Anyone file for a prescription drug exemption? UPDATE REPLY # 22

[barkley]

My suggestion is to start now into looking into which Medicare Advantage plan will cover your medication and get it set up for next year. If you decide to go this route, just make sure your doctors are in network with your plan. My mom has Humana and it covers some very very very expensive medication for her, but she had to find some new doctors, which stinks, but it’s more beneficial for the insurance to cover her medication than her doctors. She has found new doctors now and they are good doctors.

even if you find a plan that your doctor/specialists are in network for-make sure that you will be permitted to retain them. we've had to change doctors 3x in 17 years. once b/c we moved state to state (so new plan) and we found insanely long wait lists more any kind of Medicare accepting doctors and only ended up with a new PCP months in b/c dh had to go to the e/r and was ordered to see his PCP within so many days. when we told them he still didn't have a PCP they scheduled an appointment with one of their associated who kindly took pity on us and despite not taking new patients for years arranged for us to sign-on. he retired and though the practice was ambitious on finding a replacement they were unsuccesful so we took a handful of months to find another (thankfully the prior doc had given us the maximum number of refills on our scrips to submit to the pharmacy). with our current doctor I learned in late September that the Medicare advantage plan we had was closing shop but an almost identical (but an HMO that covered him and all our specialists) was available. we enrolled BUT i've dealt with hmo's before so I called once our official enrollment for 1/1/26 arrived to confirm we would retain our PCP. sure enough-i was told we could 'request' it but unless we designated a preference we would be randomly assigned within his medical group. we requested and were assigned to him. if we hadn't and he had reached his max number through requests and random assignments we would have been SOL and dealing with someone new/on a wait-list again.

with a new plan-check what it covers/who it covers/will you be able to retain providers even if they ARE covered (and do you have to formally request).


as far as prescriptions go-i'll stick with a plan that allows me to use my independently owned brick and mortar. old school/face to face/very helpful. I'm not into the mail order stuff and i'm not comfortable with the 'average' 7-10 day wait that places like express scrip show for our region (and the thousands upon thousands of 1 star reviews, bbb complaints and an entire Facebook page dedicated to 'victims of express scripts' ).

 

[tvguy]

UPDATE: My insurance called me today (yes, on Saturday). They received the request for an exemption, they call it "prior authorization", and it was approved.
Now, it will STILL cost me $1,200 for a 90 day supply. But Medicare Part D plans have an out of pocket cap of $2,500. The trick is, ONLY medications I buy through my insurance count against that cap. So GoodRX, Canadian Pharmacies and manufacturer coupons do save money, but anything I spend does not count against the deductible. I take $1,000 a month in prescription medicines so I will hit the out of pocket cap by next month. Prescription drugs are crazy expensive. My neighbor takes $10,000 a month in prescriptions, so I am on the low end.

 

[loves to dive]

@loves to dive have you called you gynecologist to see if they will refill your prescriptions? My doctor retired and I’m currently doctor shopping. My gynecologist told me not to rush the process she can do my blood work and refill my thyroid medication. It might be an option for you.

Gyno recommended about 15 years ago I stop going to him and just go to a GP since I have no inside lady parts. If I have to shop for a Gyno might as well shop for a GP. My problem is we have loads of doctors and clinics but all big box. I could easily get into one of those and my insurance would cover it, it's just a matter of me wanting to be treated like a person and not a number.

 

[Kitty 34]

UPDATE: My insurance called me today (yes, on Saturday). They received the request for an exemption, they call it "prior authorization", and it was approved.
Now, it will STILL cost me $1,200 for a 90 day supply. But Medicare Part D plans have an out of pocket cap of $2,500. The trick is, ONLY medications I buy through my insurance count against that cap. So GoodRX, Canadian Pharmacies and manufacturer coupons do save money, but anything I spend does not count against the deductible. I take $1,000 a month in prescription medicines so I will hit the out of pocket cap by next month. Prescription drugs are crazy expensive. My neighbor takes $10,000 a month in prescriptions, so I am on the low end.

That's what they called it last week when they (my local pharmacy) needed a "prior authorization" on two of the three meds I get filled out every month and have (no problem) since 2018!! My pharmacist said I had to get it from my local doctor who I then called and they sent me (via phone) to another town's office to get this authorization. Left a message of course as no human seems to answer phones anymore Meanwhile DH and I just bought the two drugs at real cost. Got the authorization a few days later.

