"I can't afford my medications!" How many times have you heard your clients complain about the cost of their medications? Here are a few things you can do to help them stop over-spending on prescriptions.
Many times, a client can lower the out-of-pocket cost by simply reviewing the formulary with their provider to find a covered alternative. Reviewing the formulary is key.If changing the medication is not possible there are still options available.
Exception to the Plan Formulary
A member has the right to ask for an exception to the plan formulary:
- If a Part D drug is not covered, ask for a non-formulary exception.
- When a medication has a quantity limit, but the doctor has prescribed more, ask for a quantity limit exception.
- Or maybe your client would like to see if they can get the medication prescribed at a lower cost. They can do that too by asking for a tier exception.
For example, if a drug is included in Tier 4, and there are drugs to treat the condition in Tier 3, your client can ask for it to be covered at the Tier 3 cost-sharing amount instead.
Prior authorization may be a solution. Certain prescription drugs may have additional coverage requirements to ensure the medication is being used safely but this doesn't mean it will not be covered. The prescribing doctor will need to provide the plan with a medical reason as to why the medication should be covered. As well as some additional criteria questions. All the necessary information is needed for review to determine approval.
Some medications may require Step Therapy. This simply means the client would be required to try or have tried a lower costing formulary medication first before the prescribed medication could be covered. If they have done so and the provider can provide information to support it was not effective for the patient, they can then step to the prescribed medication. For example, if Drug A and Drug B both treat your medical condition, your Medicare plan may require your doctor to prescribe Drug A first. If Drug A does not effectively treat your condition or work for you, then the plan will then cover Drug B.
Keep in Mind
- Keep in mind you are only allowed one request meaning you cannot ask for a formulary exception and a prior authorization.
- Don't forget PACE/PACENET is also available. There is an income-based requirement in order to qualify. Pace has an income limit of $14,500 for a single and $17,700 for married. PACENET has an income limit of $27,500 for a single and $35,500 for married. This will provide your client help with cost, deductibles and the dreaded donut hole.
So, if your feeling at a loss and looking for ways to help your clients with the high cost of medications try one of the suggestions above.