One of the aspects of losing the group health and prescription drug plans provided through IBM is we lost the help of the IBM HR employees that were assigned to shepherd us through various negotiations with insurance company claim denials. We are now on our own to figure out the myriad Medicare appeals processes.
My spouse's doctor just wrote a prescription for a new drug. When we took it to the pharmacy we were told it was denied because the brand name version of the drug is not on their formulary. The doctor was very specific - he wants the brand name version. As it happened, the brand name version of the drug was actually on the formulary until a couple of months ago. You may not know this, but part D insurance plans can change their formularies whenever they "want". Yes, they have to file paper work but then they can drop a drug they formerly covered "mid stream" in the plan year. Our illustrious congress passed laws in 2006 allowing them to do so. They also passed laws forbidding the government from negotiating with pharmaceutical companies to get drug discounts. The insurance lobby and pharma lobby are strong lobbies.
Anyway, what that means is even if you bought a part D plan that covers your drug - the insurance company can decide during 2014 to adjust their formulary any time they want and drop your drug from their list.
Because my spouse's plan dropped coverage for the brand name drug this year - they are required (by law) to provide a 30 day "transition refill" even though this is a new prescription for my spouse. If the drug were not on their 2014 formulary they would have just outright denied the drug. OK - so now what? In our case - the first step is to request an exception and ask that the brand name drug be covered for the rest of the year. The doctor had to write a letter for such a request to be even considered by the insurance company.
How do I put this politely? The letter the doctor wrote sucked. It didn't provide a compelling argument for why my spouse must take the brand name drug. I didn't tell the doctor it sucked as it would have been truly obnoxious - but I do believe the request will be denied because it was truly a lousy letter.
If the exception request is denied we will then need to go through the formal part D appeals process. If so, I will try to get the doctor's office to write a "better" letter at the next step. This might turn out to be a multi-step denial/appeal process. The truth is you do not get a fair decision until you get to the independent review board appointed by Medicare to review denials which will be the after the "3rd denial" for us. Insurance companies bet most people will give up after the first or second denial. DON'T DO IT. At least 50% of the time denials are overturned when they get to the independent review board.
How come I am so smart as to know a lousy doctor letter? Only because of the volunteer work I do at the Medicare Rights Center. Otherwise I would think it was just fine. Yesterday, ironically, I urged a caller to go back to her doctor to get a better letter for the next level of her appeal because the letter she read to me for her first appeal was truly lousy too. The Medicare Rights Center has a sample doctor letter:
You would think doctors know how to write these letters - sorry to say - they don't. The compelling argument has to be that there are significant health (and cost) implications to using a generic version of a drug. What is interesting is doctors might even tell you those implications but when it comes to writing appeal letters they go brain dead.
So the bottom line of this post - we've lost IBM advocates to help us with an onerous appeals process created by our legislators that make the navigation of the Medicare maze very difficult. It doesn't matter what your party affiliation might be. Congress acts as one when it comes to satisfying lobbyists and maintaining campaign contributions. You have to become your own navigator and expert. It's not easy but it will save you a lot of anguish and money so - just do it.
5/28/14 Update: A pleasant surprise! The exception request was granted! The insurance company left a message implying they talked to the doctor after getting the request so the letter wasn't an issue. My compliments to Express Scripts for making it so easy. The exception expires in May 2015 so we'll have to get another prescription plan in October to cover the drug unless Express Scripts is willing to extend the exception for all of 2015. At least we know it is covered for the rest of 2014. Nice.