CareWorks Health Services in California understands that 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 price tag of over $11,000 annually for the most typical prescription drugs prescribed for the elderly, it usually is debilitating when Medicare suddenly declines coverage. Nevertheless, that’s taking place a lot more frequently as Medicare plans are increasingly establishing coverage limits on older persons – frequently outside of approval from the Centers for Medicare & Medicaid Services.
Because the appeals process for denied coverage can be so complex, sadly, many seniors just accept the denial – at often an insanely high financial impact, or at potential risk to their health if required medications are stopped due to lack of Medicare coverage. As stated by 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 variety of medications must be covered by Medicare across the board (those for HIV/AIDS, depression, cancer, and seizures, to name a few), there’s a gray area by which prescription drugs are covered for other conditions – and preapproval is frequently necessary, or patients are given the specifications that cheaper options need to be tried first (also known as step therapy). Denials generally happen as a result of neglecting to fulfill these requirements.
So, what can a senior citizen do in order to obtain the drug insurance coverage to which they’re entitled? There are several important steps to take:
- First, request a formal insurance coverage determination from the senior’s Medicare drug plan. Information on filing this request can be found by clicking here.
- As soon as coverage is determined, there will be five levels in the appeals process, detailed here.
- Keep detailed documentation throughout every step of the process. To get more guidance, the Medicare Rights Center can help. It is possible to reach them at 800-333-4114.
Bear in mind it’s necessary to be persistent. Oftentimes, higher levels of appeals are approved even if initial steps generate disappointing outcomes. If you or a senior loved one is having issues with getting proper Medicare coverage, contact CareWorks Health Services in Orange County, CA for further suggestions and hands-on assistance for seniors. We can provide resources to help older persons and their families advocate for themselves, as well as specialized in-home care services to ensure that prescription drugs are taken exactly as prescribed, that prescription medication refills are handled, and much more. Call us at (949) 859-4700 and learn how you can keep your older loved one safe and flourishing!