medicare & Rx coverage

I know from reading recent posts that folks that are on schedule 2 (& schedule 3) meds have been having a hard time getting the meds covered by medicare. While I understand in part why the new hurdles have been put in place, I'm wondering if someone could briefly explain it without getting too political & possibly violating the forum rules. I'm just so confused.

I ask because an elderly parent, who is in excruciating pain from years of construction work & broken bones (has had different cancers but is in remission), is just now getting denied (it's already March so it doesn't make sense to me). The physician's office has gone to bat to get the meds covered, but it seems pretty time consuming.

The answer is probably very obvious to some; I don't quite understand. Please forgive me if this question is duplicitous. I am just so frustrated for my parent and can only imagine what it is like for those of you who have been dealing with this for some time.

Wishing all a low pain day, and thank you in advance for your assistance.

I'm even more confused because my folks have supplemental insurance which I think should pick up the extra, but for some reason it isn't. I just don't get it.
The class 2 med isn't available in generic which I guess I understand the cost factor, but why now is a med like vicodin suddenly such a problem? The generic is cheap. The only thing I can think of is my folks' PC doc treats predominantly older ppl who are either cancer patients or just elderly with horrible age related pain from arthritis & other associated degenerative disease. Maybe because this doc's patient base is old and in pain, he writes a higher volume of scheduled meds, so the DEA puts pressure on him, even tho the ppl he treats are "legitimate" pain patients. I'll ask him at my folks' next appointment. Thankfully the doc is proactive in jumping thru the hoops, but it seems like it's just a huge bureaucratic mess.

You might want to see if their prescription drug plan has a website, most of them do. Then go to the website and see if they have their formulary online. If a patient has cancer, it doesn't apply to them, there is a code the dr has to put on the rx. But, if the dr is a high prescriber, that may explain why the insurance company may be causing problems. They do have Prior Authorization that is Required for Brand meds. That is in an effort to reduce the amount of money spent on the more expensive meds.

But, if the pain is that bad, the question may be asked how have they made it without having the meds. So maybe they don't need something that strong. I don't mean to offend. But, it is a possibility.

Your fathers insurance company will have a website and the formulary for the meds covered will usually be on there. As well, most of the companies will also send out a hard copy of the formulary to all beneficiaries.

You need to look at it and see what is covered and in what amounts. You may have to talk to the insurance company on the phone to find out what the limits are. The docs office can ask for an exception to their policy and they will have to fax documentation to the ins. co. of what he has previously tried and what they want approved. They are required to answer within 72 hours.

My ins. co. has oxycontin on their approved list but at a lower dose than I am on. My docs office filed the paperwork and I got approved this year. I guess we will see what will happen next year.

Your father may have to try other prescription drugs that are on the formulary before they will approve something that is not on their formulary, I did have to do that. I have tried all other LA/ER types of drugs other than methadone and the new zohydro and they just don't work on my pain nearly as well.

Hope this helps,
Trudy

I'm going through my plan's formulary now looking for meds that are covered. Part of the problem is there is a rule that the government can't negotiate prices and has to pay the full list price. What dummy thought that one up?

For those who seem to be confused about plans: I'm one of those on Medicare (way different from Medicaid but not better) suffering from "formulary changes" (read dropping most of the meds I need). I have a PPO plan that covers hospital, doctors and medicines. PPO at least lets me choose doctors myself without a referral like with HMOs. It's an inclusive plan, not a supplement. I have to use only doctors within the plan's contracts.

My brother has regular Medicare with a supplemental plan. He can go anywhere in the world. But it's not for everyone. High deductible!

One should spend a whole year going to meetings and reading the books put out by the government about the different plans in one's area. Then you figure out what you expect to need. Plans change drastically from year to year and state to state and within states. Never for the better.

Plan formularies are posted online, but not always soon enough to change plans within the allowed change period.

My plan has recently been dropping doctors like flies too. I know some of these doctors and they are some of the best. Maybe they prescribe a few more expensive tests or treatments. So at least annually you have to look up your doctors to make sure you can still see the ones you like.