mrs. allen has a rare condition for which two different brand name drugs are the only available treatment. she is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a medicare part d prescription drug plan that covers either one of them. what should you tell her?
LectureNotes said Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?
Answer:
Mrs. Allen’s concern about the high cost of brand-name drugs and the lack of generic alternatives is valid, but there are steps she can take to find a Medicare Part D plan that could potentially cover her medications. Here’s a detailed approach to guide her:
1. Conduct a Comprehensive Plan Search
- Mrs. Allen should review various Medicare Part D plans available in her area. The Medicare Plan Finder tool on the Medicare.gov website can be very helpful. By inputting her medications’ brand names into the tool, she can see which plans cover her specific drugs and view the associated costs, including premiums, deductibles, and copayments.
2. Check the Formulary
- Each Medicare Part D plan has a formulary, which is a list of covered drugs. Mrs. Allen must ensure that her medications are included in the formulary of the plans she is considering. Formularies can change annually, so it’s important to review this information every year during the Open Enrollment Period (October 15 - December 7).
3. Utilize Special Pharmacy Networks
- Some Medicare Part D plans work with specific pharmacies to negotiate better prices for brand-name drugs. By using the plan’s preferred pharmacies, Mrs. Allen might find reduced costs for her medications.
4. Consider Patient Assistance Programs (PAPs)
- Many pharmaceutical companies offer Patient Assistance Programs that provide drugs at reduced costs or even for free to eligible patients. Mrs. Allen should check with the manufacturers of her medications to see if these programs are available and if she qualifies.
5. Review Tiered Pricing
- Some Part D plans use tiered pricing for medications. Brand-name drugs might be placed on a higher tier with higher copayments. It’s essential for Mrs. Allen to understand the tier structure of any plan she is considering and evaluate the out-of-pocket costs for her drugs.
6. Apply for Extra Help
- The Medicare “Extra Help” program assists low-income individuals with the costs of Medicare prescription drug plans. Mrs. Allen should see if she qualifies for this additional support, which can significantly reduce her prescription costs.
7. Appeal for Coverage Determination
- If Mrs. Allen chooses a Medicare Part D plan that does not cover her required medications, she can request a coverage determination or exception. This process involves her healthcare provider submitting a formal request to the plan, explaining the medical necessity of the drugs.
Final Recommendation:
Mrs. Allen should start by using the Medicare Plan Finder tool to identify potential Part D plans that cover her medications. She should carefully review the formularies, consider using preferred network pharmacies, and explore patient assistance programs. If eligible, applying for the Extra Help program can also provide substantial financial relief. In cases where a plan does not cover her drugs, seeking a coverage determination may be necessary.
By taking these steps, Mrs. Allen can find a Medicare Part D plan that minimizes her out-of-pocket expenses and ensures she continues to receive her essential medications.