Why Medicare Part D Refuses to Cover Elquis: A Comprehensive Guide

Medicare Part D is often misunderstood, leading to frustration for many beneficiaries who discover that their prescription drug plans do not cover certain medications, such as Elquis. Understanding why Medicare Part D does not cover Elquis and what options are available can alleviate much of the confusion.

The Basics of Medicare and Part D

Medicare provides only partial coverage for prescription drugs. When you have Part D, which is a private insurance component of Medicare, you are responsible for paying for the Rx medications you need. Medicare does not require every Rx to be covered and does not pay for drugs unless you have purchased a private insurance plan (Part D).

What Medicare and Part D Do

Medicare itself is the federal health insurance program that covers most people over 65, and some younger individuals with disabilities. Part D, however, is a separate private insurance plan managed by the Centers for Medicare Medicaid Services (CMS), designed to provide coverage for prescription drugs.

Medicare's Role in Part D

Even though Medicare sets the rules and regulations for Part D, the actual coverage of specific drugs is determined by the private insurers who offer these plans. This means that Medicare does not mandate which specific drugs particular insurance plans must cover, nor does it pay for any drugs directly.

Why Medicare Part D Does Not Cover Elquis

Elquis (apixaban) is an anticoagulant primarily used to prevent dangerous blood clots and strokes. Because of the nature of how Medicare and Part D function, several factors can lead to Elquis not being covered:

The wrong Part D plan: You may have enrolled in a plan that does not cover Elquis. There are over 200 Part D plans available across the country, and each plan has a different formulary (list of covered medications). Formulary restrictions: Part D plans are not required to cover every drug. They are required to cover drugs in every category based on the federal government's guidelines. However, they do not have to cover every drug within that category. Deductible and copay limitations: Until you meet your deductible or your co-pay is waived due to a copay cap, you will be responsible for the full cost of the medication.

What to Do Next

Given that you are aware that Medicare does not pay for Part D medications, you have a few options:

Change your Part D plan: Medicare open enrollment periods occur approximately twice a year, allowing you to switch to a plan that better suits your needs, including one that covers Elquis. Look for prescription assistance programs: Many pharmaceutical companies offer assistance programs for their medications, which can significantly reduce the cost of Elquis. Explore government assistance programs: There are various programs designed to help individuals afford medications, such as the Medicare Savings Programs and the Low-Income Subsidy (LIS).

Conclusion

In conclusion, understanding the intricacies of Medicare Part D is crucial to ensuring that you have adequate coverage for your prescription drugs. If you are facing issues with Elquis coverage, consider switching plans during the open enrollment period or seeking additional assistance through prescription assistance programs and government benefits.