Navigating changes to Medicare Part D formularies; Covering; The Bases

My aunt called me and was very upset. She said she received "confusing" information about her Medicare Part D drug plan. Specifically, the brand of insulin she uses will no longer be covered effective Jan. 1. She has been with the same Part D drug plan for four years, and all her medicines previously have been covered. What is going on?

Medicare Part D drug plans have formularies. Formularies simply mean a list of medicines that the drug plan will cover. Part D drug plans are required to offer comprehensive formularies. However, Part D drug plans can modify their formularies.

Every year, prior to the annual open enrollment period, Part D plans reevaluate their formularies. The period begins Oct. 15 and runs through Dec. 7. During open enrollment, a person can reevaluate their drug coverage and make a decision to either remain in their current drug plan or switch to a new drug plan.

Your aunt received her annual notice of change from her Part D drug plan. Its purpose is to alert people of any changes for the next calendar year. Plans are required to send these notices to their members yearly. These notices should be received by Sept. 30.

If a member has not received this notice, they may call their Part D drug plan and request a notice.

Since your aunt was alerted to a significant change in her Part D plan (i.e., the brand of insulin she uses is no longer on the plan's formulary next year), she is advised to reevaluate her Part D drug coverage during the upcoming enrollment.

To do so, she may visit www.medicare.gov or call 1-800-MEDICARE. Any change made during the open enrollment will be effective Jan. 1.

I just received my annual notice of change from my Part D plan. All my medicines will continue to be covered for 2019. I have one major concern. I have been taking a inhaler for three years. This particular medicine is now under a restriction called quantity limits. I use the inhaler as needed, but when I need it, I need it! Should I be concerned about this new restriction?

A quantity limit restriction means that the plan will only allow a certain quantity of a medicine to be dispensed during a certain time frame.

Let's say you need two inhalers in a month, but your plan only allows one inhaler per month - you would be affected by the quantity limit restriction. However, just because you need more medicines that are allowed under the quantity limit restriction does not mean the plan will not consider an exception to the quantity limit.

You would need to work with your plan for authorization for the higher quantity. You plan may require medical documentation showing it is medically necessary to have a higher quantity per month than the plan allows.

I would suggest you contact your Part D drug plan to see if the quantity you use is within their quantity limit amount. If what you require is beyond the plan's quantity limit restriction you may either work with the plan on an exception to the limit, or select a new Part D drug plan during the annual enrollment period that allows a higher quantity to be dispensed.

Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or [email protected].

Credit: Amy Rubino - Amy Rubino is the director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4257 or [email protected].