Question from Rick: My mother is being treated for rheumatoid arthritis, and her doctor is prescribing Rinvoq, which is not covered by her Medicare Advantage Plan. Is there something we can do to get it approved? 

Answer: There are several protections for consumers who have Medicare Advantage Plans and those on Supplements who buy Stand Alone Part D prescription policies when it comes to situations like this. 

Be advised that our clients, which Rick’s mother is, know to reach out to us whenever they have issues or questions about anything related to their policies as part of our customer services package we provide to those who allow us to enroll them in a Medicare, health, or life insurance policy. Today’s question comes directly from an email Rick sent me just last week.

I immediately forwarded it to Chelsea Bartholomai, one of our caring agents who got right to work. After researching the status of Rinvoq with the insurance company, she called the prescribing physician to inform him of the issue and what was needed to get Rinvoq approved. Thanks to Chelsea’s swift actions and the doctor and his staff’s prompt response and diligence, Rinvoq was approved for Risk’s mother within 72 hours of receiving the initial email. 

The following information and advice are for those who don’t have an agent who provides the same services and are forced to handle issues themselves. 

It’s very important to first understand when you go to the pharmacy to pick up a drug, the person who waits on you has no idea if a prescription medication is covered or not, what Tier it is, if the cost at the register is part of your deductible, etc. The only information they’re given is the dollar amount owed.

So, you go to the pharmacy to pick up a new prescription for the first time and are shocked at the cost, don’t pay it! Because if it isn’t covered, that expense won’t count towards the $2,100 out of pocket limit on Part D prescriptions for 2026. Call the Advantage Plan or Part D company first to find out why the price is so high. It very well may be covered, and the large initial cost is the deductible (up to $610) that most Advantage and Part D plans now have for Tier 3 through 5 drugs. While you’re on the phone with the company, ask for a list of Tier 1 and 2 medications that are in the same drug “class” or treat the same condition as the one that is subject to the deductible. Since Tier 1 and 2 drugs aren’t subject to a deductible and have $0 to $10 co-pays, that can save you thousands of dollars! 

If a prescribed drug is not in your plan’s “Formulary (list of covered drugs), it can still be covered, but there’s also another option. Again, a call to the Advantage Plan or Part D company should be made to get a list of covered medications in that same “drug class” as the one originally prescribed. The easiest action to take if you find yourself in this situation is to provide that list to your physician. Quite often, the doctor will simply recommend one of those, preferably a generic, to keep the costs down. However, if your physician has a legitimate reason why the original medication isn’t appropriate, which may include why the alternatives aren’t safe or won’t be effective, an appeal can be filed for a “Formulary Exception.” In most cases, these are successful. 

It’s also possible that the drug is subject to what is called “Step Therapy,” which is a tool that companies use to encourage or force people to try a less expensive drug before they will cover the other. This was the case for Rick’s mom. Rinvoq, that comes in tablet form, retails for $7,000 for a single month’s supply, which is just insane. I can’t blame an insurance company for encouraging their members to take an alternative. The medication the insurance company said she needed to try first was Hadlima, an injectable medication that had a retail of $885 for a month’s supply. 

If the prescribing physician has a legitimate reason why it isn’t safe or effective to take the alternative, an appeal can be filed to bypass the “Step Therapy” requirement and have the original medication covered immediately. I would imagine that because Hadlima is an injectable that needs to be self-administered and Rick’s mother was in her late 80’s, it might not be a safe option. The doctor quickly filed the appeal paperwork, and although we weren’t privy to what case he made to the insurance company, it was successful and the Invoq approved. 

One other protection consumers of Advantage Plans and Part D prescription policies have are “Tier Exceptions.” If you’re prescribed a drug that is a more expensive Tier 3 and you can’t afford, or would like to avoid, paying the $610 up front deductible and then hundreds more it will cost in ensuing months, you will once again want to reach out to your insurance company and ask for a list of Tier 1 and 2 drugs in that same “class” or that treat the same condition. If there are none, or they’re limited and you can’t take any due to a legitimate medical reason, an appeal can be filed to have the tier of the original drug prescribed lowered to a Tier 2 that isn’t subject to the deductible and has a $0 to $10 co-pay. 

If you have questions about today’s column or any other that are Medicare related give us a call, 724-603-3403, or email me personally. 

Do the same if you would like to inquire about becoming a client. There’s one prominent Pennsylvania Advantage plan company who will let you assign The Health Insurance Store as your agent of record with a simple form. In addition, Supplement plans can be changed all year round. With large premium increases just announced and more to come, many people should be looking to move to a new Supplement letter plan and company. Allowing us to advise and assist you in that process is another way to become a client.