The fifth article in the aakpRENALIFE series on the Medicare prescription drug benefit.

In this latest article on the Medicare drug benefit, we’ll examine “start up” problems that you or a family member may face – and some solutions.

Two-and-a–half months ago, on Jan. 1, the new Medicare drug benefit went “live.” Today, more than 15 million Medicare beneficiaries are enrolled in a drug plan – about 10 million in a “stand alone” prescription drug plan (PDP) and more than 5 million through a comprehensive Medicare health plan. Another 250,000 beneficiaries sign up each week.

The Medicare program says most people enrolled in a drug plan have had few problems, or have been able to fix any problem quickly. But as might be expected with any big, new program, there have been rough spots during start up – some which uniquely affect kidney patients, especially transplant patients. And starting April 1, Medicare beneficiaries will face a new challenge in getting their medicines as drug plans enforce their formularies.

Despite hassles with the new Medicare drug program, consider these two important points:

First, we repeat our earlier advice, getting up and running with a Medicare drug plan may be challenging – so AAKP encourages everyone to relax and take a deep breath! Medicare drug plans are a great deal for most kidney patients. Finding and making a Medicare drug plan work for you or a family member is definitely worth the effort!

Second, you should never go without the prescriptions you need. That’s why you have signed up for a Medicare drug plan. It’s important to know your rights and how a plan works – and many problems can be fixed at the pharmacy window or by contacting your drug plan or Medicare.

Here’s some general advice for getting help with a Medicare drug plan. First, start with your drug plan, which will have a free 1-800 number. You can also call the Medicare helpline at 1-800-MEDICARE (1-800-633-4227). If your problem is urgent, you may need to be very firm with the customer service representative.

In addition, it’s sometimes helpful to have an “advocate” on your side. You may ask your dialysis clinic social worker or transplant social worker if they can help – or recommend someone who can. Every state runs “SHIP” counseling program that provides assistance to people with Medicare and their families. For the phone number of your local program, check out SHIP finder online by clicking here.

Here are five problems people have reported with the Medicare drug plans:

• Confirming enrollment in a Medicare drug plan at the pharmacy window.
• Being charged drug co-pays that are too high – a problem for people with low co-pays because of Medicaid or extra financial help.
• Confusion between Medicare Part B and Medicare drug plan (Part D) coverage for immunosuppressive drugs.
• Confusion overMedicaid payment for drugs – especially immunosuppressive drugs – for former “dual eligibles” who no longer have Medicare and don’t qualify for a Medicare drug benefit.
• Restrictions on drugs that are covered by a plan (formulary coverage).

First Problem
At your pharmacy, you have a problem filling your prescription because the pharmacy can’t confirm you are in a Medicare drug plan. This has been a particular problem for dual eligibles – “government speak” for people with Medicare and Medicaid and who were automatically transferred from Medicaid to a Medicare drug plan.

Solution: If you don't have a membership card yet, show the pharmacist the letter you received from your plan that confirms you are enrolled. If you don't have a letter, ask your pharmacist to call 1-800-MEDICARE (1-800-633-4227). The customer service representative can tell the pharmacist your plan. If you are dual eligible, the pharmacist can call a special hotline (1-866-835-7595). As a last resort – and only as a last resort – you can pay out-of-pocket for a prescription, save your receipts, and request reimbursement from your drug plan.

Second Problem
Your pharmacy wants to charge you full co-pays – but you qualify for low co-pays because you have both Medicare and Medicaid (dual eligible) or “extra financial help.” Dual eligibles have the lowest co-pays – only $1 or $3.

Solution: Follow the same advice as above. For more information about extra financial help, see the July 2005 issue of aakpRENALIFE, titled Extra Financial Aid with the New Medicare Drug Benefit (available online by clicking here ).

Third Problem
Your immunosuppressive drugs are covered by Medicare Part B, but the pharmacist mistakenly charges your Medicare drug plan (Part D) and the claim gets rejected. Or your drugs should be covered by your Medicare drug plan (Part D), but the drug plan thinks the drugs should be covered by Part B and will not authorize payment for the immunosuppressive drugs.

Solution: The Medicare program is aware that there is a lot of confusion among pharmacists and plans on immunosuppressive drug coverage, and is working to improve this situation. In the meantime, you need to know whether your immunosuppressive drugs are covered under Medicare Part B or by your Medicare drug plan (Part D). You can ask your doctor to write “Part B” or “Part D” on your prescription to guide the pharmacist. If you run into a problem at the pharmacy window, you may need to be assertive with the pharmacist whether your immunosuppressive drugs are covered by Part B or Part D – and if you continue to have a problem, call 1-800-MEDICARE (1-800-633-4227). Do not skip your immunosuppressive drugs!

Fourth Problem
You were dual eligible – you had both Medicare and Medicaid – but you no longer have Medicare but were mistakenly enrolled in a Medicare drug plan. Now, your state Medicaid program won’t now pay for your drugs – including immunosuppressives.

Solution: Contact your State Medicaid program for help.

Fifth Problem
Your drug plan does not cover a specific drug that your doctor says you need – because the drug is not on the plan’s formulary. This may become a bigger problem on April 1 when the “transition period” expires where plans had to cover all drugs.

Solution: Good news – all or nearly all immunosuppressive drugs are required to be covered by every formulary. For other drugs, Medicare thinks requests for exceptions should be the option of last resort – and Medicare beneficiaries should work with their physician to find an appropriate substitute medication on the plan’s formulary. For more information on how to request a formulary exception, see the March 2006 issue of aakpRENALIFE, titled “Medicare Drug Benefit – How to Get an “Exception” to Your Drug Plan’s Formulary!” (available online by clicking here).

This article originally appeared in the May 2006 issue of aakpRENALIFE, Vol. 21, No. 6.

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