Medicare Rx: Getting Drugs After Your Transition Period
By: Source: AARP.org Date Posted: 2006-04-03 12:17:00-04:00
Effective April 1, some beneficiaries may experience new problems due to the reinstatement of prior authorization for some drugs. The Centers for Medicare and Medicaid Services (CMS) lifted the prior authorization of drugs for the last three months with the intention of lessening initial Part D implementation problems, but effective April 1 the process will begin to be enforced for all Medicare beneficiaries.
The following guidelines, provided by CMS, should help you get your Medicare Part D drugs after this transition period:
What if I am taking a drug that isn't covered by my plan, and I didn't switch to an alternate drug by March 31, 2006?
- Call your plan to make sure you understand the transition process and your rights.
- If your plan doesn't cover the drug you are taking now, it must cover an alternative drug that can work for you.
- If your physician believes that you need the specific drug you are taking now, then the plan must have a timely way for you to ask to continue with that drug.
- If the plan still doesn't allow you to continue with that drug, Medicare provides an independent review of your request. It's important to use this process if you want to continue your drug.
What can I do at the pharmacy counter if I didn't switch to an alternative drug by March 31, 2006, and I can't fill the prescription for the drug I'm taking now?
- Ask the pharmacist if there is a generic alternative. In most states your pharmacist can fill your prescription with the generic drug. In some states, the pharmacist must check with your doctor first.
- Ask your pharmacist why the drug is not offered.
- Ask your pharmacist if he or she can suggest an alternative drug that your plan covers.
- Call your doctor and ask about an alternative drug.
- If your doctor doesn't think the alternative drug will work for you, call your plan to ask for an exception.
- If it is urgent, ask the plan for an expedited review, which means they must make a decision in 24 hours.
- Ask your plan if they will cover a temporary supply of your drug until they make a decision.
- If you pay for a drug that the plan doesn't cover, and then your exception or appeal is approved, the plan is required to reimburse you up to the amount the plan would have paid if it covered the drug.
- If you have any other questions, call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Share
preview