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Retirement


IF A DRUG COPAY IS OUTRAGEOUS, MAYBE YOUR PART D PLAN DOESN’T COVER IT

Diane Omdahl
ContributorOpinions expressed by Forbes Contributors are their own.
I help people avoid costly Medicare mistakes.
New! Click on the conversation bubble to join the conversation Got it!
Oct 31, 2023,03:28pm EDT|

Are the costs of some of your drugs on your [+][-]
Medicare Part D drug plan giving you a headache?
getty

We are only two weeks into the Open Enrollment Period, and I have encountered
four clients who are very dissatisfied. They complain that the copayment for a
new drug is “insane” or “ridiculous.” In other words, they are paying way too
much. These clients have two things in common. One, they are all unhappy and,
two, the drug is not covered by their Part D plan.




They have questions about this situation so here are some answers.









WHY IS A DRUG NOT COVERED?

There are two reasons. This can happen whether you have a stand-alone Part D
drug plan or a Medicare Advantage plan that includes drug coverage.




1. The drug is not on the plan’s formulary (list of covered medications).

Medicare identifies protected classes of drugs, such as anticonvulsants and
antipsychotic, that every Part D and Medicare Advantage plan with drug coverage
must list on its formulary. Beyond those classes, a plan must cover at least
two. Two of these clients were taking insulin that was not on the plan’s
formulary.



2. The pharmacy is out-of-network.

Technically, the medication is covered but the pharmacy isn’t because it’s not
in the plan’s network and you pay full price.





WHAT ARE THE REPERCUSSIONS IF YOU TAKE A NONCOVERED DRUG?

The first, and probably most significant, is that you pay full retail cost. For
example, a common drug for blood clots has a retail price in one plan of $545. A
specialty medication for treatment of arthritis is over $6,000.

A second repercussion is more in the weeds. What you pay for this noncovered
drug does not move you through the Part D payment stages. If you pay hundreds of
dollars for a covered drug, you could land in Catastrophic Coverage and not pay
anything for medications the remainder of the year. But that won’t happen if a
drug is not covered. You’ll just keep pulling out your credit card.







WHY DID THIS HAPPEN?



The physicians sent an order to the clients’ pharmacy of choice that filled the
prescription and delivered it to the question this because rising drug costs are
just a sign of the times. It’s possible that the pharmacy staff was just too
busy to check or communicate with these individuals, which may be another sign
of the times.





WHAT CAN YOU DO TO PREVENT THIS?



 * Make sure the pharmacies you use are in your plan’s network.
 * Then, if the price seems out of line, ask a pharmacy staff member what’s
   going on.
 * Better yet, be proactive. Log into your medicare.gov account, add the drug to
   your list, and then check out the plan details. By clicking a couple links,
   you’ll see the coverage status and how much you can expect to pay.









WHAT CAN YOU DO ABOUT A NONCOVERED DRUG?

If the drug is not on your plan’s formulary, you have options.



 * For a brand-name medication, ask your doctor whether a generic equivalent
   might work. I have found that if there is an acceptable generic drug
   available, plans tend not to cover the brand.
 * Find out whether there are any other prescription drugs in your plan’s
   formulary that would be effective. This is what our two clients who take
   insulin are discussing with their physicians.
 * Ask your physician to submit a formulary exception, a request to obtain a
   Part D drug that is not included on a plan’s formulary. The physician’s
   statement must prove that the noncovered drug is necessary to treat the
   medical condition and no alternatives on the formulary would work. If the
   plan denies the request, there is an appeals process.
 * Check out whether a coupon or discount card would save money. You must do
   this outside of Part D coverage so tell the pharmacist not to process it
   through the insurance.
 * Pay for the drug out-of-your-pocket. This may be the last resort for a vital
   medication.
 * Investigate other plans during the Open Enrollment Period, October
   15-December 7. There’s a good chance you can find one that will work and save
   money in the process.




Get the best of Forbes to your inbox with the latest insights from experts
across the globe.
Check out my website or some of my other work here. 
Diane Omdahl

I have been helping people navigate the complexities of Medicare for more than
three decades. I am a nationally recognized Medicare expert, a registered nurse,
serial e…

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