Part D Plan Appeals

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If you have ever received a denial letter from your Medicare Part D plan for coverage of a medication you have been on for a good while, please know that you have options. You do not have to be held at the mercy of the Part D plan drug company if you cannot take an alternative medication on their formulary. This is my story…

During the last two months I have been dealing with the appeal process to get approval for my long-acting pain medication which my Medicare Part D Plan dropped from the formulary in January 2016. I used this plan last year and it covered all my medications except one. Considering the number of drugs I take I felt this coverage was very good. Because I was pleased with the coverage, I did not seek another Part D plan during the window Medicare patients can switch plans during Nov/Dec 2015 window. I was not notified by the Part D plan that they had dropped me from the premium plan to a savings plan which is why several of my once covered drugs were no longer covered. They stated they sent all their clients a letter but I did not get one… my word against theirs. Had I known they were making changes I did not authorize I would have compared plans during the open window when Medicare patients can change Part D plans. I did call Medicare to complain about the change of plan without my authorization and was told by the Medicare official that the Part D plan insurance company can change your plan at anytime in the year without your authorization, but they must notify you by letter.  This is a rather unfair practice in my opinion. If a drug company changes your plan in the year, you should then have an equal opportunity to seek a competitive plan!

I have been using the Butrans Transdermal pain patch for several years now for round the clock pain relief. It is in a classification of drugs that do not require a 30 day written prescription and can still be e-faxed to the pharmacy. This patch is worn 7 days at a time. When I received the letter from the Part D plan insurance company that they filled a one time 30 day supply of the patch but denied further refills because the drug was dropped off the formulary, my heart sank. You see, this drug made a huge difference in my life. My pain had become so severe that I was unable to sleep more than 2 hours a night and I was in bed an average of 3 days a week due to severe pain. Once my pain levels were brought under control through the use of this pain patch I got my life back! I no longer wake up unable to move because joints are locked. Although, I still have pain it is a tolerable 3-4 range most mornings on waking vs. 9-10 range it once was on the 0-10 pain scale. That is a vast improvement! Losing this patch I’ve been on for the last 3 years would have been devastating to me.

I started the appeal process fairly confident that my Part D plan insurance company would come to see reason and allow me to stay on this drug and cover it. I was surprised when the denial letter came in the mail with recommendations for medications covered on their formulary to which I am allergic or were unreasonable because the strength was too much (ten times the strength of morphine). I called the company and asked why I had been denied. I was told that I needed to contact my doctors office and let them deal with the appeal. This began a two month process in which multiple appeals were denied. My physician’s office had filed 5 first level appeals and they were all denied! I had called the insurance company 5-6 times myself only to be transferred to the incorrect party multiple times, to be given a case number that was non-existent when you called back to follow up, or to find that your appeal was denied because the physician’s office wasn’t open on a Sunday afternoon to meet the filing deadline on paperwork sent to them after hours the Friday before!

I was able to get an emergency refill of the Butrans patch after much haggling with the Part D plan representatives and then my appeal was denied again. When I called to ask the next step, I was told I needed to file a secondary level appeal but I was not told how to file this appeal. When I  asked how to file a secondary appeal I was given the run around time and time again. The insurance nurse representative at my doctors office was ready to rip her hair our because she had complied in filing every form they sent her. This nurse at my doctors office told me she had never dealt with a company that had denied appeals over and over when it was obvious the formulary choices they recommended were not appropriate. Finally I found through reading all the literature I’d been sent from Medicare, that a secondary level appeal is a independent appeal from a appeal company that works for Medicare, not the Part D plan insurance drug company! The Part D plan representatives could have given me this information but they chose to withhold it because they did not want to pay for this pain medication outside their approved formulary. After a one week period of reviewing my secondary appeal which just consisted of a letter containing my name, medicare number, and the reason for the appeal, this independent agency agreed the Butrans patch should be dispensed and the Part D plan must comply in allowing the medication to be dispensed through their plan!

So, you see, we have rights but you need to be informed. Read your Medicare handbook and don’t be afraid to call Medicare and ask questions. Do be wary when dealing with the Part D drug plan because they may not have your best interest at heart as they are a for-profit business. I can’t imagine what would have happened if I’d thrown up my hands and given up. I don’t want to think about those dark days of sleepless nights and pain so off the charts I wanted to die. We have rights.

 

 

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About Mischelle Jackson

I am a middle aged, single lady living with Rheumatoid Arthritis and other chronic illness which have led me into early retirement from a nursing career. I have a fur-baby, Jaycee, a Chihuahua, who makes me laugh and helps me get out of myself when I'm having a bad day. I crochet for relaxation when the RA allows. My faith sustains me.

One response »

  1. You are the first person I could find on the internet acknowledging this unfair treatment by drug plan companies changing their formulary after Medicare enrollment.

    My drug for asthma was dropped right after the enrollment period had finished and left me with no financial support for most of the year! This is a travesty and should be rectified.

    Medicare needs to address this problem!!

    I agree with you that “If a drug company changes your plan in the year, you should then have an equal opportunity to seek a competitive plan!”

    We are stuck until Oct 15 before we can enroll in a new plan, and of course they could change their formulary and your drug maybe dropped again, even with the new plan.

    Thank you so much for your information about a secondary level appeal. We need to spread the word and demand a change.

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