Seniors, can we talk?
“My prescription shows 5 mg 2 times a day. Why can’t I get that? Why do I have to get 10 mg and cut them in half?” Ruth said. I told Ruth that Medicare prescription plans have limits on the quantity of some drugs that they cover. This is known as “quantity limit” restrictions. I told Ruth to call the customer service number on the back of her ID card and ask for an exception. Her doctor may need to submit a quantity limit exception form for approval. If her request is not approved, she has the option to Appeal their decision. I’m thrilled Ruth called and told me about her situation. If you’re in a similar situation, you don’t have to continue cutting pills in half – make a call and ask for an exception. You may be able to get authorization for the higher quantity. Ruth and I also talked about the other two “management tools” or rules that Medicare prescription plans have for safety and cost reasons. Prior authorization is needed for certain drugs. This means that either you or your health care provider need to contact your prescription plan to find out if there is any specific criteria that must be met before your prescription can be filled. Your health care provider may need to show that the drug is medically necessary for you to take. Your prescription plan's formulary guide should show if you need prior authorization for a specific drug. Yes, this may be an extra step in the process but don’t consider it a “road block”. Step Therapy is the third management tool. Some plans require that you try one or more similar, lower-cost drugs to treat your medical condition before they will cover your prescribed drug. If your prescription plan's formulary guide shows that step therapy is used for a specific drug, your health care provider will have to submit a step therapy exception form for approval. Ok, so how does this step therapy work? Let’s say you take premarin (a hormone replacement drug) that has been around for a long time and is expensive. There may be other hormone replacement drugs that work as well but cost less. Your plan may require your health care provider to prescribe a lower-cost drug. If the lower-cost drug does not work, then the plan will either ask you to try another hormone replacement drug or they will just cover premarin. You can also work with your prescription plan and health care provider to get an exception. I told Ruth to check her 2016 formulary book to make certain drugs she knows she’s going to be taking in 2016 are covered. Do they require any of these “management tools”? Every year covered drugs are added and deleted. Ask questions NOW and be prepared for 2016. Need help walking through this to find out if your drugs are covered and if they require any extra steps? Call me at 501-868-6650 and say “Caroline, can we talk?”
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AuthorCaroline Beauchamp specializes in personalized life and health insurance solutions. Archives
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