Things you should know about Medicare Part D - Part two of a series on Medicare Part D Drug Program

Formulary – take it with you!

The process of selecting an insurance policy for Medicare Part D begins with entering a list of prescription medications including the dosage (strength) and the frequency (number of times a day or during the week that a drug is to be taken) into the formulary finder at http://www.medicare.gov or with a pharmacy or insurance representative.

This process will generate policies that cover your prescription medications. Remember that the only way to ensure that you are able to view all of the available insurance policies is to go to that Web site, which gains no benefit from one choice or another.

When a person’s formulary is entered, the various insurance policies will state if preauthorization or step therapy is required and if there are quantity limits.

Prior authorization requires that the doctor or healthcare provider must prove that there is a medical necessity for a particular drug.

Step therapy can be a part of prior authorization. It can require that Drug A is tried first; if the doctor or healthcare provide finds the drug to be ineffective, a request for Drug B can be submitted.

Quantity limits, simply stated, means that the insurance company can determine how much medicine a person can receive in a given period of time. If your doctor or healthcare provider decides you should take a medicine two times a day and the insurance company decides that a person can only have it once a day, that person must pay for the extra medication.

Remember that the insurance company, not your doctor or healthcare provider, has the final word as to whether a particular drug or dosage is approved. When choosing an insurance company, think about whom you want making your medical decisions, your doctor or healthcare provider or your insurance company.

The drug formulary is a list of all of the drugs covered by that insurance company. It is usually presented by the insurance company in a booklet after a person signs up for a particular plan.

Although persons generally want their doctor or healthcare provider to be in charge of their healthcare decisions, it is important to view ourselves as partners with our medical providers. A person can assist their doctor or healthcare provider by bringing their formulary book to each appointment.

The formulary book lists all drugs covered listed under drug categories. A doctor or healthcare provider can look at a person’s formulary and choose a drug that will be covered, possibly a less expensive generic brand. Since doctors do not necessarily know a person’s drug formulary or their financial limitations, they will appreciate a person’s assistance with making appropriate choices.

The next article will discuss resources for assistance with medication during the gap and for assistance from unbiased sources and 2008 Medicare Part D changes.

Note: As mentioned in the previous article, changes can be made to Medicare Part D during the year by organizations but not by consumers. One such change occurred this year in regards to the coverage limits. The coverage limit before a person was responsible to pay for their drugs was lowered in some cases to $2,400, with the insurance resuming at $3,850, not at $3,600.

Madelyn Lewis is a Registered Nurse in the community working with the Fallbrook Healthcare District to educate the public about Medicare Part D.