This article was made available by the Kansas Senior Press Service, a partnership of the Kansas Department on Aging and Johnson County Human Services & Aging.

Q: What can I do if my drug plan will not pay for a drug on its formulary?

A: You should make a formal, written request to your plan, asking it to pay for the drug you need. This is called “asking for an exception.” You may ask your plan for an exception to:

           Cover a drug that is not on its formulary.

·         Override plan restrictions (such as prior authorization, step therapy, or quantity limits) so your drug will be covered for the rest of the year without need for you or your doctor to make monthly requests.

·         Put your drug on a lower cost tier for you so it will cost less.

You may not ask for a tier exception when the drug you need is in a “specialty tier” (often the most expensive drugs) or you want to access a brand-name drug at the same co-pay tier as a generic drug. The process is the same whether you are in a Medicare private health plan with drug coverage (MA-PD) or a stand-alone private drug plan (PDP).

You are unlikely to be granted an exception if your drug is excluded from Medicare coverage by law.

Most of the time, you will find out that your drug is not covered or has restrictions when you try to fill your prescription at the pharmacy. Do not give up at this point! To ask for an exception:

1.      Obtin a written supporting statement from your prescribing doctor. You or your doctor may request an exception. However, you will need a letter from your doctor certifying that the drug prescribed is medically necessary and other drugs or quantities on your plan’s formulary are not as effective or are harmful for you, or other drugs or quantities on your plan’s formulary are likely to be ineffective or harmful to you. In an emergency, your doctor may ask the plan to make a faster decision. Your doctor should explicitly state in the supporting letter that you need an “expedited decision” because your “life, health, or ability to regain maximum function” is at risk.

2.      Find out where to file for an exception. Call your plan or look at your plan’s Web site or “Evidence of Coverage” booklet to learn where to fax or mail your request and your doctor’s supporting letter and whether you need to submit any other forms. Keep proof (such as fax transmission reports or certified return receipts) of when you submitted your exception request. You will need this proof if your plan does not respond to your request on time.

3.      Make sure your plan responds when it should. Plans must respond within 72 hours of receiving your doctor’s written statement explaining why the drug is medically necessary for you. In an emergency, plans must respond to expedited requests within 24 hours. These are clock hours, not business hours. Your plan should contact you with a decision—but if you do not hear in the proper time frame, call and ask for the plan’s decision.

4.      If the plan does not respond within the required timeframe, then the lack of a decision is considered a denial and you may submit your appeal to the Independent Review Entity yourself. You may also want to file a complaint with your plan.

5.      Make sure the plan authorizes coverage for the remainder of the plan year. When a drug is covered by your Medicare private drug plan but is subject to prior authorization, your plan may grant coverage for as little as one month at a time. In some cases, you may have to get authorization from your plan each month that you need the medication. To get authorization for a restricted drug for the remainder of the plan year, you or your doctor will need to request an override to the restriction by following the same procedure as you would to request an exception.

6.      If the plan denies your exception request, you may appeal the plan’s decision. Your plan should respond to you in writing with a letter titled “Notice of Denial of Medicare Prescription Drug Coverage.” The letter will tell you how to appeal.

 For more information, contact Senior Health Insurance Counseling for Kansas (SHICK) at 1-800-860-5260 to schedule a free, confidential counseling session with a trained, unbiased counselor in your area.Source: Medicare Rights Center

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By Mike Shields

KHI NEWS SERVICE

WASHINGTON, D.C., – Infections acquired at a hospital, clinic or doctor’s office rank among the leading causes of death in the U.S., costing needless suffering, billions of dollars and about 100,000 lives every year.

“It is a largely preventable epidemic but we are not doing nearly enough to prevent it,” said U.S. Rep. Henry Waxman, a California Democrat and chairman of the House Committee on Oversight and Government Reform.

A hearing on the topic of hospital-acquired infections was held Wednesday by Waxman’s committee with the focus on a new report from the Government Accountability Office.

“The costs…are borne not only by the patients who suffer the infections, but also by those who pay for care such as the Centers for Medicare and Medicaid Services (CMS),” said GAO health care expert Cynthia Bascetta.

GAO concluded that the Department of Health and Human Services should do a better job integrating and using the information it collects about hospital-acquired infections and that the agency also should prioritize the 13 guidelines and 1,200 recommended prevention practices provided by the Centers for Disease Control so that it can better promote hospital compliance nationwide.

In October, CMS is scheduled to begin implementing its so-called “no-payment” rules, halting reimbursements for care due to harm caused by a hospital, including infections associated with urinary tract and vascular catheters and mediastinitis, a type of infection from heart bypass surgery.

According to the CDC, “in American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections,” yearly of which:

·        32 percent are urinary tract infections

·        22 percent are surgical site infections

·        15 percent are pneumonia (lung infections)

·        14 percent are bloodstream infections

Five bills have been introduced in Congress that would establish a national infection reporting law and more aggressive prevention, including some patient screening, according to Consumers Union, which has been campaigning against hospital-acquired infections for about five years. Twenty-two states already require infection reporting. But Kansas is not among them.

“It is not a required reported item. We do not have that in the state, nor do we have that nationally,” said Larry Pitman, president of the Kansas Foundation for Medical Care, a non-profit organization that works with various government agencies, including HHS, to improve the quality of medical care.

Pitman said there was no way to know the rate of infections in Kansas hospitals or how they might compare with those in other states.

Most accredited hospitals will have a nurse or team in charge of quality assurance that tracks patient infections. That information is made available to the medical staff and discussed regularly but rarely made public.

HHS recently announced its new Hospital Compare Web site which provides consumers access to information about most hospitals in every state, including how often the facilities use proven surgical infection prevention techniques. But the site doesn’t offer information about the hospital’s infection rates.

“There has been a consistent lack of strong leadership in the federal government to fight hospital-acquired infections,” said Lisa McGiffert, director of Consumer Union’s anti-infection campaign. “The work that has been done rarely focuses on the public interest or demonstrates sensitivity to the years of horrific and painful recovery an infected patient must endure. Rather, it has focused more on the need of the health care providers than the threat to the public – with voluntary reporting and limited visible enforcement of Medicare’s requirement that hospitals implement infection prevention policies.”

McGiffert said required public reporting was essential to fighting the problem.

“When state legislators began responding to our activists’ requests to take action against hospital-acquired infections, it stimulated a public discourse on the subject throughout the country and put this problem front and center where it should be.”

Dr. Peter J. Pronovost, medical director of Johns Hopkins’ Center for Innovation in Quality Patient Care testified that “the majority of federal research funding supports…efforts to understand disease biology and identify promising new therapies.”

But “for every dollar the federal government spends on traditional biomedical research,” he said, “it spends a penny on research to ensure patients actually receive the interventions identified through biomedical research. Given this imbalance, it is understandable, perhaps predictable, that the U.S. has some of the best basic and clinical science research, yet the worst patient health outcomes in the industrialized world.”

-Mike Shields is a staff writer for KHI News Service, which specializes in coverage of health issues facing Kansans. He can be reached at mshields@khi.org or at 785-233-5443, ext. 123.

The ADVOCATE was born on July 4, 2005 & lived until Jan. 2008. It will remain an online newspaper until it will return as a REGIONAL KANSAS MAGAZINE.in 2013.