Now I'm concerned...Will I have to get this prior authorization every month??? Nobody seemed to know that answer. I'm BC/BS Medicare

 

[TippyThomas]

That's what they called it last week when they (my local pharmacy) needed a "prior authorization" on two of the three meds I get filled out every month and have (no problem) since 2018!! My pharmacist said I had to get it from my local doctor who I then called and they sent me (via phone) to another town's office to get this authorization. Left a message of course as no human seems to answer phones anymore Meanwhile DH and I just bought the two drugs at real cost. Got the authorization a few days later.

Now I'm concerned...Will I have to get this prior authorization every month??? Nobody seemed to know that answer. I'm BC/BS Medicare

Kitty, I have to get pre-authorization for a drug I take and the insurance says it needs to be done once a year. I've been on it almost 3 years now and they've never asked for any followup authorization. I don't know if that'll be the case for you, but it has been for me. I'd just count on needing to do it yearly just in case. Heck, do it a month in advance and save yourself the cost if it is needed.

 

[Kitty 34]

Kitty, I have to get pre-authorization for a drug I take and the insurance says it needs to be done once a year. I've been on it almost 3 years now and they've never asked for any followup authorization. I don't know if that'll be the case for you, but it has been for me. I'd just count on needing to do it yearly just in case. Heck, do it a month in advance and save yourself the cost if it is needed.

That's how I feel; I've been on three of these meds for years and yes I need to get authorized for two of them every three months (from my Dr) but I had never heard of this prior-authorization from doctor office--to---insurance before this past week. I guess wording or something has changed and I just have to do this every year. What's weird is one the meds didn't need this and none of them needed it before this year??

It's so confusing I don't even know how to word some of this!!

Thanks for the reply.

 

[lanejudy]

Prior Authorization for meds is common when a prescription plan has tiered coverage. The formulary first approves lower-cost drugs; the higher-cost drugs are 2nd (or 3rd) tier and the doctor must show medical reason why the lower-cost meds aren’t suitable. Our pharmacies (both local and mail order) get the prior authorization directly from the prescriber. My family has needed them several times over the years, and I think our only pre-authorization that wasn’t approved was a CGM because the patient has never used insulin so insurance won’t approve coverage.

 

[Kitty 34]

Prior Authorization for meds is common when a prescription plan has tiered coverage. The formulary first approves lower-cost drugs; the higher-cost drugs are 2nd (or 3rd) tier and the doctor must show medical reason why the lower-cost meds aren’t suitable. Our pharmacies (both local and mail order) get the prior authorization directly from the prescriber. My family has needed them several times over the years, and I think our only pre-authorization that wasn’t approved was a CGM because the patient has never used insulin so insurance won’t approve coverage.

That makes sense LaneJudy. What doesn't make sense in my situation the two meds I just paid at cost were actually cheaper than my one med that didn't need this prior authorization. That's what's confusing.


Sorry TV Guy if I stole your thread. I'm glad you posted it.

 

[barkley]

Kitty, I have to get pre-authorization for a drug I take and the insurance says it needs to be done once a year. I've been on it almost 3 years now and they've never asked for any followup authorization. I don't know if that'll be the case for you, but it has been for me. I'd just count on needing to do it yearly just in case. Heck, do it a month in advance and save yourself the cost if it is needed.

it's crazy with prior authorization stuff on scripts. my oldest was prescribed a new med and when the pharmacy tried to fill it was initially denied due to needing a 'prior authorization' which entailed the doctor attesting to having prescribed a less costly alternative for at least a couple of months that the insured had filled. ummmm-the insurance company paid for THAT med and already had verification in their own data base but nope-doctor had to fill out a form to submit to the insurance company. waste of time for doctor, pharmacy, insurance company.

 

[Disneytat76]

Hello everyone, I work in a doctor's clinic at a local hospital. Part of my job is to submit these medication PAs(prior authorizations). @lanejudy is correct as they are quite common. Unfortunately for most of these medications that have copay assistance offered by the manufacturer do not allow people on Medicare or Medicaid to participate. However, there are grants that can assist instead. Google PAN foundation, the assistance fund or patient advacte fund. Just search for your medication or disease state to see if they are open. Another great resource is needymeds they offer links to multiple assistance websites. Hope this helps. MOD if this post violates and posting rules I apologize. It just upsets me to see predatory habits of large insurance and large pharmacies take advantage of people when I see the types of margins they can have by steering people to take certain medications.

