Clarification to last column's answer:

While each plan must have a transition process, these processes vary with each plan. Generally, any plan's transition process should allow new members to leave the pharmacy with a 30–day refill. Persons who get a transition refill before March 1, 2006 are entitled to additional refills through March 31, 2006 (up to a 90–day supply) .

Q. I just got a new prescription from my doctor and when I went to fill the prescription, the pharmacist told me that this medication is not on my Medicare private drug plan's formulary. Is there anything I can do?

A. Yes, there are a couple things that you can do. First, you should ask your doctor if any of the drugs covered by the plan would work for you. If so, ask for a new prescription for that drug.

Second, if your doctor feels that only the drug originally prescribed will work for you, you should file an exception request.

You have the right to an exception to the plan's formulary (list of covered drugs) when

  – your doctor prescribes a drug not on your plan's formulary because your doctor believes the drugs on the plan's formulary will not work for you; or

   – you are using a drug covered by your plan, but that drug is removed from your plan's formulary for reasons other than safety.

You generally cannot file an exception request at the pharmacy. You must call your Medicare private drug plan directly to request an exception. (You, someone you appoint, your legal representative or your prescribing doctor can file an exception for you.)

Your doctor will have to submit an oral or written statement certifying that the drug prescribed is medically necessary because other drugs are not as effective or may be harmful for you.

Generally, plans must grant these requests when they determine that it is medically appropriate to do so. Plans must respond to your request in writing within 72 hours or sooner if your health requires quicker attention.

You can also ask for a faster response (an expedited request) when your "life, health or ability to regain maximum function" is in jeopardy. (Plans must expedite exceptions if your doctor certifies that such action is necessary for your health.) Plans must respond to expedited requests within 24 hours or sooner if your health requires such immediate attention.

If a plan grants your request, it determines what your copayment will be for that drug. The plan must continue to cover refills at that copayment for the rest of the calendar year as long as the doctor continues to prescribe that drug, and it continues to be safe. It is up to the plan to decide whether you have to file a new exception request for that drug the next calendar year (if you renew membership).

If your Medicare private health plan denies your exception request, you can appeal the plan's decision to Medicare.

Notes:

   – You cannot ask for an exception for drugs specifically excluded from Medicare coverage by law.

   – You can request an exception to get a lower copayment for a drug assigned to a higher-cost tier that is already included in your drug plan's formulary. But if you had to request an exception to get your plan to cover your prescription, you cannot then file a second exception to get a lower copayment for that drug.

   – You can request an exception to other coverage restrictions, such as dose and dosage limitations, substitution requirements and step therapy.

Next, learn more about how Medicare drug plan formularies work!

Help your doctors help you. Give them the Medicare Rights Center's handout "What Physicians Need to Know to Ensure Their Medicare Patients Get the Drugs They Need"
( http://www.kintera.org/TR.asp?ID=M714295848099374124216565)
and the easy–to–use form letter "Physician's Exception Request Letter on Behalf of Their Patients to the Private Drug Plans."
( http://www.kintera.org/TR.asp?ID=M714295858099374124216565)

Q. My dad is on a number of medications, all of which are covered by his Medicare drug plan. Yet the copayments are still quite expensive. Is there a way he can lower these costs?

A. Yes, there are a number of things he can do to try to lower his costs. One option is to try mail order if your father's drug plan allows that. Mail order can often be cheaper than buying at the local pharmacy.

Your father should also talk to his doctor. He can ask if there are generic or cheaper brand–name versions of the drugs he is taking that are covered by his plan. That could lower his out–of–pocket costs a lot.

If your father's doctor believes no other covered drug will work for him, he has the right to ask his Medicare private drug plan to lower his copayment for that drug. He can also do this if the copayment is suddenly raised for any covered drug he has been using.

By asking to lower the copayment, your father is asking the plan to change the "tier" that the drug is assigned to in the plan's list of covered drugs (formulary). Most plans have different cost–sharing tiers. Lower tiers have lower out–of–pocket costs and usually include generic versions of the drugs. Higher–tier drugs will cost you more because they generally include the more expensive brand-name drugs.

Your father can ask his plan to lower his copayment by filing an exception request. This works in much the same way as a request to have the plan cover a drug that is not on its formulary (see question answered earlier in this article). For more information about how to ask for a lower copayment, your father should check with his individual plan–each plan will create its own process. In all plans, however, your father will need his doctor to certify that only that drug will work for him.

If you need to report a plan that is not following Medicare rules, you should e-mail your regional Medicare Part D Assistance Center at BostonPartDInquiries@cms.hhs.gov. Be sure to include specifics about the incident, including time, date, names (if possible) and the nature of the problem. Also, you should call 1–866–RXMAINE 1–866–796–2463 Maine’s Pharmacy Help Desk.

Medicare Drug Benefit: Helping or Hurting?

The Medicare Rights Center is collecting stories about the new Medicare drug benefit for the Medicare Rights Center's Part D Monitoring Project. Is it working for you and your loved ones? If not, why?

Tell us about it by visiting http://www.medicarerights.org/partdstories.html
( http://www.kintera.org/TR.asp?ID=M714470178099374124492365).

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)