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Warning for all Medicare & Medicaid beneficiaries....

On Health & Drugs & Medications » Pain Diseases

22,156 words with 8 Comments; publish: Sun, 16 Dec 2007 20:48:00 GMT; (900187.50, « »)

This is a warning for all medicare and medicaid beneficiaries. As you probably are aware, as of 01/01/2006 state medicaid programs around the country will no longer be covering prescription medications for people that also have medicare coverage. This is because as of 01/2006, medicare part "D" prescription drug coverage will begin for all medicare beneficiaries and will take over prescription coverage from medicaid for "dual eligibles" (people with both medicare and medicaid). If you, or someone you know falls into the dual eligible category, a private ins. co. contracted by medicare will cover your prescriptions. Costs for brand and generic medications are supposed to remain the same as they were under medicaid, by law. BUT, the coverage will be changing, which will directly effect people on Benzos. Benzos and barbiturates will no longer be covered (because most state medicaid programs covered benzos, but medicare excludes these medications from coverage under any medicare drug plans.) So medications like valium, xanax, phenobarbitol, knonipin, ativan, etc. that had been covered by medicaid, will NOT be covered under medicare by any of the medicare drug plans. The only way this can be rectified is if the state medicaid program covers these medications now for dual eligibles, they are being encoraged by the feds to continue coverage of these medications under the medicare program for dual eligibles. But it is up to each state as to whether they will fund the coverage of these meds (if they do, the feds will provide federal matching funds). If the state that you live in does decide to cover these drugs, the coverage will be seamless, meaning that these drugs will be added to the list of approved drugs under your new medicare drug plan, without any action on your part. But, I would strongly advise any patients that are at risk of losing coverage for these meds, to call and lobby your state medicaid director, to continue coverage of these important meds, under the medicare program, for dual-eligibles.

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  • 8 Comments
    • Hey Wirry, I don't have medicaid but my understanding is that private insurance carriers must at least meet the criteria set forth by the new section D program for madicare, did you call every providor in your state or the country for that matter to deterimine that an independent providor is going to exclusd something they don't have to cover. In most areas the private insurance carriers are offering better coverage than what was laid out in the medicare plan.

      I think you might be jumpng the gun a bit. I still have to reseach every available private insurance carier to see what there levels of coverage are and what meds are aproved and not aproved. Like I said in most cases the private insurance companies are offering better coverage than those layed out in the medicare plan. Simply because medicare doesn't cover a particlur drug doesn't mean that the private insurance won't. I haven't even been able to see a list of aproved drugs yet and have gotten the 2006 medicare book and checked their web site, Untill I call each and every company, about 16 in my area alone, I won't know which one provides better coverage for the premium or which meds are covered.

      You may have to pick a programn that has higher levels of coverage but if you qualify for medicaid in most cases your premium will be covered anyway, so you still have pretty much the best script coverage available at no cost.

      Can you confirm this with a link to medicare aproved drugs, I have yet to see one as some plans are still undescided and limits aand premiums haven't been set. I would also imagine you have the same exemptions for meds of neccesity that these major companes like Cigna, Kaiser, Aetna, BC BS and many other plans offer. The guidelines that medicare set forth are the very least a private carrier can offfer.

      I will be calling this week to gather info to make a decision but have gone without many meds after a my heart attack for years due to cost so at this point any help is a god send to me. Although I don't qualify for any govt or PAP assistance aside from medicare and Socail secuity it doesn't mean I can afford to spend 80% of my disability income on prescription drugs.

      I'll do some more resarch and see what I find in my state. I do presently take a benzo for RLS after tryng every other med on the market to treat this and pay cash every month, it would be nice to have some assistance but if I didn't, it wouldn't be a change for me.

      Good luck and don't jump the gun, I don't think anyone could possibly know all the ins and outs of this new plan as ability for registration just started saturday and today is the first day you can truly gather information and some plans don't even have their info together yet. The person you may have spoke to may be wrong or not even know all he ins and outs of this complex plan that's farmed out to dozens of private carriers.

      Dave

      PS. I just called medicare and spoke to a customer service rep and asked if they had a list of aproved drugs and non aproved drugs by medicare or any of their private carriers and they had no information and told me to call back at the end of the month?

