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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.
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.
Here is an update with an example of our fouled up system.
After all I explained, today 2/21 in the mail we received a notice that our Rx appeal was denied. I was annoyed and prepared to send off a complaint, even contact the insurance commission.
Then Connie opened another envelope. That letter said the denial had been reversed and the drug was approved for a year.
The first letter was dated 2/13 and the second 2/18. But of course, arriving on the same day.
Our system is like “The Who’s on First” comedy act.
Dick, great explanation of the process you have gone through and why Good Rx many times does not save money for the patient with insurance.
Most pharmacies, especially independents, should offer to process the prior authorization(appeal) on your behalf. You should not have to call the Part D plan yourself. It is an automated process coordinated by a third party between the pharmacy, your healthcare provider, and the insurance company.
Great information about appeals, thanks, Dick
Way to fight for your rights, Richard! Thanks for the information on how to submit an appeal.
The process probably varies by Part D plan. Initially I was told I had to fill out a form, then have doctor complete a section. In the end it was just the call.
I think what they did was add drug to formula probably only to the extent it will go toward Medicare OOP, but I’ll take it.