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The “donut hole” (or coverage gap) is a gap in prescription drug coverage that occurs after the total cost of medications during the year has exceeded a certain amount. Please call us to discuss any questions you may have.

Your plan might require prior authorization for certain prescriptions to make sure they are used correctly. Before your plan will cover these drugs, your provider will need to contact your insurance provider and provide an explanation as to why the medication is medically necessary for you.

A quantity limit is a limit on how much medication you can get in a certain timeframe. Insurance companies place quantity limits on certain prescriptions for safety and cost reasons. If you are prescribed more than the quantity limit, your provider will need to send a medical note to the insurance company to prove medical necessity for the additional amount.

In some situations, certain vaccinations may be covered. However, most provider offices are unable to bill these claims to the prescription drug portion of your plan. Typically, most have an easier time obtaining coverage by getting vaccines from a pharmacy instead of the provider’s office. If you have questions about the specifics of your plan’s benefits, please call our team.

Step therapy is the process of treating a medical condition with the most cost-effective medication before progressing and providing coverage for a more costly medication. It is a type of prior authorization required by the insurance company.

A prescription drug deductible is the amount you must pay annually before you start paying the fixed copays as outlined by your plan. Not all Medicare plans have a prescription drug deductible. You can refer to your Summary of Benefits to determine the amount of your deductible and copay amounts.

Generally speaking, Part B covered medications include those administered by a doctor in an office or hospital setting and are determined medically necessary by a provider. Part D medications are generally maintenance medications that you take yourself (the kinds you pick up from the pharmacy). Please visit Medicare’s website to learn more.

If you are having trouble paying for medication costs, you may have options. If the medication is not listed on your formulary, it is possible for your provider to request a formulary exception from the insurance company by providing medical documentation for its necessity. Another is to contact the Social Security Office to determine your eligibility for a federal program called Extra Help. If you would like assistance or have further questions, please contact our team.

During a hospital visit, any routine prescriptions you need that are dispensed by the hospital are considered self-administered drugs. These medications are typically not covered by your hospital co-pay unless they are required for the hospital services you are getting, so you will most likely be billed for the full amount. Once you have paid your bill, you are able to request reimbursement from the Part D portion of your plan through a form called a Prescription Drug Reimbursement Claim Form. We advise you check the hospital’s policy on bringing in your own medications, which may allow you to avoid these types of bills. Please contact our team to learn more.