Drug Plan Formulary

[melody60]

I'm not sure if I'm posting in the right place, but here is my question. I thought I did everything right; under 65, chose Medicare A & B, Medigap supplement, and Medicare PDP. Just received the 2014 Prescription Drug Formulary and Avonex is not on the list for 2014, only on formulary thru Dec. As it stands now, I can appeal or I can enroll in yet a new drug plan that will cover Avonex for 2014. I'm frustrated because the 2014 drug formulary without Avonex was updated on 8/1/2013, and I spoke to the rep on 8/29/13, and she said the drug would be covered in 2014.

Has anyone who has a Medicare Prescription Drug plan lost coverage for your DMD, and if yes, did you appeal the decision, and did the drug company eventually cover your drug, or did you just enroll in another plan?

[onlyairfare]

There are limits on when and how often you can change plans, and if you are under age 65, you may have a limited selection of plans than offer coverage.

I think the 2014 open enrollment is coming up soon, so you may need to change plans if you are doing well on Avonex and want to continue with it. I'd be sure to confirm in writing that Avonex will be covered throughout 2014 by whatever plan you choose.

If you can prove that the company representative told you Avonex is covered throughout 2014, you might have a successful appeal, but that might not be easy.

One other point - Avonex would be probably be covered under Part B if you got the injections in your doctor's office. If you self-inject at home, it's under Part D. If your drug co-pay is 25% of list price, it could be cheaper to go to the doctor's office.

I don't have an answer to your real question which is "Can they really do this or is it against the rules? What should I do?" Your state insurance commissioner or Medicare or your senator's office might be able to tell you what your rights are.

[akafearless]

I think they have to cover some interferon. But my plan has Avonex as tier 5 which is 33%. So Biogen is paying for it an not bothering with my health plan.

I'm not sure if I'm changing plans for next year yet so haven't checked to see what they will do for next year.

[melody60]

Thank you both for your responses. I guess I'll just try to appeal with my Neuro's assistance. If that doesn't work, I'll look for another plan during enrollment period between Oct. and Dec. I don't want to stop the avonex , since I've been injecting it for close to eight years, without any major exacerbations that I know of. That's a good idea if one can get the shot at the Dr's. office, but it probably wouldn't work for me. You're right, probably can't prove what they told me when I enrolled.

Thanks again.

[MierryLea]

I also can't answer your original question but I can tell you that I get financial help from active access. It was super easy to set up, I just talked to the person about how much money I make and so on. They figured out how much they would cover and they set it up with the pharmacy.

There was a small issue in the beginning, there was a mix up with my account with the pharmacy and they kept sending me a bill for $2300 the first couple months but I called each time and told them they have a CC on file with active access to bill. Now it's all figured out and I don't stress about it, I just set up my avonex delivery once a month!

So that might be an option if you don't want to mess around with the insurance...although I'm not sure how medicare/medicaid gets formulated into how much you'd owe--it couldn't hurt to talk to the people at active access though

[BigA]

I think Avonex is the cheapest of the MS Drugs, so I'm surprised that it's not on the formulary. Call biogen and see if they can help.