MEDICARE D CONSUMER RIGHTS: DRUG STABILIZATION

Case Flash: Mid-Year Changes To Drug Coverage

Ms. V has both Medicare and Medicaid and takes more than 30 different prescriptions each month. In January 2006, she chose the Medicare drug plan that covered the greatest number of her prescriptions. Recently, one of Ms. V's prescriptions was taken off of her drug plan's list of covered drugs ("formulary"), and when she tried to pick up a refill at the pharmacy, Ms. V was told that her plan would no longer help her pay for that drug. Ms. V called her local State Health Insurance Assistance Program (SHIP) for help.

A SHIP counselor told Ms. V that the information that she got from both her Medicare drug plan was wrong. Once you have been stabilized on a drug (you have filled a prescription for it at least once before, and a long period of time has not passed between prescriptions), your drug plan must continue to cover that drug for you even if the plan takes it off of its formulary. Ms. V's drug plan should not have denied her coverage for her prescription because she had been taking that drug consistently since she first joined the plan.

-From the Medicare Rights Center. To read more cases by subject, go to "Interesting Cases" at www.medicarerights.org/interestingcasesframeset.html

11/06