 

[lanejudy]

What doesn't make sense in my situation the two meds I just paid at cost were actually cheaper than my one med that didn't need this prior authorization. That's what's confusing.

I assume that 3rd med is for a very different medical issue. It’s within a specific “market” or diagnosis/need.

 

[Kitty 34]

I assume that 3rd med is for a very different medical issue. It’s within a specific “market” or diagnosis/need.

Yes it is. I'm just wondering if I have to get this "prior authorization" every month or hopefully it's just a yearly thing.

 

[lanejudy]

Yes it is. I'm just wondering if I have to get this "prior authorization" every month or hopefully it's just a yearly thing.

It shouldn't be more than yearly, unless you change pharmacies.

 

[Kitty 34]

It shouldn't be more than yearly, unless you change pharmacies.

Good. Thanks for your replies. Very helpful.

 

[tvguy]

Hello everyone, I work in a doctor's clinic at a local hospital. Part of my job is to submit these medication PAs(prior authorizations). @lanejudy is correct as they are quite common. Unfortunately for most of these medications that have copay assistance offered by the manufacturer do not allow people on Medicare or Medicaid to participate. However, there are grants that can assist instead. Google PAN foundation, the assistance fund or patient advacte fund. Just search for your medication or disease state to see if they are open. Another great resource is needymeds they offer links to multiple assistance websites. Hope this helps. MOD if this post violates and posting rules I apologize. It just upsets me to see predatory habits of large insurance and large pharmacies take advantage of people when I see the types of margins they can have by steering people to take certain medications.

I had a manufacturers coupon for another medication and I could have gotten one for this one also, not sure why being Medicare would be an issue? Regular Medicare does not provide prescription drug coverage, Some Medicare Advantage Plans do. I am on regular Medicare, and my prescription drug coverage is called Medicare Part D, but I buy it from a private insurance company. Medicare pays no premium or any of my drug costs.

 

[Disneytat76]

I had a manufacturers coupon for another medication and I could have gotten one for this one also, not sure why being Medicare would be an issue? Regular Medicare does not provide prescription drug coverage, Some Medicare Advantage Plans do. I am on regular Medicare, and my prescription drug coverage is called Medicare Part D, but I buy it from a private insurance company. Medicare pays no premium or any of my drug costs.

My comment about manufacturer assistance was about copays . Yes regular Medicare is actually part A which is for hospital and part B which is for medical insurance. Part D is for pharmaceuticals. Also there are some medications that are only covered under Part B like some self-injectables. The grants I spoke about only work after processed through some kind of insurance. The manufacturer coupons you talk about don't go through any insurance. The grants would go toward your $2500 max.

 

[barkley]

It shouldn't be more than yearly, unless you change pharmacies.

I think with some meds the insurance companies will only authorize for however many months they have set for the reccommended re-evaluation by a doctor. I recall one med I had that the doctor was required to do a face to face every so many months to get reauthorization on (I goofed once and didn't do an appointment timely, needed a refill and the best the doctor/pharmacy could do was a small partial refill to allow time for the doctor to get me in). if prescribed something that requires a pre-authorization it's a good idea to ask the medical provider how long it's good for/if a face to face is required to re-new (and with Medicare plans certain medical supplies in general require appointments at certain intervals with the doctor or specialist-dh's CPAP stuff can't get filled unless he does a face to face yearly which they book a year out at a time).

 

[lanejudy]

I had a manufacturers coupon for another medication and I could have gotten one for this one also, not sure why being Medicare would be an issue?

Federal law prevents kick-backs for government programs such as Medicaid and Medicare. While a private insurance company handles your Part D coverage, they get reimbursement from the government. So there is Medicare involvement on the back-end, just not the patient side.

 

[tvguy]

Federal law prevents kick-backs for government programs such as Medicaid and Medicare. While a private insurance company handles your Part D coverage, they get reimbursement from the government. So there is Medicare involvement on the back-end, just not the patient side.

Wow. That's confusing as Part D, just like Part G is optional privately provided coverage. Not sure why the government would have any involvement in my Part D coverage. That is a new one on me.