CASE FLASH: PART D DRUG EXCEPTIONSMs. R is enrolled in a Medicare private health plan with prescription drug coverage. She has high blood pressure and diabetes. It took a lot of trial and error for Ms. R and her doctor to find a medication that controlled Ms. R’s blood pressure but did not produce negative side effects that complicated her diabetes. Ms. R and her doctor finally found one medication that worked, and Ms. R had been taking it for about a year. Early in October of this year, Ms. R received a letter in the mail from her Medicare private health plan saying that beginning in January of next year the plan will no longer cover her blood pressure medication. Ms. R called the Medicare Rights Center and spoke to a counselor about the letter she received from her plan. The counselor explained to Ms. R that Medicare private drug plans can change their formularies, or lists of covered drugs, at any time. However, if your doctor can explain to your plan (request an exception) why no other prescription drug on its formulary will work for you, your plan should cover the prescription. The counselor told Ms. R to ask her doctor to write a letter to her health plan explaining the medical necessity and her medical history. The hotline counselor urged Ms. R to keep a copy of the letter that her doctor wrote for her records. The MRC counselor also reminded Ms. R that she always has the option of switching her Medicare private health plan during the Annual Coordinated Election Period (November 15 to December 31), either to a new Medicare private health plan or to Original Medicare with a stand-alone prescription drug plan (Part D plan). Ms. R contacted her doctor, who wrote a very persuasive letter to Ms. R’s health plan. In the end, the health plan made an exception and agreed to cover the prescription for her for the following year. -From Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 10, No. 21: October 16, 2007.
10/07