Inside Medicare | Why is Medicare Insurance Making it Hard to Get My Prescriptions Filled?

Question:

I went to fill my medications and I seem to be having problems. One medication was no longer covered, another one needed “permission” first, and then I received a letter saying I have to switch to another medication for a third drug I took last year. Why is this happening when they were all covered before?

Answer:

Well, this is a common occurrence in the first three months of the year with Medicare Part D. Remember that each year, plans change not only the premium they charge, but also the medications they cover, and how they cover those medications. The Formulary is the list of medications each insurance company will cover, and it breaks down how each medication is covered. Sometimes medications get removed from a plan formulary, and this can result in 3 different steps you’d have to take to get coverage. You’ve run into all 3 situations, so I will explain.

First, notification that “the medication is no longer covered” is the most severe situation with formula changes. Your insurance company is required to tell you in advance that they are NOT going to be covering a medication you take. A letter with this should have been mailed to you early in the last quarter of 2025. The problem is, we all get lots of mail, and we don’t understand all of it. Sometimes, we throw out by mistake without reading, sometimes we don’t understand, and sometimes we read and don’t remember to act. If you are notified that a medication you take is no longer covered, then you must speak with your physician to ask them what to do about it. Your physician may contact the plan to ask for an exception/waiver so you can continue to get coverage for your medication. Your physician could also look into alternate medications that may be available for you to take. An alternate medication would simply require a new prescription. This may be the easiest solution, if you and your doctor are both comfortable with that change of medication.

Second, notice that “permission is needed first” is called a Prior Authorization requirement. This is generally taken care of by the pharmacy and you may not even know it happens. When the pharmacist puts your medication refill into the computer, it will come up “prior approval required.” This plan now requires that your prescribing physician contact the insurance company to review this medication. The pharmacist generally contacts the prescribing physician and notifies them of the request for more information by the insurance company. Hopefully this can be resolved between the physician and the insurance company efficiently enough that you don’t run out of medication. In the past few years, this Prior Authorization was usually a very simple step. This year, I am finding that in some situations, this Prior Authorization is used a ‘Yes, but NO” for the insurance company. It allows them to keep the medication on the formulary, but in practice there are very FEW occasions where individuals like yourself are actually allowed to get the medication. Probably the most common this year are medications like Ozempic and Mounjaro, but we have run into many others.

The third situation is when a medication has gone into the category of “Step-Therapy” medication. This situation comes about when a medication is technically approved, but only for 30-days. After you fill that first 30-day supply, your insurance company sends a letter requesting you to consider switching to an alternate medication. This letter usually gives you a list of alternate medications they “prefer.” This list should be reviewed with your physician quickly. Your physician can then contact the insurance company to let them know of your decision regarding the change. Sometimes the insurance company will continue to cover the same medication you were on, but sometimes a change in medication is necessary. Again we are finding that approval for this Step Therapy limited medication is seldom approved by the insurance company. Again I use the phrase “Yes but NO.” The insurance company keeps the medication on the formulary list, but it rarely actually allows individuals to stay on that medication.

I should note a fourth scenario, known as a Quantity Limit, which is usually the least restrictive. Quantity Limit is as it says, the insurance company limits the amount of that type of medication you can get. Sometimes it is limited to a 30-day supply. Sometimes, the limit does not effect your typically dosage, but sometimes it means you will be short on your supply – like if you normally take 2 doses per day per month, but it limits to only 30 doses per month. In that instance, you would have to ask your physician to get an exception to get a larger number of pills. Sometimes you can work around this by going to a higher dosage, but that is not always the case.

I believe this time of year is the hardest for pharmacists. They attempt to fill your medications the way they always do, and it seems the new plans – sometimes even the same plans – have changed all the rules. The pharmacists can’t warn you in advance. They try hard to do their best, but the plans make changes, the doctors and patients need to be informed of the changes, and it all takes a LOT of time. The pharmacists try hard to keep everyone happy and informed of what is happening, but that first yearly refill of your medication is when those changes are flushed out.

Don’t wait until the last minute to refill a medication. If any of these “hassles” happen, you may not have the medication you need tomorrow. So refill your medication four-to-seven days in advance at the local pharmacy, or three weeks in advance if using mail order. This extra time will give you and your pharmacy the time you need to correct any problems and still have your medication on time.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email jsluga@lawleyinsurance.com.