Mrs. allen has a rare condition for which two different brand name drugs are the only available treatment. she is concerned

General
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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?

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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 concerns about the high cost of her medication and the lack of generic alternatives are understandable. Here is a detailed guide on what Mrs. Allen should consider and the steps she can take to address her concerns:

1. Check Medicare Part D Formularies

Mrs. Allen should begin by checking the formularies (the list of covered drugs) of various Medicare Part D prescription drug plans. Each Plan D sponsor offers a formulary which can be different, so it is crucial to check multiple plans:

  • Visit the Medicare Plan Finder on the Medicare website (www.medicare.gov).
  • She can enter her specific medications and dosages to find plans that cover her drugs.
  • Compare the premiums, co-pays, and out-of-pocket costs of different plans.

2. Enrollment Periods

  • Ensure that Mrs. Allen is aware of the Initial Enrollment Period for Medicare Part D, which is when newly eligible individuals can sign up.
  • She can also make changes to her prescription drug plan during the Annual Enrollment Period (October 15 to December 7) or if she qualifies for a Special Enrollment Period.

3. Exception Requests

If Mrs. Allen’s current or chosen Part D plan does not cover one of her necessary medications, she has the option to request a formulary exception:

  • Her doctor can provide a statement explaining the medical necessity of the brand name drug due to her rare condition.
  • The plan must respond to the exception request within a specific period (usually 72 hours).

4. Consider Extra Help and Financial Assistance Programs

Mrs. Allen may qualify for financial assistance to lower her drug costs:

  • Medicare’s Extra Help program (also known as the Low-Income Subsidy) assists eligible beneficiaries with the costs of their Medicare prescription drug plan.
  • Pharmaceutical Assistance Programs (PAPs) offered by the drug manufacturers might provide her medications at reduced or no cost.

5. Explore Non-Medicare Coupons and Discounts

While these might not be compatible with Medicare, she can explore:

  • Manufacturer coupons or discount cards.
  • Websites such as GoodRx that offer discounts on prescription medications that might help temporarily.

6. Speak with a Medicare Counselor

Mrs. Allen can benefit from speaking directly with a Medicare counselor:

  • State Health Insurance Assistance Programs (SHIPs) offer free, impartial assistance to help understand Medicare plan options and can guide her through the process.

Final Answer:

To address Mrs. Allen’s concerns effectively, she should:

  1. Check multiple Part D plan formularies to find coverage for her medications.
  2. Consider an exception request if her medication is not covered.
  3. Look into financial assistance programs like Extra Help.
  4. Utilize discount programs for short-term relief.
  5. Consult with a Medicare counselor for personalized guidance.

By following these steps, Mrs. Allen can maximize her chances of finding a Medicare Part D plan that meets her needs and manage the high cost of her essential medications.