Do you already have a health care plan or medicare? If so, your insurance should cover your basic healthcare needs. Hospitalization, surgery, and prescriptions should be covered.
But what if you need a prescription that isn’t covered by your insurance? Or, what should you do if you have reached the limit on your prescription coverage? How can you get extra help to cover your medications?
This article will answer those questions. I will go over where you can find extra help, who qualifies for certain assistance programs, and the application process.
There are programs available to those who qualify to help cover your prescription needs.
Read further to learn more about replacing your Medicare card.
Quick Navigation Article Links
- What Medications Does Medicare Cover
- What Is Considered As An “Extra” Prescription
- Where Can I Go To Get Extra Help With My Prescription
- What Is The Extra Help Program
- Who Qualifies For The Extra Help Program
- What Information Will I Need To Provide When Applying For The Extra Help Program
- How Can I Apply For The Extra Help Program
- How Long Does The Application Process Take
- When Will I Receive The Extra Prescription Coverage
- Do I Have To Keep Renewing My Coverage
- What If I Am Rejected For Extra Help
What Medications Does Medicare Cover
Part A and Part B Medicare can cover some medications and drugs depending on when they are used. Part A will cover drugs prescribed during a Medicare-covered hospital stay.
What Does Part B Cover
Medicare Part B will cover the majority of prescriptions you receive through your healthcare provider or a dialysis facility. Part B covers some outpatient prescriptions such as oral cancer drugs.
Part B should cover drugs infused through durable medical equipment (DME). These would be drugs received through a pump or nebulizer. Some antigens may be fully or partially covered by Part Bas long as they are prepared and administered properly with supervision.
If you are a woman with osteoporosis who meets certain qualifications for Medicare home health benefits, Medicare may cover injectable drugs. You must have your doctor certify that you need the injection and cannot give it yourself. You, your family members, or other caregivers must be unable or unwilling to give the injection for Medicare to cover the cost.
If you have End-Stage Renal Disease (ESRD) Medicare will help cover erythropoietin injections.
Medicare may help cover the cost of clotting factors you give yourself through an injection if you have hemophilia.
Medicare will hello cover nutrients fed through intravenous and tube feeding if you are unable to absorb nutrients.
Medicare helps to cover IVIG, and Intravenous Immune Globulin that is provided at home/ A medical professional must determine it is necessary for you to receive this treatment at home. IVIG will be covered, however, any other items or services needed may not be covered.
Shots or vaccinations may be covered. Immunosuppressive drugs and transplant drug therapy may be covered if Medicare covered the initial organ transplant.
Any other infused or injectable drugs may be covered by Medicare if they are administered by a licensed medical professional and are not commonly self-injected.
Other drugs that you are prescribed and need to pick up at a pharmacy can be covered by Part D. Part D can be used to cover many other drugs that Part A and Part B would not cover.
What Does Part D Cover
Medicare plans cover a variety of common drugs and prescriptions. Generic drugs, protected class drugs, Specialty Drugs, and addiction treatment drugs may be covered by Medicare.
Prescriptions such as drugs to treat cancer and HIV/AIDS are considered “protected class” drugs. They should be covered by most Medicare plans. Over-the-counter drugs like Tylenol, Aspirin, or laxatives are not usually covered.
Drugs that fall under different “tiers” or your specific plans’ “formulary” may or may not be covered.
A formulary is a list of what drugs your specific plan will cover. Your medical health insurance provider can change or edit the formulary at any time. So, a drug you need may be covered when you initially purchase your plan but the provider could later remove the drug from their formulary.
Drugs are organized in tiers based on the cost of the drug. For example, one medicare plan could list its tiers as:
- Tier 1 – lowest cost drugs, lowest copayment.
- Tier 2 – medium-cost drugs, medium copayment.
- Tier 3 – higher copayment, non-preferred, or brand-name prescription drugs.
- Specialty Tier – very expensive specialty drugs, highest copayment.
To confirm what drugs are covered you will need to read over your plan in detail. You should also request to see the formulary of any plans you are considering.
In certain situations you and/or your doctor may be able to request an exception or discounted payment for a specific drug.
What Are Considered Outpatient Drugs
Outpatient drugs are any prescription you receive from a doctor that you must go and fill at a pharmacy.
Click this link to view the 25 most commonly used outpatient drugs. It may be a good idea to confirm your health insurance plan covers these drugs.
What Are Considered Self-Administered Drugs
These are drugs and medications that you take yourself. Whether you take a pill, give yourself an injection, or use any other method to administer the drug to yourself.
