My medicare d plan said my drugs would be covered and they have denied two of them, so far.?

Question

is this legal? i bought the expensive plan based on the advice of the insurance rep. after divulging a list of my medications. i am on my third appeal.

anyone else have a similar story. this one is for provigil. i will be appealing the denial for my marinol which i learned was denied today.

Answer 1

Yes, it's legal.

Some medications are, depending upon the company you have the Part D plan through, subject to prior authorization, step therapy, or quantity limits. The remedy for the denial will depend upon why the medication was denied. Oftentimes you'll need to get your doctor involved with the appeal. The company may listen to the doctor.

Answer 2

The insurance company should be informing you as to the reason for the denials.

Sometimes, insurance companies require that a cheaper version of the drug be tried first. If you've tried the less expensive versions of the drugs and cannot tolerate it or it does not work or if your MD has another reason why you can't take the less expensive version of the drugs, he/she should write a letter stating the reason(s) why you cannot take the less expensive versions and this should be submitted w/ your appeals.