Can Medicare Part D deny coverage for a brand-name drug if a generic isn’t available?
Answered by 3 licensed agents
Medicare Part D can’t deny coverage for a brand-name drug just because a generic isn’t available—plans must cover it if it’s on their formulary and medically necessary, based on your doctor’s prescription, though they might require prior authorization or step therapy to justify it over other options. Upon enrollment, I always encourage my clients to call me if their medication regimen changes during the year so we can verify coverage details with the carrier and avoid surprises. I’ve dealt with this plenty, and as long as the drug’s listed and no generic exists, your plan has to honor it under CMS rules, but check your formulary or call your provider to confirm it’s not excluded or restricted. If it’s off-formulary, you’d need an exception, which can be a hassle but doable with your doctor’s help.
Answered by Brian Moore on March 27, 2025
Broker Licensed in OH
There is a Medicare rule that states (I am paraphrasing this): Should your Part D plan no longer offer a particular drug, they are required to sell you a one-month supply while you search the web (both US & Canadian discount websites) for a supplier who does include that (usually Brand Name drug) in their drug formulary. If you wish email me at [email protected], I'd be glad to send you my "Drug Discount Websites" digital file which I developed for the Medicare classes which I voluntarily have taught for many years at the University of AZ, here in Tucson.
You want to make sure all of your prescriptions are listed on the specific plans prescription formulary from the start.
Tags:
Coverage
Medicare Part D
Prescription Drug
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