The private companies that Medicare approves to provide prescription plans for beneficiaries may put restrictions on certain drugs they cover. Stand-alone prescription drug plans that supplement Original Medicare (Part A and Part B) and the drug coverage that comes with Medicare Advantage plans both have coverage restrictions. These restrictions can include prior authorization, quantity limits and step therapy.
--Prior authorization means that your doctor must get special approval from your plan in order for that prescription to be covered. It is also sometimes called pre-authorization or pre-approval by your plan. You will need to discuss this with your doctor and request he or she write a letter to your drug plan; the details of that letter are noted below.
--Quantity limits are when your plan will only cover a certain amount of a prescription drug. For example, your plan will only cover 30 pills for a particular drug every month even though your doctor has prescribed you 60 pills a month.
--Another restriction is step therapy. Step therapy is when your plan requires you to first try another, less expensive drug to see if it will be effective before your plan approves the drug that your doctor wrote the prescription for. Again, you will need to discuss this with your doctor and request he or she write a letter.
You can challenge such restrictions with the help of your prescribing doctor. You should talk to your doctor about whether you can change your prescription to a drug that would be equally effective, but does not have the same restrictions. Or you can ask your doctor to write to your drug plan and ask them to remove the restriction on the drug for you. This letter should tell the plan that other drugs on the formulary would not work as well for you or could be harmful. Or, that there are medical reasons for the prescribed dose.
The deadline for enrolling in a new Medicare Prescription Drug Plan for 2012 is Dec. 7.
2012 Medicare changes and the Special Election Period (SEP) for enrollment in 5-star MA Plans and PDPs
As part of the 2012 Medicare changes, a new Special Election Period will be available starting Dec. 8. The SEP was developed by the Centers for Medicare and Medicaid Services to allow Medicare beneficiaries to enroll in one of the following options with a 5-star rating at any point during the year:
1. Medicare Advantage plan,
2. Prescription Drug Plan,
3. Medicare Advantage Prescription Drug Plan
This overall plan summary rating is provided by CMS prior to the Annual Election Period and is effective through the next contract year (January to December). Any beneficiary who requests enrollment into a 5-star plan after the 2012 Medicare changes will be enrolled the month after the request has been received. Because the summary rating is effective for a contract year, the effective dates of enrollment requests using the SEP are limited to Jan. 1 through Dec. 1 of the year the plan has the 5-star rating.
A plan must have the overall plan summary rating to qualify with these 2012 Medicare changes. Even if a plan has received five stars in some rating categories, if it does not have an overall 5-star rating, it will not qualify with the 2012 Medicare changes.
Beneficiaries are limited to using the SEP once in the year. Once they use the SEP to enroll in a 5-star plan they will once again be limited to making changes only during other applicable periods not affected by the 2012 Medicare changes, such as the Annual Enrollment Period.
The SEP does not convey any additional right to select other coverage outside the normal enrollment periods unaffected by the 2012 Medicare changes. If beneficiaries leave an MAPD to enroll in a 5-star PDP without health coverage OR a 5-star MA plan without prescription drug coverage, they will be unable to complement their coverage with a separate plan until the next valid enrollment period according to the 2012 Medicare changes.
These 5-star plans have been informed of these 2012 Medicare changes and will be required to accept these SEP requests until the plan closes due to a CMS-approved capacity limit.
According to the CMS pamphlet "Choose Higher Quality for Better Health Care," the Centers for Medicare and Medicaid Services (CMS) developed a quality rating system for Medicare Advantage plans a few years ago. The scoring system is based upon well-established measures of health care delivery quality. These measure a plan's quality of care, access to care, responsiveness and beneficiary satisfaction provided by the plan. CMS rates Medicare Advantage (MA) plans based on a one to five star scale, five being the highest quality of care. CMS has used this information to monitor plans.
CMS has also been rating Part D plans since fall 2006, using a 3-star scale in 2006 and 2007. Starting in 2008, CMS began using the 5-star rating with Part D plans. There are many different measures that PDPs are rating upon, such as call center hold time, members' ability to get prescriptions filled easily when using the drug plan and plans' fairness in denials to members' appeals.
Medicare drug plans are rated on how well they perform in four different categories:
1. Drug plan customer service
2. Member complaints, problems getting services, and choosing to leave the plan
3. Member experience with drug plan
4. Drug pricing and patient safety
Medicare health plans are rated on how well they perform in five different categories:
1. Staying healthy: screenings, tests, and vaccines
2. Managing chronic (long-term) conditions
3. Plan responsiveness and care
4. Member complaints, problems getting services, and choosing to leave the plan
5. Health plan customer service
David Zimmerman is consumer assistance division director at the North Dakota Insurance Department.