Medicare's coverage of Gastrocrom is limited and depends on which part of Medicare you have

Gastrocrom (cromolyn sodium) is a medication that prevents symptoms of mastocytosis, a rare condition where mast cells build up in the body and release chemicals that cause itching, flushing, and digestive problems. Medicare Part B covers Gastrocrom only when it is given by injection in a doctor's office or hospital outpatient setting. If your doctor prescribes Gastrocrom as an oral capsule or solution to take at home, Medicare Part B does not cover it, and you would need to check your Part D prescription drug plan instead.

The coverage difference matters because the injectable form is less common than the oral form. Most people with mastocytosis take Gastrocrom orally at home. If that is your situation, your out-of-pocket cost depends entirely on which Part D plan you chose during your last enrollment period — some plans cover it with a copay, some require prior approval from the insurance company, and some do not cover it at all.

Key Takeaways

  • Medicare Part B covers Gastrocrom only when injected in a medical setting, not when taken as a pill or liquid at home.
  • If you take Gastrocrom orally, coverage comes from your Part D prescription drug plan, and coverage varies widely between plans.
  • You can call your Part D plan directly to find out whether Gastrocrom is on their formulary and what your copay would be.
  • If your plan does not cover Gastrocrom, you can ask your doctor to request a prior authorization or switch to a different Part D plan during open enrollment.

How Part B covers Gastrocrom in medical settings

Part B covers Gastrocrom when a doctor or nurse administers it by injection in a hospital outpatient department, ambulatory surgery center, or doctor's office. You pay the Part B coinsurance (usually 20 percent of the Medicare-approved amount) after you have met your Part B deductible for the year. The facility bills Medicare directly, so you do not pay upfront and then wait for reimbursement.

This coverage applies only to the injectable form. If your doctor believes the injection is medically necessary — for example, if you cannot tolerate the oral form or if you have severe mastocytosis — ask whether your doctor's office can administer it. Some practices do; others refer patients to a hospital outpatient center. Either way, make sure the facility is in-network with Medicare to avoid surprise bills.

Part D coverage for oral Gastrocrom at home

If you take Gastrocrom as a capsule or oral solution at home, your Part D prescription drug plan decides whether to cover it. Each plan has a formulary — a list of drugs it covers — and Gastrocrom is not on every formulary. Some plans cover it with a standard copay (often $15 to $50 per month, depending on the plan). Others require prior authorization, meaning your doctor must submit a request to the insurance company explaining why you need Gastrocrom before the plan will pay for it. A few plans do not cover it at all.

To find out what your specific plan covers, call the customer service number on the back of your Part D card. Have your prescription ready so you can give the pharmacy name and the dose your doctor prescribed. The plan representative can tell you whether Gastrocrom is covered, what your copay is, and whether prior authorization is required. This call takes about 10 minutes and saves you from finding out at the pharmacy that your plan will not pay.

What to do if your Part D plan does not cover Gastrocrom

If your current plan does not cover Gastrocrom or requires a copay you cannot afford, you have two main options. First, ask your doctor to submit a prior authorization request. Even if the plan's formulary does not list Gastrocrom, the insurance company may approve it if your doctor documents that you have tried other treatments and they did not work, or that you have a medical reason you cannot take them. Prior authorization decisions usually come back within 72 hours.

Second, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year). Before you switch, use the Medicare Plan Finder tool on Medicare.gov to compare plans in your area and see which ones cover Gastrocrom. You can also call 1-800-MEDICARE to ask a representative to search for plans that cover your specific medications. Switching plans takes effect on January 1 of the following year.

The cost difference between plans

Part D plans vary widely in what they charge for Gastrocrom. One plan might cover it with a $25 copay per month; another might charge $100 or more. Some plans place Gastrocrom on a higher tier, which means you pay a larger share of the cost. The monthly premium you pay for the plan itself also differs — a plan with lower premiums might have higher copays for specific drugs, and vice versa.

When you compare plans during open enrollment, look at the total cost: the monthly premium plus what you would pay out of pocket for Gastrocrom and any other medications you take regularly. The cheapest plan is not always the best plan if it does not cover the drugs you need. Medicare.gov's Plan Finder lets you enter your medications and see the estimated yearly cost for each plan.

What to ask your doctor

Before you fill a Gastrocrom prescription, have this conversation with your doctor: "Does my insurance cover Gastrocrom, and if not, is there another medication that treats mastocytosis that my plan does cover?" Your doctor may know from experience which plans in your area cover Gastrocrom, or they may suggest an alternative. Some doctors also have samples of Gastrocrom in the office that they can give you while you work out coverage with your insurance company.

If your doctor believes Gastrocrom is the right medication for you and your plan will not cover it, ask whether they can submit a prior authorization request. Provide them with your insurance information and the name of your plan. The prior authorization process does not cost you anything, and it sometimes succeeds even when the formulary says no.

When to contact Medicare directly

Call 1-800-MEDICARE if your Part D plan denies coverage for Gastrocrom after your doctor submits a prior authorization request. Medicare has an appeals process, and you have the right to ask for a review. You will need your claim number (on your denial letter) and your doctor's clinical notes explaining why Gastrocrom is medically necessary for you. The appeals process can take 30 to 60 days, so start it as soon as you receive a denial.

You should also contact Medicare if you believe you were charged incorrectly for Gastrocrom at a hospital or doctor's office. If you received an injectable dose and paid more than the Part B coinsurance, or if you were balance-billed (charged the difference between what the provider charged and what Medicare paid), report it to Medicare. Keep your receipt and the explanation of benefits letter from Medicare.

Frequently Asked Questions

Can I get Gastrocrom without a prescription drug plan?

If you are on Original Medicare (Part A and Part B) but did not enroll in a Part D plan, you can still get Gastrocrom, but you will pay the full pharmacy price out of pocket. You can enroll in a Part D plan during the annual enrollment period or if you have a may have access to life event. If you missed the important date, call 1-800-MEDICARE to ask about your options.

Does Medicare Advantage cover Gastrocrom differently than Original Medicare?

Medicare Advantage plans (Part C) include prescription drug coverage built in, so coverage depends on that plan's formulary. Call your Medicare Advantage plan's customer service number to ask whether Gastrocrom is covered. The copay and prior authorization rules may differ from Original Medicare Part D plans.

What if the pharmacy says my insurance will not pay?

Ask the pharmacy to contact your insurance company directly to confirm the denial. Sometimes there is a processing error. If the plan truly will not cover it, ask the pharmacy whether they have a generic version or a discount program. Some pharmacies also offer cash prices lower than the retail price if you pay out of pocket.

Can I use a manufacturer coupon or discount card for Gastrocrom?

If your Part D plan covers Gastrocrom, you cannot use a manufacturer coupon — you must use your insurance. If your plan does not cover it and you are paying out of pocket, you may be able to use a discount card or coupon from the drug manufacturer. Ask your doctor or pharmacist whether one is available.

What happens to my Gastrocrom coverage if I switch Medicare plans?

Coverage can change when you switch plans. Before you switch, use Medicare.gov's Plan Finder to confirm that the new plan covers Gastrocrom. If you switch and the new plan does not cover it, you have 60 days to switch back to your old plan without penalty.