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Thread: Sudden formulary change in Part D.....question from a friend of mine

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    Distinguished Community Member Lazarus's Avatar
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    Post Sudden formulary change in Part D.....question from a friend of mine

    Has anyone else run into this problem?

    When it came time to sign up for the Drug plans last year, I was pleased to find so many plans covered all of my drugs.

    I switched from Aetna to Express-Scripts because my co-pay for Gilenya was 417.00 per month. I went through the hoops to secure pre-authorization and was notified on Jan. 17th that I had been approved for a year. The same day, I received a letter saying the drug was not in their formulary. I assumed that the approval was the letter that mattered.

    Today, I received a second letter telling me Gilenya was not on the formulary. Last week I was notified that two other oxybutinin and modafinil are not on the formulary. I have taken these for years.

    This led me to the medicare.gov site for Medicare D plans, and to my horror, no plan covers all my meds. Quite different from the info on their site in November and early December of 2018

    If anyone has a similar experience, or any suggestions of what to do, please let me know.


    Thanks.

    ***ifanyone has any answers I will pass it along..Linda
    Linda~~~~

    Be the kind of woman that when your feet hit the floor each morning the devil says:"Oh Crap, She's up!"

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    Linda, I have Express-Scripts as my Part D also. The way I found out what they covered was to go into their web site and put in all my drugs. They came up as all being covered.

    If there has been any change they have not let me know. I probably should go back and check again, but I just renewed as of January 1st. I have been with them for at least 3 years. I do take mostly generics. It is hard to get them to cover anything else.

    You have to go through listing all your drugs and then it will give you the price for where you get them filled and it will say out to the right of the drug if it is covered or not. I do this every year during the period when you reenroll in Part D.
    Virginia

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    Distinguished Community Member Sunshine's Avatar
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    If a drug isnt on the formulary, you call the Plan and ask for a “Formulary exception”. There is a process where they tell you how to have the doc call in with a request for exception. Doc says you had adverse reaction to the comparable one on the formulary or whatever the reason to keep you on that drug, an not the one the plan covers.

    This worked for me on an uncovered drug. And, it Carried me over to the next year too.

    If they cover NO Ms meds, then I would call NMSS and ask what to do.

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    They do cover MS drugs in this case, because my Rebif is covered.
    Virginia

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    Distinguished Community Member Lazarus's Avatar
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    Quote Originally Posted by Sunshine View Post
    This quote is hidden because you are ignoring this member. Show Quote
    If a drug isnt on the formulary, you call the Plan and ask for a “Formulary exception”. There is a process where they tell you how to have the doc call in with a request for exception. Doc says you had adverse reaction to the comparable one on the formulary or whatever the reason to keep you on that drug, an not the one the plan covers.

    This worked for me on an uncovered drug. And, it Carried me over to the next year too.

    If they cover NO Ms meds, then I would call NMSS and ask what to do.
    Thanks. I did forward this to her.
    Linda~~~~

    Be the kind of woman that when your feet hit the floor each morning the devil says:"Oh Crap, She's up!"

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    Distinguished Community Member Cherie's Avatar
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    None of the plans in Medicare Part D cover ANY self administered disease modifying therapy and none cover Modafinil. I am surprised on the oxybutynin.

    Virginia,
    I am surprised about your Rebif. My co-pay was $2400/month since the drug retails for nearly $9000/month now and we pay 33-40% of the retail cost with part D plans. Our Agent told us that all Part D plans have the same formulary but different deductibles and out of pocket costs.

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    Cherie Express-Scripts pays their share and then HealthWell Patient Assistance pays what they are going to pay for my Rebif.
    Virginia

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    Distinguished Community Member Sunshine's Avatar
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    The formularies do differ from one plan to another. I just switched from bcbs to AARP UHC, there were differences. We looked at several plans and some were worse than others re asthma meds

    I don’t know about the DMTs for MS. I didn’t check those. Likely Ocrevus and rituxan are covered as they’re hospital based infusions by IV.
    Last edited by Sunshine; 01-27-2019 at 02:39 AM.

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    Cherie, it occurred to me that I should have explained that the co-pays that the patient assistance programs pay go way down once you get to the catastrophic stage. On one of the DMDs that is usually late January or February at the latest because they are so expensive.

    Once the catastrophic stage is reached the payment is usually around $400.00 per month, which for me is still a lot because I pay all my other co-pays myself.
    Virginia

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    Quote Originally Posted by Cherie View Post
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    None of the plans in Medicare Part D cover ANY self administered disease modifying therapy and none cover Modafinil. I am surprised on the oxybutynin.

    ...
    Things may have changed since I was taking Avonex, then Copaxone, but back then I never paid a cent for either one. I was covered only by Medicare/Medicaid. Probably Medicaid was picking up the tab?

    They may no longer be doing that. My guess is that those drugs were just too costly.
    MS diagnosed 1980. Avonex 2002-2005. Copaxone 6/07 - 5/10.
    Member of this MS board since 2001.

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