Making Sense of THE MAZE

​After You've Enrolled, Plans Can Drop Your Medication

March 18, 2006

By Jennifer B. Cona, Esq.

You finally found a Medicaid drug plan that you believe is the best one for you. So now you’re covered and there’s nothing else to worry about, right?

Maybe not.

Beginning March 1, the company that operates your Medicare Part D plan was allowed to remove drugs from the list they cover or reduce the amount they will reimburse you for each drug. You, however, cannot change your plan until the next open-enrollment period, Nov. 15- Dec. 31. And even then, your new plan won’t begin until Jan. 1, 2007. Even if your health situation changes and you need drugs not covered by your plan, you still must wait until Jan. 1.

Elder law practitioners say it is troubling that the new program seems tilted in favor of the private companies, not the seniors they are supposed to be serving.

"I would say it’s 100 percent favorable to the insurance companies," said Jennifer Cona, a partner and director of the elder law division at Cona Elder Law, a Melville based law firm. There is nothing to stop an insurance company from dropping a drug from its list, especially if covering its eats into profits. "It could be just a bottom-line decision," Cona said.

The company must tell you in writing it is revising its plan 60 days before the change goes into effect, so keep a close eye on all correspondence. Remember, the notice will not come from Medicare in an official-looking government envelope. Once you select a drug plan, you are dealing with a company, not Medicare.

If a drug you’re using is no longer covered, you will need to pay on your own or find a substitute that the plan covers.

"If you look at the procedural protections that seniors are supposed to have, like 60 days’ notice, that’s great in theory, but what does it get them?" Cona said. "They can’t change until the annual time period, so it gets them nothing."

Cona advises you to hold on to all receipts and statements. If the company reverses its decision and reinstates a drug after dropping it, you may need the paperwork to get reimbursed.

Most of all, Cona says, be alert if you are suddenly being charged more for a drug than before. Your plan may have changed without your knowing about it.

"The law says they are entitled to that notice," Cona said.

"But a lot of people did not get the notice whether their employer or union coverage is creditable, so there already are notice problems, and we’re hardly off the ground," she said.