Usually, Part B does not cover self-administered outpatient drugs. Only special circumstances are covered.
If Part D covers your self-administered drugs they will need to check where you got your prescription. They will confirm if you were given the drugs from an in-network pharmacy.
You may need to pay for these drugs out of pocket when you fill the prescription. You should be able to claim a refund later as long as your plan covers your drugs.
You may need to cover your plan’s deductible, any uncovered charges, copayments, or coinsurance charges for your treatment or drugs included.
If your plan does not cover the drugs you will need to pay the hospital or pharmacy and you could try to submit an excursion request to your provider. This, however, does not guarantee your provider will cover the drugs.
What Is Considered As An “Extra” Prescription
An extra prescription would be any medication or drugs that are not covered by your plan. You need to check the formulary and health insurance plan to confirm what medications are covered and what medications would not be covered.
If you need a medication that is not on the formulary, you may have to jump through a few hoops to get that medication covered by your healthcare provider. This can be very tedious and stressful, especially if you are currently sick.
It is advised to go over your health care plan(s) in as much detail as possible BEFORE you purchase them.
Where Can I Go To Get Extra Help With My Prescription
You have many options when it comes to getting help covering the drugs you need. Hopefully, you already have Medicare Part A and Part B. For the sake of this article, I will be providing options for individuals that already have Part A and Part B.
Read the subheadings below to learn more.
1 Contact Your State Health Insurance Provider To Get More Information
The first thing you can do is contact your provider to see what options are available to you and request assistance. A healthcare agent can work with you to inform you of your options or clarify what your plan covers.
Explain your situation in as much detail as possible. Your provider may have certain conditions a person must meet to get special coverage.
You should be able to find the contact information of your provider on your health care plan. Most plans offer a page where their contact information and your coverage is displayed.
2 Contact Your Provider And Request An Exception
You can contact your healthcare provider and send in a written request for an exception. You will need your doctor’s collaboration to do this.
This request when submitted by a medical professional is usually accepted. If your doctor provides evidence your drugs are medically necessary you will most likely be approved for a drug coverage exception.
You must submit a statement and any medical proof to show the drug is medically necessary. You can submit a tier exception request or a formulary exception request. You can submit the request verbally or in writing. However, if you submit the request verbally you may be contacted to provide a follow-up written statement.
Once you have submitted the request it will be processed within 72 hours. Your plan provider will notify you of their decision. If they decide to cover your medication they should do so within 14 days.
If your provider decides not to grant an exception they will explain why. You may then file for redetermination to try and receive an exception.
Click this link to learn more.
Go to the Medicare contact page, click here. You can file a complaint or request an appeal on your provider’s decision. You could call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
3 Purchase Another Healthcare Plan That Covers The Drugs You Need
If you have Plan A and Plan B, you may decide to purchase another medical plan to cover extra drugs. Plans such as Part C, Part D, or a separate health insurance plan can cover other medications and drugs.
You can enroll in a drug plan finder at that link and access other resources.
Make sure to read through your plan’s details and medication coverage list. Talk with your doctor to see if the plan is right for you.
4 Research Alternatives Your Insurance Covers
As mentioned before, there are different tiers of medications and different brands. An alternative medication or treatment may be covered by your health insurance plan.
Research all the drugs that could be used for treating your specific condition. You could also ask your doctor to look into alternative treatment options and present an option that would be covered by your plan.
In some cases, you may be able to trade a very high-cost brand-name drug for a similar drug that doesn’t have the brand name and costs significantly less.
5 Look Into The Extra Help Program
The Extra Help program will help cover the cost of your prescription drugs and medical costs. You must qualify for this program by being a US citizen or lawful permanent resident. You must fall within the max income limit and currently have Medicare. Read the next few headings to learn more about the Extra Help program.
What Is The Extra Help Program
The Extra Help Program is a program that helps individuals and families cover Medicare prescription costs. This program helps individuals save hundreds of dollars a year on Medicare and prescription costs.
In 2023, those who qualified for the Extra Help program are charged $4.15 or less for each generic drug they need. They are charged $10.35 or less for each name-brand drug.
These savings add up and help to lighten the burden many individuals and families feel when covering their medical costs.
You can qualify for partial or full Extra Help assistance based on your circumstances.
Who Qualifies For The Extra Help Program
To be eligible for the Extra Help program you must meet the following criteria:
- Your total assets and resources must be under $15,510 for an individual and under $30,950 for a married couple who currently live together.
