July 18, 2017
With seniors in the United States taking, on average, 15-18 different medications, Medicare coverage of these medicines is often a necessity. And with a typical pricetag of greater than $11,000 per year for the most common drugs prescribed by doctors for the elderly, it usually is devastating when Medicare unexpectedly denies coverage. Yet nevertheless, that’s occurring more and more frequently as Medicare plans are increasingly imposing coverage limits on elderly people – generally outside of affirmation from the Centers for Medicare & Medicaid Services.
Since the appeals process for denied coverage can be so frustrating, sadly, a great many seniors simply accept the denial – at frequently an outrageously high financial impact, and also at great risk to their well-being when required medications are stopped as a result of lack of Medicare health insurance coverage. According to David Lipschutz, senior policy attorney at the Center for Medicare Advocacy, “A lot of people fall through the cracks. They simply don’t know what to do. Or they try to go through the process, and it’s complicated and time-consuming and they just give up.”
Even though a variety of prescription drugs must be covered by Medicare across the board (medications for HIV/AIDS, depression, cancer, and seizures, to name a few), there’s a gray area by which medications are covered for other conditions – and preapproval is usually required, or patients are given the requirements that cheaper measures need to be used first (also called step therapy). Denials often occur because of a consequence of failing to fulfill these requirements.
So, exactly what can a senior do in order to get the drug insurance coverage to which they’re entitled? There are several key steps:
- First, ask for a formal coverage determination from the older adult’s Medicare drug plan. Details on submitting this specific request can be found by clicking here.
- Once coverage is established, there are 5 levels in the appeals process, specified here.
- Keep detailed documentation throughout each and every phase of the process. For additional assistance, the Medicare Rights Center can assist. You’ll be able to reach them at 800-333-4114.
Remember it’s necessary to be persistent. Oftentimes, higher levels of appeals are approved even if preliminary steps generate unsatisfying results. Call Continuum for more suggestions and hands-on support for older adults. Our Ladue caregivers can provide resources to help aging adults in addition to their families advocate for themselves, together with specialized in-home care services to make certain medications are taken just as prescribed, that prescription medication refills are handled, and much more. Call us at (314) 863-9912 and discover how to keep your senior loved one safe and flourishing!