Question: My doctor just prescribed me a new medication. The plan I have doesn’t cover it. Is there anything I can do since I can’t change plans until next year?
Answer: There are plenty of ways to solve your dilemma. First of all, you may indeed be able to change to a plan that covers your drug prior to 2020. If you are currently enrolled in PACE or PACENET, or if you qualify and apply, you can change plans right away. For those readers who don’t know, these programs are designed to reduce the cost of medications for seniors. Income limits are as follows: $29,108/year for a single individual and $38,716/year for a married couple. Agents at either of our office locations can help you determine if you qualify and apply, and we never charge a fee for that service or any others we provide.
If you are found to be eligible for PACENET, your problem is likely immediately solved. PACENET covers almost every drug on the market, where Medicare plans don’t cover as many.
Don’t panic if your income is over the limit. I’m confident you will find a solution by the end of the column. Most people don’t know this but all Medicare Part D prescriptions plans (sold as stand-alone policies or included in approximately 95% of Medicare Advantage Plans) are highly regulated and must allow the insured to file for an “exception to the formulary,” as well as other protections. If your doctor has a valid medical reason you need that particular drug (allergies, you have taken the others without success, etc.), in most cases they will have to cover it, minus your co-pay. Also, all Part D companies must offer an emergency 30-day supply of a prescription that is not on their formulary, giving you time to make other arrangements. Pharmacy employees often are unaware of this. They simply need to call the insurance company and ask for a one-time override so that script can be filled.
If you are not able to get the exception or even before you try, I suggest you do two things. First, find out what drugs your plan does cover as a substitute to the one you’ve been prescribed. Then consult with your pharmacist. Ask him or her how they feel about them a safe alternative. Also let them know that you would prefer something that comes in generic to keep the cost down. Then take that recommendation back to the prescribing physician. The feedback I have gotten from my clients who have done this is that their doctor almost always follows the pharmacist’s advice. Generally, when a drug isn’t on a formulary or is a higher tier, it’s due to it being an expensive brand name and is going to be costly even if it ends up being covered and likely to put you into the “Doughnut Hole.”
I also recommend doing the same if you are prescribed a brand name medication before you have tried a generic. Remember, just because the drug your doctor prescribed doesn’t come in generic, that doesn’t mean there isn’t one available you could take instead. Unless you are insulin dependent or have a more serious disease like Multiple Sclerosis, Cancer etc., there should be a generic option(s) that could work just as well for you. And again, taking a generic could literally save you thousands of dollars in co-pays and costs associated with the dreaded “Doughnut Hole.”
If all else fails, there are a couple more option out there for those in a situation where a drug isn’t covered or maybe unaffordable. There are many foundations and programs available to assist in paying for medications and the income limits are much higher than PACENET. Some don’t even have income limits.
Pharmaceutical companies and pharmacies hate when I mention this. You may also want to research and consider getting your prescription(s) from a Canadian Pharmacy. We have literally hundreds of clients utilizing them. You need to make sure you find a legitimate pharmacy however. There are several who are not reliable or reputable. We can give a recommendation for one our clients have been very pleased with and is also accredited. You will be shocked at the differences in prices. Often, you can buy drugs out of Canada without using any insurance for less than what your co-pay is here in the States. Many people who use a Canadian Pharmacy do it to simply save money. Others order from Canada to avoid hitting the “Doughnut Hole” or paying the ridiculously high prescription prices once they fall in it.
If going through Canada or any of the possibilities mentioned in the column aren’t an option, you certainly want to consider changing plans to one that covered that drug during the next Open Enrollment Period, which runs from October 15th through December 7th.