- Yearly income under $20,385 for a single individual. Yearly income under $27,465 for a married individual.
- You have full Medicare coverage
- You get help to pay your Part B premiums through Medicaid
- You receive SSI benefits
Contact Medicare to learn more and see if you qualify for the Extra Help program.
If you have Medicare coverage and SSI or Medicare and Medicaid you do not need to apply for the Extra Help program. You should already be reconvening extra assistance with your Medicare costs.
What Information Will I Need To Provide When Applying For The Extra Help Program
You will need to provide documents that confirm your:
- Investments value (stocks, bonds, ETF’s, IRA’s, Mutual Funds, 401K, Savings Bonds)
- Property value
- Savings account balances
- Any cash you have at home or anywhere else
- Relationship status
- Documents that prove your identity
- Your spouse’s financial information and the value of their assets
What Does Not Count As A Resource
Your primary residence doesn’t count as a resource but any other houses you own will count toward your resources. Your personal possessions, vehicle(s), and jewelry do not count as a resource.
If you own multiple houses but rent them out for income or grow crops those properties are not considered as a resource.
Life insurance policies, burial expenses, or interest you earn on money saved to cover burial expenses are not counted as resources.
Retroactive Social Security payments you hold for 9 months are not counted. Housing assistance, the compensation you receive as a victim of a crime, or relocation assistance you hold for 9 months will not be counted.
How Can I Apply For The Extra Help Program
You can apply online or you can also call the SSA. Visit Medicare’s website by clicking here.
Call SHIIP at 1-855-408-1212. You can reach a Medicare agent Monday through Friday from 8 am to 5 pm. A Medicare counselor will provide important information and help you begin the application process if you wish.
Visit this link to apply online.
You can call the Social Security Administration at 1-800-772-1213. TTY users can call 1-800-325-0778.
What Does The Extra Help Program Cost
You will not have to pay for the Extra Help program. The aim of this program is to help struggling families or individuals cover their medical costs.
You may still have to cover premiums, deductibles, copayments, coinsurance, and certain outpatient drugs but the cost may be reduced.
Usually, though, people who qualify for extra help do not pay for their monthly premiums or deductibles.
It is estimated that the Extra Help program is work $5000 dollars a year per person. Many people qualify for the program without knowing it! Make sure to check if you are eligible and if so, begin the application process.
How Long Does The Application Process Take
Once you submit your application and the requested documents, the process should take between 3 – 14 days to process.
If you do not hear back after 14 days, contact 1-800-MEDICARE (1-800-633-4227)
When Will I Recieve The Extra Prescription Coverage
If you are approved for Extra Help partial or full coverage you will receive a Notice of Award. This is a written statement/letter that details your coverage and the start date.
This means your monthly premium will be lower, and your copays and deductibles should also be reduced.
Do I Have To Keep Renewing My Coverage
You will need to confirm that you are still eligible periodically. You will need to fill out the Review Of Your Eligibility for Extra Help form (SSA-1026B) and submit it. Please note, the link to form SSA-1026B is an example. Do not fill out that form and mail it in.
You will be sent a form in the mail to complete if the SSA would like to confirm your continued eligibility.
In that form, you will need to confirm your income, bank balances, investment amounts, and the value of any other resources you have. The form includes instructions on how to fill out your information and where you can mail the form.
What If I Am Rejected For Extra Help
If you will not be accepted into the Extra Help program you should receive a Pre-Decisional Notice before you are formally denied. This notice will detail why you are not eligible for Extra Help.
If you do not agree with the decision or think there has been a mistake you have 10 days from the date on the notice to contact the SSA to correct anything. You can contact the SSA by mail or phone. Phone, of course, would be faster.
Once the SSA has made its final decision you will receive a Notice of Award which will explain the level of assistance you have received or a Notice of Denial.
You can appeal a denial or particle coverage. It is recommended to appeal and not completely reply. If you win the appeal your coverage will be retroactive from the first day of the month you applied.
What Are The Steps To Appeal
- Contact the SSA to request a hearing or a case review within 60 days of your denial or partial coverage acceptance.
- Confirm a date for the hearing by contacting your local SSA office.
- Attend your hearing and present your evidence. Explain why you disagree.
- Wait to receive a notice from the SSA with their final decisions.
If you disagree with their second decision you can then appeal in a Federal District Court.
I hope you found this article informative and are able to use it to reduce your medical costs. Take a look at the references below to research more.