Medicare coverage of medicines for seniors is often crucial, especially because on average, older adults take a shocking 15-18 prescription medications. And with the standard pricetag of over $11,000 per year for the most common prescription drugs prescribed by doctors for the elderly, it usually is debilitating when Medicare suddenly declines coverage. Yet nevertheless, that’s taking place ever more frequently as Medicare plans are progressively imposing coverage limitations on seniors – frequently outside of affirmation from the Centers for Medicare & Medicaid Services.
Considering that the appeals process for denied coverage can be so intimidating, regrettably, many aging adults just accept the denial – at often an insanely high financial impact, or even at potential risk to their health and wellness if necessary medications are discontinued as a result of lack of Medicare insurance 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.”
Even though a number of prescription drugs must be covered by Medicare across the board (medications for HIV/AIDS, depression, cancer, and seizures, as well as others), there’s a gray area in which prescriptions are covered for other conditions – and preapproval is often required, or patients are given the specifications that less expensive measures have to be tried first (also called step therapy). Medicare denials frequently occur because of a result of neglecting to satisfy these requirements.
So, what can a senior citizen do in order to obtain the medication coverage to which they’re entitled? There are several key steps:
- First, ask for a formal coverage determination from the person’s Medicare drug plan. Details on submitting this kind of request can be found by clicking here.
- After insurance coverage is determined, there are five levels in the appeals process, detailed here.
- Keep detailed documentation throughout every phase of the process. For additional guidance, the Medicare Rights Center can assist. It is possible to reach them at 800-333-4114.
Keep in mind that it’s important to be persistent. Oftentimes, higher levels of appeals are approved even if preliminary steps bring about discouraging outcomes. Get in touch with North River Home Care in Cape Cod for more strategies and hands-on assistance for older adults. We can provide resources to help aging adults in addition to their family members advocate for themselves, as well as specialized in-home care services to make certain medications are taken exactly as prescribed, that prescription medication refills are taken care of, and much more. Call us at (781) 659-1366 and discover how to keep your older loved one safe and flourishing!