      #1; Sun, 16 Dec 2007 14:58:00 GMT
    • With all due respect shoreline, don't be so quick to dismiss my post. The medicare legislative exclusion of several classes of critically important drugs is a topic that has been swept under the rug by the medicare policy wonks in Washington. But these exclusions are real and are a major problem with the new "part D" medicare prescription drug benefit. As it stands right now, without a national legislative "patch", a medicare patient requiring one of the excluded medications would be forced to pay completely out-of-pocket regardless of any medicare approved prescription drug plan they have. Now if that person happens to have medicaid, the feds are urging the state medicaid director to approve coverage of these excluded meds under the state medicaid programs' funding (especially if that state currently covers the excluded meds under their program, and most states do cover most of the federally excluded meds for medicaid recipients), whereby the medicare approved drug plan would be reimbursed by the state for adding coverage for the excluded class of medications to their formulary. The feds have said that they would then reimburse the state 50% of the cost, using federal matching funds. But this scenario requires action by each individual state's medicaid director to get the ball rolling. And in that scenario, these excluded meds would only be covered for extremely low income medicare beneficiaries, who qualify for medicaid. The following classes of medication are excluded according to federal law (Medicare Improvement and Modernization Act of 2003). Medicare Part D Excluded Drugs: Medicare will not pay for the following:

      1. Drugs for weight gain or weight loss (including those agents

      used for the treatment of cancer and HIV related weight loss);

      2. Fertility drugs;

      3. Drugs for cosmetic purposes or hair loss;

      4. Prescription Vitamins (except for prenatal vitamins and

      fluoridepreparations);

      5. Drugs for the relief of cough and cold symptoms;

      6. Over-the-counter (OTC) drugs;

      7. Barbiturates, and

      8. Benzodiazepines.

      This article has complete details of this coverage lapse (it was written with nursing home residenets in mind because they make up a large share of dual eligibles, and they often require benzos and barbiturate; but the article is completely applicable to anyone and everyone on just medicare and/or both medicaid & medicare) http://www.ascp.com/MedicareRx/docs/ASCPPaperExcludedMeds.pdf

      Here are more official articles regarding this medicare medication exclusion:

      http://pn.psychiatryonline.org/cgi/content/full/40/15/1

      www.**************.org/benzoreport.pdf

      Here is the info straight from the federal Centers for Medicare and Medicaid Services (CMS) [very long link]

      http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_adp.php?p_faqid=4608&p_created=1113837066&p_sid=OyzBoiSh&p_lva=&p_sp=cF9zcmNoPSZwX3NvcnRfYnk9JnBfZ3JpZHN vcnQ9JnBfcm93X2NudD0xMDUmcF9wcm9kcz0mcF9 jYXRzPSZwX3B2PSZwX2N2PTIuMjM3JnBfc2VhcmN oX3R5cGU9YW5zd2Vycy5zZWFyY2hfbmwmcF9wYWd lPTE*&p_li=&p_topview=1

      #2; Sun, 16 Dec 2007 14:59:00 GMT
    • Hey Wirry, I wasn't trying to be quick to dismiss you post but try to prevent a panic this a new syetem using private corps whose guideline is to at least meet the basic criteria that medicaid or medicare offer, It doesn't prevent them from offering beter benefits, and from what I have seen most offer better.

      I'll check the links but I don't believe the will prevent a private corp to offer better coverage than the minmum standards. There isn't a formulary available from anyone in my state as of yet.

      A new formulay will overide any previous formulary but there isn't one available yet. Untill a formulary is available I wouldn't fan a speculative fire.

      This is the beginning of article from that long addy with the info you posted that says they may exclude Benzos and barbtuates, BUt I may get hit by a buss before I ever see a single prescription benefit, I haven't in 3 years, or another private carrier may offer coverage on these drugs.

      In accordance with section 1860D-2(e)(2) of the Act, the definition of a Part D drug specifically excludes drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid under section 1927(d)(2) of the Act,

      I would rather see a $250 a month supply of Plavix covered before I see aa 30 dollar script for xanax or klonopin. Not that we know at this point anyway. You are speculating on a govt formulary that will or may be updated or one offered by a private carrier that's not presently available.

      That article basically said there may be certain drugs that aren't covered. Of course there will be drugs that aren't covered.

      How about the foks that qualify for nothing and can't spend 100% of their income on life saving drugs but don't qualify because they can't afford to take the meds to show the need. Unfilled prescriptions don't count as far as showing need and out of pocket expense applied towards a spend down amount. When you file for medicaid you can't claim the meds you can't afford to take because cost precludes them.

      There seems to be some inequity when a poverty line dicatates whether someone may recieve 5K in free meds a month, free healthcare, housing subsidies and food stamps and someone a few hundred dollars above that line will go without any benfits and life saving meds that exceed their income.

      I think you need to pick your legislative battles and fighting for what may happen as far as coverage of benzos needs to be weighed against those going without life saving meds because they don't meet the criteria for any assitance. A lot more people have fallen through the cracks and recieve nothing than will be affected by the posibilty of benzo's not being covered.

      #3; Sun, 16 Dec 2007 15:00:00 GMT
    • Here is just One formulary for One plan I sent away for information today but checked their website,They also covered every LA opiate, the antiseizure meds, every antidepressant I can name, Soma, Androgel along with amphetamines and phenobarbitol.It even covers Viagra and birth control for those in need.

