Part D Problems

It’s only three weeks into the new year and I’ve received calls from several people about their Part D problems. Unfortunately, they can’t change their Part D plan unless they are enrolled in a Medicare Advantage plan.

The calls I got are from clients who are paying for a Medicare supplement and a “stand-alone Part D plan”.

Can a person change their Medicare Advantage plan at this time of year? (January, February, March) Yes, but…… it’s a secret.

But back to my clients and their Part D problems

Betsy (not her real name) called me on January 10th to tell me she just found out that Viberzi will no longer be covered by her Humana-Walmart Part D plan. Viberzi treats irritable bowel syndrome and Betsy says she must have this medication or she can’t leave her house.

I looked up Viberzi through the Medicare.gov Plan Finder and, sure enough, her plan does not include it on their 2019 formulary. Other plans do cover it, but they call it a “specialty drug”, which means she would pay 33% of the retail cost. And here’s the kicker: The retail cost for Viberzi is over $1,100.00 !

But it doesn’t really matter how other plans cover Viberzi because Betsy cannot change her Part D plan at this time of year.

Besty was distraught by the prospect of not having access to Viberzi.

What can you do if you have Part D problems?

I told Betsy she should ask Humana for a “formulary exception”. Actually, her doctor will fill out forms to ask Humana to make an exception and cover Viberzi for Betsy.

The doctor has to state that other medications have been tried by Betsy and only Viberzi has worked for her. From my experience with other clients who had Part D problems like Betsy, insurance companies will make an exception to their formulary.

From my experience with other clients, the insurance company can’t say, “Tough luck, but we will not pay for the only drug that works for your condition”. But, Betsy’s doctor (and his staff) must do the required paperwork and jump through the necessary hoops.

How to avoid Part D problems.

I told Betsy that Humana must have informed her of the change to their formulary (the list of drugs they cover) before or during the Annual Enrollment Period (October 15 – December 7). Once informed of such an important change, she should have looked for another Part D plan that would cover her drug in 2019.

It turns out that Betsy did get a notice from Humana, but…. she says she never looks at the monthly statements she gets from her Part D plan. I told her she is not alone and I figure about 90% of people do not look at the monthly statements they receive from their plan.

I guess I need to remind my clients during the Annual Enrollment Period to be sure to read their drug plan monthly statements.

My question is: Why are people who are enrolled in a stand-alone Part D plan not allowed to change their plan during the new Open Enrollment Period (OEP)? (January – March). It turns out that the new rules for the OEP apply only to people who have Medicare Advantage.

The new Open Enrollment Period (January – March) does not apply to people who are on Original Medicare with a Part D drug plan.

I think I know the answer to my question. It’s because folks in Washington, DC want people to move to Medicare Advantage and get out of Original Medicare. So…. if someone enrolled in a Medicare Advantage plan is unhappy with her plan, she used to be able to drop her Advantage plan and go back to Original Medicare during OEP (which ran from January 1 to February 15). A person could not change to another Advantage plan during that time.

Now, with the new Open Enrollment Period, people can move from one Medicare Advantage plan to another. They can also disenroll from their Advantage plan and go back to Original Medicare and get a Part D plan.

But this OEP is a secret and is not to be advertised by insurance companies or insurance agents.

Meanwhile, people who have problems with Part D are stuck with their plan for the rest of the year.