Q. I'm trying to enroll in a drug plan and want to know which plans will cover my medications. When I called a few of the plans in my area though, they wouldn't let me read through my specific list of drugs to see which would be covered by their plan. Are they required to tell me?

—James

A. Dear James,

No, Medicare private drug plans are not required to confirm coverage of specific medications over the phone. Plans must post a current, shortened list of covered drugs (formulary) on their web site–updated at least monthly–and must mail their abridged formulary to anyone who requests it.

The abridged formulary must include at least two drugs in each drug class, even if the plan covers more. Formulary information must also indicate if the plan places certain restrictions on coverage of particular drugs, such as prior authorization, step therapy and dosage limits, but it does not have to explain how these restrictions work.

Only currently enrolled members have the right to get the entire formulary mailed to them upon request.

In addition to formulary information, plans must provide information to their members and prospective enrollees about their service areas, benefits offered under the plan, cost–sharing amounts (the amount they will charge you), transition policies, pharmacy network, appeals and grievances, and any other aspect of coverage.

This information must be provided in writing at the time of enrollment and annually after that, and it must also be available in writing upon request and on the plan's web site. The plan must also operate a toll–free number during business hours and be able to give you this information. In addition, plans and pharmacists are required to tell you if you could save money by using a generic drug.

Q. My mother was automatically enrolled in a Medicare private drug plan. As advised, she checked to make sure that it covered all her drugs and was told it did. But when she went to the pharmacy to refill her prescription, she was told she needed prior authorization for that drug. How can she get the medicine she needs?

—Nina

A. Dear Nina,

Because your mother is a new member, her Medicare private drug plan should cover a one–time refill of her drugs under its transition process.

While each plan must have a transition process, these processes vary with each plan. Generally, any plan's transition process should allow members to leave the pharmacy with a 30–day refill. They are entitled to get up to two more refills through the first three months they are in the new Medicare private drug plan (up to a 90–day supply).

To qualify for coverage under a plan's transition process, you must meet the following two qualifications:

1. You take a medication that is not on your plan's list of covered drugs (formulary) or your plan places certain restrictions on coverage of particular drugs, such as prior authorization, step therapy and dosage limits. (Note: transition policies do not apply to drugs excluded from Medicare coverage by law.)

2. You are a new member or recently changed your care setting (for example, you move from a hospital to a nursing home).

For details about your plan's transition process, check the plan's web site or call your plan to request this information in writing.

In order to bill for the prescription under the transition policy, the pharmacist will have to get an override code from your mother's Medicare private drug plan. To get long-term coverage of her medication, she will probably need to file an exception request. (Information on filing an exeption request in our next issue.)

For questions and problems you can begin at The State Health Insurance Program telephone numbers for Maine
toll free number: 800–262–2232
local number: 207–287–9200

A service of the Medicare Rights Center (MRC) (http://www.medicarerights.org) (the largest independent source of Medicare information and assistance in the United States. Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.
(reproduced at AbilityMaine with Permission)