Naples woman denied for medication on Medicare Part D plan

May 19--Janis Lewis is struggling with swelling in her legs and feet, a condition she blames on her Medicare drug plan denying one of her medications.

She's been taking a blood pressure medication, nisoldipine, for several years and said it's the only thing that works for her.

Her Part D plan with AARP Medicare Rx always tries to put her on a different medication, but she had always prevailed through an appeal with the help of her doctor.

That wasn't the case a few months ago when she was denied the medication five times and experienced swelling.

"It was the reaction I got," Lewis, 77, of Naples, said. "They ruined my health. They have ruined my social life."

The Medicare Rights Center and other nonprofit advocacy organizations for seniors lobby the U.S. Centers for Medicare & Medicaid Services to change rules to make appeals easier, according to a March letter to CMS in response to annual requests for comments on proposed policy changes.

The national nonprofit, with offices in New York and Washington, works on behalf of older adults on Medicare access issues.

"Medicare Rights continues to hear from people with Medicare who face persistent confusion and challenges when denied access to a medication at the point of sale and encourages CMS to strengthen the appeals process," the group said.

Medicare Rights operates a help line and fields 17,000 calls annually where denial of medications is a common complaint.

Lewis had her preferred blood pressure medication reinstated in March, but the side effects of the swelling and pain are slow to go away.

She receives therapeutic massages and spends hours in the community pool at her Island Walk home to help alleviate the pain.

"I'm now in the fifth week of going to the pool," she said.

All Medicare Part D plans have approved drug lists, called formularies, but they change from year to year with substitutes offered, and there are changes in what seniors make in co-payments.

It's an annual rite of passage that puts many seniors in a jam if they don't review their medications against the existing plans' updated approved drug list.

Often seniors need to switch plans after reviewing which of their medications are covered and which are out-of-pocket expenses.

Open enrollment in Part D is from mid-October to early December with plan coverage taking effect Jan. 1.

An estimated 41 million Medicare beneficiaries are enrolled in Part D plans.

Lewis received multiple letters explaining her blood pressure medicine was not on her plan's approved list.

Sometimes the letters conflicted. One day a letter said she was getting a temporary reinstatement, followed by a denial letter the next day.

When she got back on her preferred medication with persistent help from her doctor, her share of cost went from $6 to $21.

"That's a big difference," she said.

Local data isn't available for how many seniors face drug denials and need to file appeals, said Stephanie Hoffman, manager of SHINE, which stands for Serving Health Insurance Needs of Elders.

An enrollment volunteer with SHINE in Collier County, Hallie Devlin, said any plan denial must authorize a 30-day supply of the medication to give the beneficiary and physician time to request an exception.

The Medicare Rights center is pressing CMS to make good on pledges to examine pitfalls with the appeals process and improve it, said Casey Schwarz, senior counsel for education and federal policy with the group.

"In terms of appeals, it's a problem we hear about on our help line consistently," she said.

She said the problems fall into three areas: a drug is not on the formulary, it is covered but with restrictions, or it is on the formulary but requires prior authorization.

"One of the issues we hear about is people don't necessarily know which one of these buckets they are in," Schwarz said.

Another underlying problem is lag time for coverage determination, where a Part D plan makes a decision whether a medication will be covered, Schwarz said.

"Right now CMS does not require plans to treat presentation of a prescription as a request for coverage determination," she said.

That's something her organization and other groups say should be changed when a prescription is presented at a pharmacy counter, which could save at least 24 hours in the appeals process, if not more, she said.

Similarly, another solution her organization supports is for CMS to remind plans to use grandfathering policies where prior authorization decisions can be carried forward to future plan years to eliminate repetitive appeals.

"As such we encourage CMS to take this policy further and require 'grandfathering' policies," according to the group's letter to the federal agency.

What the Medicare Rights center objects to is CMS potentially giving drug plans more time than the current limit of 72 hours to decide whether a medication will be covered for a patient after receiving a coverage request.

A similar group, the Center for Medicare Advocacy, said federal government audits on Part D plans show denials are widespread, said David Lipschutz, senior policy attorney with Medicare Advocacy.

As such, the federal government said it is only focusing on the plan providers with the worst track record of denials not getting sent to an automatic review, which is required, he said.

What many seniors may not realize is they can also apply for an exception to prior authorization, even for a prescription that is not on the plan's approved list, he said.

"Some of the appeals regulation require a lot of intervention and time on the part of the physician," he said, recognizing that physicians and their staff are busy enough. "I think a lot of people show up at the pharmacy and because (a denial) doesn't trigger an appeal, they give up."

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