Stuck With a Bad Medicare Part D Plan? Here's What You Can Do

Many things can make you feel like you are trapped in a lousy Medicare Part D plan. High drug costs, coverage denials, or losing a preferred medication can leave you feeling helpless.

Fortunately there are steps you can take right now to fix the problem. These actions can help you avoid wasting money in retirement.

Take advantage of special enrollment periods to change plans

If you experience certain events — such as your plan dropping coverage of your drugs, or your own decision to move to a new state — you may qualify for a special enrollment period (SEP) that allows you to change your Part D plan.

These SEPs let you bypass the yearly enrollment window and pick a plan that suits your needs now.

Appeal coverage decisions

If you are denied coverage through Medicare and feel the decision was unjust, you can appeal.

When appealing the decision of a Medicare drug plan, you may face as many as five levels of appeal. The first level is known as a "redetermination," and it can be made by you, your prescriber or a representative.

The standard waiting period for an appeal decision is seven days, but you can ask for an expedited appeal if you are concerned that waiting might harm your health.

Request formulary exceptions for non‑covered drugs

If a drug you need is not covered, you may request a formulary exception. For example, if your plan stopped covering your $300 diabetes medication, you and your physician can request an exception and cite the fact that no alternative works.

If the plan deems the drug to be medically necessary, it will grant the exception request.

Access manufacturer discount programs and patient assistance

Drugmakers often offer coupons, copay cards, or patient support programs to offset high costs. However, the law states that such coupons cannot be used with Part D plans.

There may be situations where a coupon saves you so much money that it makes more sense to use the coupons on your medication and skip having Medicare cover the prescription.

If your income is low, you also might qualify for cheap or even free medication through a patient assistance program (PAP). However, not all states offer such programs.

Compare costs at different pharmacies within your network

The cost of medications often varies significantly from pharmacy to pharmacy. So, always compare costs at local pharmacies, mail order options, or even big-box chains.

Regular price-checking ensures you're not overpaying needlessly.

Use Medicare's low-income subsidy program if eligible

The Low-Income Subsidy (LIS) program — also known as "Extra Help" — subsidizes Part D premiums, deductibles, and copays for those with limited income and assets.

Some people — including those eligible for Medicaid or Supplemental Security Income (SSI) — are automatically enrolled in the program. But you can also apply for the program through the Social Security Administration (SSA).

Switch to generics with doctor approval

Generic drugs cost far less than brand names, often just a fraction of the price. Yet, they provide the same level of treatment as more expensive brand-name alternatives.

Ask your doctor whether a generic is available for your medication. Switching can immediately reduce costs without sacrificing care.

Calculate if paying out-of-pocket is cheaper than copays

Sometimes paying out-of-pocket for low-cost generics may be cheaper than facing the copay charged by your Part D plan.

Compare retail cash prices online or directly call pharmacies for quotes and use those findings to inform your strategy. If cash is cheaper, pay upfront and skip the insurance.

Bottom line

You aren't powerless if a Part D plan stops covering your medications, hikes costs, or denies care.

Leveraging SEPs, filing appeals, and using discounts or generics all can help you get costly drugs covered. Take action today to make your Medicare Part D plan work for you and help ensure a stress-free retirement.

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