Don’t give up on your Part D costs

A few weeks ago I wrote about the Medicare Part D out-of-pocket limit of $2100.

When I went to fill Connie’s prescription last week I learned it was not on our plans formulary. I previously wrote it would cost $500 a month. It turned out it was almost $600. She needed the drug as it was giving her relief so I said I would pay cash. However, I used GoodRx The cost was then $529.

However, that meant no credit toward the $2100 out of pocket limit.

With little confidence of success, I decided to appeal to our drug plan to have the drug covered. I called, explained it all to the rep who entered it in his computer and told me it would go to Connie’s doctor and the drug plan review panel. We would be notified of the decision in a few days.

A week went by and nothing, our doctor had not received any request, so this morning I called again, explained it all again and amazingly I was told it had been approved.

The bad news is the co-payment is $488, not much gained there. However, it does mean the cost now goes toward our $2100 OOP limit. That’s a big win.

Now, could I get reversed what I had done before the formulary approval? Off I went to our Walgreens. They confirmed the drug was now covered and happily refunded the extra $40 I had paid. They resubmitted to the Part D plan and now we have credit toward the $2100.

There is a lesson here. It helps to be aware of the rules, the appeal procedure – there are always ways to appeal insurance decisions – keep good records of your claims and follow up when necessary.