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Drug Plan Coverage

Dear Advocate

My mother lives in a nursing home and takes many medications. Her Medicare drug plan just informed us she must change one of her medications because it does not cover the drug. This particular medication is working well. Given her fragile condition, why must we mess with success?

Frantic in Fremont

Dear Frantic in Fremont,

Your mother should not be forced to change medications just because her Medicare drug plan does not include the medication on its list of covered drugs (formulary). You have several options to resolve this concern. Medicare drug plans must allow members to stay on their current medications at least through the end of March 2006.

You can appeal the drug plan’s decision by seeking an “exception.” Ask your mother’s doctor to notify the plan that the medication she uses is necessary and that the drugs on the plan’s formulary are not effective substitutes or might have adverse effects.

If your mother is on Medi-Cal and has a share-of-cost, she can keep her own income to pay for the medication. This right is provided by a California lawsuit settlement in Johnson v Rank.

Your mother may switch to a different Medicare drug plan that covers her medications.

Ultimately, Medicare and Medi-Cal certified nursing homes must provide your mother with drugs that are part of her care plan even if the Medicare drug plan does not pay for them. 42 USC §§1395i-3(f)(1) and 1396r(f)(1).

For more information, see CANHR’s fact sheet, Medicare Part D. (update 2013: please refer to CANHR’s Helpful Links on Medicare Part D.