The possible implications of Medicare D(isaster)’s heavy reliance on generic rx’s, as opposed to prescriptions written DAW (Dispense As Written) are reviewed in an ealier diary.

Patients can also incur unnecessary stress, which can also cause/exhacerbate physical symptoms…changes to less expensive generic rx’s w/increased side effects, more office visits and additional testing are necessary to determine if aditional physical problems are a result.

One of the reasons for this could possibly be the compostition of generic rx’s as the medicine in the generics is the same, but the fillers are not.  For this reason, some patients are unable to take generics w/o experiencing severe side effects.  And, after conferring w/their doctor, their prescriptions are  written DAW (Dispense As Written) out of medical necessity.

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Medicare D(isaster) plans rely heavily on the cost of the rx’s in question as supporters claim it “lowers” the cost of rx’s.  However, this often conflicts with the best medical judgement of the treating doctor and the health of the patient.  For this very reason, the majority of prescriptions that are medically necessary to be written DAW need a prior-authorization.  On paper, it appears that a prior-authorization necessitates a phone call or the completion of a form.  In practice, it appears that the opposite may be true.

For an exception to obtain a necessary rx that is not covered under the formulary, one must go through five steps from hell/the five step appeal process.  This is CMS’s website for “guidance” through the appeal process.  This site was designed to assist physicians in preparing appeals for Medicare D(isaster) denials for necessary prescriptions.  Medicare D(isaster) is spread among too many insurance carriers, with each insurer establishing its own policy and procedures for appeals that conform to CMS regulations that there possibly could be variations in each.  (The site and a phone call made with a question refer a person to the insurance carrier’s site.)

This bears an eerie similarity to the earlier complaints about navigating the Medicare D(isaster) website and the difficulties that people have encountered when they attempted to obtain information to decide on a plan.  In spite of this, people who are in need of rx coverage are repeatedly hearing about the wonders of Medicare D(isaster) and not being informed about some of the changes in coverage and what the implications could be.  It is entirely possible that this coming month will be a repeat of early January and February, due to the strict interpetation of the formularies.

CMS spokesman Peter Ashkenaz stated that the government has been

“working with the plans and providers and pharmacists on a standardized, and hopefully simpler, form to request these exceptions and make appeals.”

Second, Ashkenaz claimed that Medicare has been reminding insurers that they should provide coverage for drugs not on their formularies until appeals from doctors have time to get reviewed.  However, this is not mandatory.

Third, Ashkenaz’s reminds Medicaid patients that they are able to switch plans as often as once a month, although no specific details for doing so are given.  If one decides to follow Ashkensaz’s “suggestion”, here are a some possibilities to keep in mind–all happenned to the same person!

  •  A Medicaid recipient could find him/herself in two plans, and have co-pays for each automatically deducted from a Social Security check, despite the fact that the original plan was notified of one’s wish to change to a different plan;
  •  The original Medicare D(isaster) insurance carrier may not want to “dis-enroll” a person that was auto-enrolled;
  •  The second insurance carrier may not send an card that designates rx coverage;

So, as a result of taking the Ashkensaz’s suggestion, a person still may not be able to receive his/her rx’s!  

And why is that?

…the government is responsible for the confirmation of any switching of Medicare D(isaster) plans.  For verification of this, a notice of disenrollment is sent to the original plan, and a notice of confirmation is sent to the plan that one switches to.  But, according to the NYT,

the government mistakenly sent both notices to the second plan, so the first plan did not know that the person had left its rolls…[resulting in] some plans…quit processing disenrollments because they could not tell which notices were valid.


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