory and choose a different pharmacy that still has your prescription drug in stock. You may want to contact your plan to arrange having the prescription transferred to the other pharmacy.
- If the pharmacy belongs to your stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan’s network, ask the pharmacist why the pharmacy can’t refill your Medicare-approved drug.
You may also want to check if your plan has mail-order pharmacies as part of its network. Through a mail-order pharmacy, you can usually buy up to a 90-day supply of prescription drugs, which are conveniently mailed to your home.
If you, or your doctor, feel that you need a prescription drug that’s not in your plan’s formulary, you or your doctor may be able to ask your plan for an exception.