On average, seniors are each taking 15 – 18 different prescribed medications, so Medicare coverage of these medicines is often extremely important. And with an average price tag of greater than $11,000 yearly for the most typical drugs prescribed by doctors for the elderly, it could be debilitating when seniors see an increase in Medicare denials of coverage. Nevertheless, that’s happening ever more frequently as Medicare plans are progressively establishing coverage limitations on elderly people – frequently outside of affirmation from the Centers for Medicare & Medicaid Services.
Considering that the appeals process for denied coverage can be so frustrating, unfortunately, a great many aging adults just accept the Medicare denial – at often an outrageously high financial impact, or even at potential risk to their health if required medicines are discontinued due to lack of Medicare coverage. As outlined by 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.”
Although a number 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 in which prescriptions are covered for other conditions – and preapproval is frequently necessary, or patients are given the requirements that less expensive methods must be tried first (also known as step therapy). Denials often happen because of a result of neglecting to satisfy these requirements.
So, what things can a senior try to obtain the drug insurance coverage to which he or she is entitled? There are a few key steps:
- First, obtain a formal insurance coverage determination from the person’s Medicare drug plan. Information on filing this request can be found by clicking here.
- After coverage is established, there will be 5 levels in the appeals process, outlined here.
- Keep detailed documentation throughout every phase of the process. For additional help, the Medicare Rights Center can help. You’ll be able to reach them at 800-333-4114.
Keep in mind that it’s important to be persistent. Usually, higher levels of appeals are approved even if preliminary steps result in unsatisfying outcomes. Call Heaven at Home Senior Care for further strategies and hands-on support for older adults. We are able to provide resources to help seniors as well as their families advocate for themselves, as well as specialized in-home care services to ensure that prescription drugs are taken exactly as prescribed, that prescription medication refills are taken care of, and much more. Call us at (940) 432-5670 and learn how you can keep your older loved one safe and thriving!