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Medicare Part D.....how is works




I am learning how Medicare Part D works. I want to share what I have learned so far. My new job is processing part D prior authorizations. This means...quantity limits, non-formulary and tiering and priorauthorizations.

Every insurance plan has drugs that they cover and quantities that they allow.

Only members or their physicians can request a determination. If you have a power of attorney on file then you can do this for your loved one.

I do believe that members can augment their care by calling their insurance company and start the process. This means that you call and request a case started for eg: non-formulary. This means that the insurance company will set up a case and call your MD to get this done. You can help by mentioning some important information. We need to know tried and failed medications (especially those formulary alternatives that are listed). If you do not know the formulary alternatives then ask the rep what they are. Jot down this information, you can give it to your doctor. If there are no formulary alternatives then you get the non-formulary approve--d. The fall back is that you will have to pay at the highest tier (co-pay). Another way to get the non-formulary approved is for the MD to state that it is a medical necessity for the patient to continue this medication. Changing or stopping this therapy will result in harm to the patient's health.

Quantity limits are the easiest to get approved. A statement has to be made that the formulary dose has been tried and has been ineffective or is inappropriate for this patient. An example is when the insurance wants you to split a pill. The MD just has to state that it is not possible for you to split a pill because of your handicap.

Tiering is a good thing to ask for. Eg. your drug is in the most expensive tier. Just request a tiering consideration. They just might bring it down to a lower tier if possible. It is amazing how many times this is approved.

Step therapy is another request that comes in. There are always conditions. Just ask the insurance company for the restrictions. Usually you have to try some drug first. Again the MD will state that you have used this drug or it is inappropriate in your condition.

The insurance companies have been overwhelmed at the beginning of the year. The company that I work for has relaxed the criteria because of the onslaught of too many claims. We cannot seem to get over the gigantic amount of claims that have come in.

This is an exciting job. I learn new stuff all the time. They always have overtime because of the huge amount of claims. I really did not realize how easy it is get approvals. A quest just has to be made. The insurance company can fax over alot of this stuff to the MD's office. Just ask the insurance company to do this. Every year criteria change. They need new forms every year.

Some of the authorizations are good for ten years. It is amazing.

If you case is denied. Send it back for a redetermination. The redeterminations are often approved. Just be persistent.

I do hope that you this helps inform you a little.




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Great info, and the same holds for private insurance. Their entire MO is to refuse everything the first time; but resubmit and you have a good chance of getting what you should have go in the first place. You snooze, you lose.

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Very helpful information. Thanks so much for sharing. I don't know why they have to make it so hard but it is nice to know that consistent effort can yield good results. ~~Donna

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This is very good information for you to share Ruth. I remember when Larry was discharged from inpatient and able to go home. The amount of prescription medication was overwhelming, not to mention very expensive. I was shocked that one med was $300/for 30 days, not approved by Medicare. I asked if I could get the amount down to 15 days until Larry saw his internist. Thankfully, he downsized or weaned Larry off a lot of the meds and took him off the expensive one.


It is somewhat unfair that we have to pay a premium each month for our

Medicare Part D, in addition to paying for any meds we may or may not need to take. The doctor does not seem to know or care about the cost of these prescriptions. I am grateful we can get most drugs in generic form.



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Everything you are learning will be valuable down the road and always great to know anytime. I get emails daily about applying for these kind of jobs and it's always a shortage of nurses and other specialized medical fields in this area for women and men. Many of them are office jobs too. We got five full all services hospitals right here and I don't know how many stand alone clinics.


We need all of them and they stay full with shootings, car and motorcycle wrecks and suicides. Lots of drug raids and deaths too. If I had use of both sides of my body I would apply for driver of emergency vehicles. In many cases both the EMS guys are working on the person in route to the nearest facility for care to save their lives.

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Okay Ruth, just got a letter from Express Scripts on a prescription I use. It says I have gotten a temporary supply of this and it is either not included on the list of covered drugs (called our formulary) or subject to certain limits. Interesting, this is something new, but I am not concerned as I will speak to my Dr. when I go this month.



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Ruth: just printed this out and put it in the medical file. Bruce just got added three new drugs, so I know at some point I may need to know all this. Thank you so much. Debbie

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