Medicare Corner
Know How to Fix Issues When Accessing Your Medications • Know how Medicare covers your drug. Call Medicare to find out which part of Medicare should cover your drug. Check if your Part D drugs are on your plan’s list, also called a “formulary.” Also check for any coverage restrictions, such as rules you must follow before your plan covers your drug. • Ask your pharmacist to submit claims to the right part of Medicare. Your pharmacist could be billing your prescription incorrectly. This could explain a drug coverage denial or why your pharmacist is having trouble with your plan. If your provider doesn’t know how to submit these claims, they can reach out to your plan or to Medicare for help. • Make sure your provider or pharmacist has the documentation they need. This is helpful for drugs that are covered differently depending on the situation. For example, if Part B should cover your insulin because you use an infusion pump to take it, you may need to show proof that you have an insulin pump. • Appeal any denial. You have the right to appeal Medicare’s or your plan’s denial. Ask your doctor to help prove your drug is medically necessary and that you meet the coverage criteria.
Be on the lookout for pharmacy fraud. A common example of pharmacy fraud is when a pharmacy bills Medicare for a drug you didn’t get. They could also refill a prescription you don’t need without you knowing it. For example, you don’t pick up the prescription, but the pharmacy still bills Medicare and gets paid. Another example is when a pharmacy gives you a different medication than what your doctor prescribed. A pharmacy could bill you for an expensive custom pain cream, instead of the cheaper generic one your doctor ordered. Pharmacy fraud could also happen when a pharmacy intentionally gives you less medication than your doctor ordered for you. It’s important to check your Medicare statements if there is concern about pharmacy fraud. Report potential fraud to your Senior Medicare Patrol (SMP).
Take Action: 1. Call 1-800-MEDICARE (633-4227) if you need help understanding how Medicare covers your medication. 2. Work with your provider or pharmacist if you have trouble getting your medication. 3. Call your State Health Insurance Assistance Program (SHIP) if you need help appealing a drug denial. 4. Call your Senior Medicare Patrol (SMP) if you have experienced potential fraud, errors, or abuse. PCOA is the local SHIP/SMP for Pima County and can be reached at (520) 546-2011 for more information.
July & August 2025, Never Too Late | Page 7
Pima Council on Aging
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