Medicare coverage of medicines for seniors is often crucial, especially because on average, older adults take a shocking 15-18 prescription medications. And with an average price tag of greater than $11,000 annually for the most common drugs prescribed by doctors for the elderly, it could be devastating when Medicare suddenly denies coverage. And yet, that’s taking place ever more frequently as Medicare plans are increasingly enforcing coverage limits on elderly people – often outside of affirmation from the Centers for Medicare & Medicaid Services.
Considering that the appeals process for denied coverage can be so difficult, unfortunately, a great many seniors just accept the denial – at often an outrageously high financial impact, or even at great risk to their health if necessary medications are stopped because of lack of Medicare 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.”
Although several medications must be covered by Medicare across the board (those for HIV/AIDS, depression, cancer, and seizures, among others), there’s a gray area in which medications are covered for other conditions – and preapproval is often necessary, or patients are given the criteria that cheaper measures have to be used first (also known as step therapy). Denials generally occur as a result of neglecting to satisfy these requirements.
So, what things can a senior try to get the drug insurance coverage to which they’re entitled? There are several important steps:
- First, request a formal insurance coverage determination from the older adult’s Medicare drug plan. Details on filing this kind of request can be found by clicking here.
- When insurance coverage is established, there are 5 levels in the appeals process, specified here.
- Keep detailed documentation throughout every phase of the process. To get more assistance, the Medicare Rights Center can help. You can reach them at 800-333-4114.
Bear in mind it’s important to be persistent. Usually, higher levels of appeals are approved even though initial steps result in discouraging outcomes. Get in touch with Independence-4-Seniors Home Care’s caregivers for further ideas and hands-on assistance for older adults. We can provide resources that can help older persons as well as their families advocate for themselves, together with specialized in-home care services to make sure that prescription drugs are taken exactly as prescribed, that prescription medication refills are handled, and much more. Call us at (630) 323-4665 and discover how to keep your senior loved one safe and thriving!