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Medicare recipients win one

By Jennie L. Phipps · Bankrate.com
Thursday, March 10, 2011
Posted: 4 pm ET

Controlling health care costs is an increasingly important part of retirement planning. Even if you're already on Medicare, there can be expensive surprises. The most common is denial of payment for a prescribed drug -- affecting about 20 percent of Medicare participants -- says the Medicare Rights Center. Of those, about one in six, according to a recent study, are  for what's known as off-label uses. That means the drug is approved for a different ailment or even for a different age group.

In a decision published this week, a federal judge in the Southern District of New York, which includes most of New York City, held that regulations that bar Medicare drug plans from covering medically necessary, "off-label" prescription drugs is an "unsound interpretation" of the federal law providing drug coverage to Medicare recipients.

"This sets an important precedent for all people with Medicare," said Joe Baker, president of the Medicare Rights Center, in a statement. "Since the start of the Medicare drug benefit, the Medicare Rights Center has received calls from consumers who have struggled to obtain coverage of off-label, medically necessary drugs. This ruling brings us closer to removing a sizable obstacle to coverage of these drugs."

Being denied reimbursement for a medically necessary drug can be a financial blow for someone living in retirement. So if this happens to you, don't be afraid to fight back.

Here are the steps that the Medicare Rights Center suggests you take:

  • Get a substitute. Ask your doctor if there is another acceptable alternative.
  • Shop around. See if you can find the drug someplace else. The rights center points people toward NeedyMeds.org, a nonprofit resource for people who can't afford to pay for their prescriptions.
  • Ask for an exception. Your drug plan should have a procedure for this.
  • Launch an appeal. If you are denied an exception, appealing is the next step.

The Medicare Rights Center says that until you get in the later stages of appealing, you don't need any legal assistance -- just personal persistence. So if you find yourself in this situation, keep pushing. You could come out of this a winner.

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