Seniors across the United States are routinely facing a potentially scary situation; they are unable to get coverage for the medication they need. In many cases, a senior takes the same medication for a long time, and everything seems fine. Then, he or she goes to the pharmacy to fill the prescription as usual only to discover that the insurer no longer covers the drug. In too many cases, the affected party gives up and changes medication, but you don’t have to inconvenience yourself in this manner right away.
A Question of Policy
According to the Kaiser Family Foundation (KFF), almost 41 million Americans received prescription drug coverage as of the end of 2016. All drug plans must comply with a set of rules. For example, they must offer a wide range of drugs in the following categories:
- Anti-convulsive treatments for seizures
- Immunosuppressive medications
- Antipsychotic medications
In addition, plans can’t cover drugs for cosmetic purposes, including drugs for weight loss, coughs and colds, fertility, and sexual difficulties. They can’t cover non-prescription drugs either. Beyond these universal rules, drug plans have a lot of flexibility. For instance, plans can choose their own formulary, quantity limits, step therapy, prior authorization, and cost-sharing tier rules.
If patients and their drug of choice fail to meet all of these requirements, a denial is likely. For example, a drug plan might require the annual prior authorization of a drug. Refusal of the drug means you could lose your coverage.
One of the main reasons why patients suddenly have their drugs denied is because their plan updates its formulary. A formulary is a list of approved drugs covered by the plan. If a drug’s price skyrockets and a cheaper alternative is available, your plan will usually drop the more expensive option. If you happen to use the expensive drug, you’ll no longer receive coverage for it if your plan removes it from the formulary.
Insurance companies must provide plan members with adequate notice if they are planning to remove a drug from the formulary. They must also update their website. However, consumers are must keep up to date so they can plan ahead if an insurer removes their drug of choice.
Seniors Must Play Detective
Don’t assume that your insurer has followed the right process when refusing your drug coverage. In fact, a 2015 government audit revealed some staggering data regarding the behavior of insurers:
- 64% of plans added quantity limits that the CMS did not approve
- 41% of plans dealt with prior authorization or plan requirement exceptions incorrectly
- 70% of denial notices did not offer adequate reasons for taking that action, were incorrect, or were written in a manner that the reader couldn’t understand
- 45% of plans did not contact Medicare physicians or members to get more information when making a coverage decision.
In simple terms, seniors should not take a refusal lying down. You should supply the relevant materials to expedite the process and improve your chances of success. Your best bet is if your physician writes a letter that clearly and comprehensively states why you must take a certain medication. It is imperative that he/she outlines why you are at risk if you are not able to take that particular drug.
Navigating the Appeals Process
It is a mistake to believe that you conclusively have grounds for appeal if a pharmacy refuses to give the medication. In reality, you have to request a formal exception request from the plan before you can start the appeals process. You need a doctor’s letter when filing this request; your plan should reach a decision within 72 hours. If you believe your health is at risk by waiting three days, you can file another special exception request (expedited) to receive a decision within 24 hours.
You receive coverage if this request is successful, but if the plan refuses, it must send a Notice of Denial of Medicare Prescription Drug Coverage. You must start the formal appeals process within 60 days of the date on the notice. The appeals process involves five levels:
- Redetermination by your drug plan
- Reconsideration by an Independent Review Entity
- A Hearing conducted by an Administrative Law Judge
- The Medicare Appeals Council will review the decision
- A Federal District Court will also review the decision
Note that appeals can drag on for a very long time, so prepare to wait for a favorable outcome.
It is normal for the early stages of the process to cause you distress, but you should not give up, as appeals are often successful at the later stages of the process. In 2015, MAXIMUS, the independent reviewer, reversed 30 percent of drug plan decisions. For best results, keep meticulous records of every person you speak to, including what each says. Remain in close contact with your physician’s office and take note of your out-of-pocket expenses because you could recover them later on.
If you don’t want to appeal or else your appeal failed, don’t panic. In the vast majority of cases, you’ll find another drug on the formulary that works every bit as well. Of course, you can always change to a plan that has your drug on its formulary during the relevant Enrollment Periods.
Seniors should stay on top of health insurance news. Make sure you regularly visit your insurer’s website to see if your drug is still on the formulary. Although your plan is supposed to inform you of any changes, don’t rely on the company to get in touch. If you remain informed, there is a much lower chance of receiving a nasty surprise in the form of a denial at the pharmacy.