Why Did My Medicare Plan Deny My Medication — and What Can I Do About It?

If you’re enrolled in a Medicare Part D or Medicare Advantage plan with drug coverage (MAPD), you expect your prescriptions to be covered — especially if you’ve taken them for years. But it’s not uncommon to be shocked at the pharmacy with a medication denial. In this post, we’ll explain the 4 main reasons plans deny medications and show you how to fight back or find better coverage.

 1. The Medication Isn’t on Your Plan’s Formulary

Every Medicare drug plan has a formulary — a list of medications it covers. If your prescription isn’t on that list, it won’t be covered unless you request a formulary exception.

 What You Can Do:

• Ask your doctor to submit a Formulary Exception Request
• Provide medical evidence explaining why this drug is necessary and no alternatives work

 Tip: Formularies can change each year. A drug covered in 2024 may be dropped in 2025.

 2. Your Drug Requires Prior Authorization

Some medications — especially expensive or high-risk drugs — require your doctor to get approval from the plan before it will be filled. This is called prior authorization (PA) and is designed to make sure the drug is:

• Safe for your condition
• Medically necessary
• Being used correctly

 What You Can Do:

• Ask your provider to submit the prior authorization request as soon as possible
• If denied, you can appeal the decision

 3. Step Therapy Is Required

With step therapy, the plan asks you to try a lower-cost or “preferred” drug first — usually a generic or similar option — before it agrees to cover the more expensive version your doctor prescribed. If you skip that step, the plan will deny the prescription until you go through the proper steps.

 What You Can Do:

• Try the lower-cost option first
• Or request a step therapy exception if:
  • You’ve already tried and failed that drug
  • Your doctor believes the “step one” drug is medically inappropriate

 4. Quantity Limits Are in Place

Medicare plans often place limits on how much of a drug you can get at once — especially for:

• Controlled substances
• Specialty medications
• High-cost therapies

If you try to refill too early or request more than the plan allows, your request can be denied.

 What You Can Do:

• Ask your doctor to submit a Quantity Limit Exception Request
• Provide medical documentation showing why a higher dose or larger supply is necessary

 How to Appeal a Medication Denial

If your medication is denied, you have rights under Medicare. Here's what to do:

 Step 1: Request a Coverage Determination

This is a formal request to your plan asking for an exception to the rule (for formulary, prior auth, step therapy, or quantity limits). Your doctor must explain why this drug is the only option that works for you.

 Step 2: File an Appeal if Denied

If the coverage determination is rejected, you can submit an appeal — with your doctor’s support — for a second-level review.

 Should You Switch Medicare Plans?

If your current plan frequently:

• Denies needed medications
• Has a restrictive formulary
• Adds roadblocks through step therapy or prior authorizations

... it might be time to switch plans during:

• AEP (Oct 15 – Dec 7)
• OEP (Jan 1 – Mar 31, if you’re in a Medicare Advantage plan)
• Or a Special Enrollment Period (if you qualify)

 FAQs: Medicare Medication Denials

1. Why do Medicare plans use step therapy and prior authorizations?

To control costs and prevent unnecessary use of expensive or risky medications — but it can delay care if not handled quickly.

2. What if I can’t afford the lower-cost alternative either?

You may qualify for Extra Help or Medi-Cal, which reduces drug costs dramatically.

3. Can I appeal a denial more than once?

Yes — there are multiple levels of appeal, and we can help you navigate them.

 Get Help From a Medicare Expert — No Cost to You

At Peace & Grace Insurance Services, we help clients:

• Understand why their medication was denied
• File the right requests and exception forms
• Compare and switch to better plans when needed

 Call/Text: 209-812-4026  Email: CSinsurepng@icloud.com  Proudly serving all counties in California.