The Sick Game of Medicare D Formularies

The letters are usually four pages long and begin by saying that my patient has received a temporary supply of the medication I prescribed.

Next, there are general paragraphs about how the drug either isn’t on their formulary or the quantity exceeds the plan limits. None of these letters contains a reference to an online formulary physicians can access to compare covered alternatives.

Then there are several cumbersome explanations about the appeal process needed to request a formulary exemption. There are always toll free numbers to call.

Missing from 90% of these letters are mentions of which similar or alternative drugs actually are covered on the company’s formulary. This information is also missing from the smartphone app and website most doctors use to try to avoid these rejection letters – epocrates, the industry standard for looking up drugs, doses and formularies, doesn’t have access to this information from more than a handful of Medicare D plans.

This presents a choice between a few courses of action for the average doctor:

1) Desperately Google “medicare D formulary megapharm insurance corporation” (a fictitious insurance company name, to protect this writer from unnecessary litigation), only to end up following links to help consumers choose a plan in their geographic area, and not finding the more or less secret formulary.

2) Switch the patient to the oldest, least effective and least expensive medication in the class, or even in an older generation of generics, and hope it will go through at the pharmacy cash register. This is still not guaranteed to work, since the costs of some very old medications have skyrocketed in the past year or two.

3) Have your nurse call the patient to let him or her know they’ll have to pay for the medicine themselves or go without, since there is no reasonable alternative.

4) Have your nurse dial up the Medicare D provider, wait on hold for ten or twenty minutes, answer several questions about the patient’s policy number, diagnosis and so on and beg them to reveal which alternative drugs are covered or at least fax over a Prior Authorization form you can chip away at if there is ever a “free” moment in your day.

5) Make the calls yourself, contain your frustration as you listen to the Muzak, see your productivity level and patient volume go down, increase the wait times for patients calling for an appointment, and prepare to see your salary go down after your next performance review.

It is hard to imagine that the Megapharm Insurance Corporations of America are unknowingly wasting paper and postage on these letters that say what’s not covered without advising prescribers which drugs are covered. I am making a very educated guess that the purpose and net effect of these letters is that many patients don’t get the intended prescription, or even an alternate one, thus increasing the company’s profits. For the cost of a single presorted bulk mailing, they can easily save a hundred dollars every single month from this moment forward on one single, hapless victim – excuse me, “member”.

5 Responses to “The Sick Game of Medicare D Formularies”


  1. 1 Ann Lewis January 31, 2015 at 12:40 pm

    My insurance company takes it a step further. We were just switched to a high deductible insurance, which is a joke! Anyway, I started shopping around for the best deals till I learned the ugly truth. They will only cover a 90 day prescription filled by one specific on-line pharmacy. This means that even though I can find the meds for significantly less money elsewhere if I do that zero of the amount spent will be credited against my deductible. Unfortunately I was just diagnoses with Crohns the middle of December, two weeks before the insurance switch. My 90 script filled in December cost me $25. The next fill, through the ‘preferred’ on-line pharmacy would cost $1248! Through a big box store I could get it for $780, but it won’t dent the $3000 deductible, that rolled over again on 7/1/15 (lucky us coming in mid year). I’ve applied to the drug manufacturer for assistance. If I get it great. If I don’t I will have to take my chances going un medicated for now. I am also contacting my senator. It seems to me that a monopoly has been created between the insurance company and the pharmacy. Hopefully I can light a fire somewhere. Sad, sad, sad. I took this job 19 years ago for the great benefits, not the salary, Now, at 59, I don’t see the reality of getting a new one. Sorry this is so long, but I’m fired up about this right now.

  2. 2 meyati January 31, 2015 at 2:43 pm

    I hate the the mindset of doctors having to deal with Pharmaceutical Formulary Boards. I belong to NM Presbyterian HMO/Advantage Plan. I have IBS-D. In the 90s, the Air Force put me on Librax. It’s fairly cheap- even cheaper than what Ann Lewis is using. The FDA seemed to decide that it shouldn’t be produced in the US. They were running out, and there was a bidding war, I was paying $200 a month for it.

    Now it’s imported from Venezuela, Taiwan, and Europe. I haven’t had to pay over a $125 a month, but sometimes it’s $25. The problem is that every so often, the Pres Formulary Board and legal eagles decide that I don’t have the right to buy a prescribed legal med all by myself. Then I get doctors that want to change my med. I tell all concerned that it’s effective. I’m scared of change, especially since some of the alternatives didn’t work in the past.

    The mindset is to get me on something that the Pres Formulary Board approves of, so they don’t have to fight with the board. I sometimes receive letters from Medicare and the Pres Formulary that my doctors are prescribing unauthorised drugs, and we are breaking the laws. I take the forbidden Armour too.

    I’ve have been counseled by phone several times, how I am ruining the compliance of Pres, and they can be fined. I tell them that I will double up with cramps, sweat til my hair is wet, need assistance in walking. I will visit-actually live in the ER waiting room with a 5 gallon bucket and a roll of toilet paper. When the other patients leave, somebody comes out to try to control the situation, and the janitor is trying to clean up–I will tell them your name, and the Formulary Board will not allow me to buy, with my own money, a med that lets me live a normal life. I will add that after a week of this, I also discharge huge amounts of mucous.

    I was at one civilian clinic before I was on medicare, and the head doctor had me see her to change from Librax. I told her that about the 5 gallon bucket-that the rest rooms always had a line. She said, “You wouldn’t?” I said, “I can’t hold it.”

    If a drug is legal, and the medical condition calls for the type of med- it should be covered. The patient and doctor shouldn’t be caught in this dilemma caused by drug companies and federal agencies.

    No wonder my doctors are so stressed out!!

  3. 3 Konstance February 3, 2015 at 1:53 pm

    A word to the wise Medicare Part D Patient: Bring that booklet of your formulary with you to your visits to the doctor. Saves everyone the hassle of those 4 page rejection letters!

  4. 4 Dr Judson Black February 26, 2015 at 3:42 pm

    As an endocrinologist I have a terrible time getting growth hormone and other expensive medications reapproved despite the fact the information was sent to them in the beginning and they are required to keep the information for 10 years after the last provided the drug per state law. When I ask to speak to the company’s endocrinologist who reviews these drugs usually the doctor does not understand why he having to review it because all the criteria are in the records he has. Also I have been asked to do a Growth Hormone Releasing Factor test as a second test despite the known fact is that the ITT is the gold standard and GHRF has not been available in the US for years! I will not give up and am considering a law suite but no body want to sue the pharmacy benefits company or the insurance company.

  5. 5 Deb Stover March 16, 2015 at 12:31 pm

    Big Pharma gets rich while doctors jump through hoops and patients suffer. Medicare Part D is touted as “better than nothing,” but as generic drug prices skyrocket and unregulated formularies rule, for a lot of patients it’s still a choice between eating or taking medication.


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