      I'm still looking for benzo's but they do mention non formulary drugs being aproved when medicly neccesarry.

      This plan cost 42 dolars a month, covers the gap betwen 2000-and 3600 if you use generics and the 25% copays. This would cover at least a thousand dollars a month in meds I can't presently take, If I do have to pay 30 bucks a month for Klonopin I'll still be a happy camper.

      Note: Requires Prior Authorization

      Formulary Alternative(s): phenytoin

      PHENOBARBITAL phenobarbital 100 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 15 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 16.2 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 20 mg/5mL Elixir Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 30 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 32.4 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 60 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 64.8 mg Tablet Tier 1 Preferred Generic

      PHENOBARBITAL phenobarbital 97.2 mg Tablet Tier 1 Preferred Generic

      Stimulants

      ADDERALL amphetamine-dextroamphetamine 10 mg Tablet Tier 1 Preferred Generic

      ADDERALL amphetamine-dextroamphetamine 12.5 mg Tablet Tier 1 PreferredGeneric

      ADDERALL amphetamine-dextroamphetamine 15 mg Tablet Tier 1 Preferred Generic

      ADDERALL amphetamine-dextroamphetamine 20 mg Tablet Tier 1 Preferred Generic

      ADDERALL amphetamine-dextroamphetamine 30 mg Tablet Tier 1 Preferred Generic

      ADDERALL amphetamine-dextroamphetamine 5 mg Tablet Tier 1 Preferred Generic

      ADDERALL amphetamine-dextroamphetamine 7.5 mg Tablet Tier 1 Preferred Generic

      ADDERALL XR amphetamine-dextroamphetamine 15 mg/24HR SR Capsule Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      ADDERALL XR amphetamine-dextroamphetamine 20 mg/24HR SR Capsule Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      ADDERALL XR amphetamine-dextroamphetamine 25 mg/24HR SR Capsule Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      ADDERALL XR amphetamine-dextroamphetamine 30 mg/24HR SR Capsule Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      ADDERALL XR amphetamine-dextroamphetamine 5 mg/24HR SR Capsule Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CONCERTA methylphenidate hcl 18 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CONCERTA methylphenidate hcl 27 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CONCERTA methylphenidate hcl 36 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CONCERTA methylphenidate hcl 54 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CYLERT pemoline 18.75 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CYLERT pemoline 37.5 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      CYLERT pemoline 75 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine, dextroamphetamine Sr, methylphenidate, methylphenidate Sr, Adderall, Focalin

      DESOXYN methamphetamine hcl 5 mg Tablet Tier 5 Non-Formulary

      Formulary Alternative(s): dextroamphetamine

      DEXEDRINE dextroamphetamine sulfate 10 mg/24HR SR Capsule Tier 1 Preferred Generic

      DEXEDRINE dextroamphetamine sulfate 15 mg/24HR SR Capsule Tier 1 Preferred Generic

      DEXEDRINE dextroamphetamine sulfate 5 mg/24HR SR Capsule Tier 1 Preferred Generic

      DEXEDRINE, DEXTROSTAT dextroamphetamine sulfate 5 mg Tablet Tier 1 Preferred Generic

      DEXTROSTAT dextroamphetamine sulfate 10 mg Tablet Tier 1 Preferred Generic

      FOCALIN dexmethylphenidate hcl 10 mg Tablet Tier 3 Standard Brand or Generic

      #4; Sun, 16 Dec 2007 15:01:00 GMT
    • Medicare will not pay for the following:

      1. Drugs for weight gain or weight loss (including those agents

      used for the treatment of cancer and HIV related weight loss);

      2. Fertility drugs;

      3. Drugs for cosmetic purposes or hair loss;

      4. Prescription Vitamins (except for prenatal vitamins and

      fluoridepreparations);

      5. Drugs for the relief of cough and cold symptoms;

      6. Over-the-counter (OTC) drugs;

      7. Barbiturates, and

      8. Benzodiazepines.

      I understand and apologize for your alarm, but most insurance companies don't pay for these drugs. I'm very familiar with prescription drug programs since I've worked in the industry for years, and most of these drugs aren't covered in plans. The Medicaid program is the only program that's been without a strong formulary for years. Heck, I've had Medicaid patients want diapers run under their insurance, and it was done. I think that they're finally just catching up to the rest of the insurance world.

      As far as Medicare, their prescription benefits are relatively new, and of course were going to be subject to change.

      #5; Sun, 16 Dec 2007 15:02:00 GMT
    • I'v done a little more research and now I'm panicking or just depressed. Basicaly if you need something other than generic morphine SR in limited quantities and a BT med no stronger than pecocetl, nothing is covered. No soma, No Roxicodone,no duragesic, no aqtiq, nada.. zip.. nothing. I hope flexerill and low dose morphine works for all. Sorry Wirry, we have more to worry about than benzos which are cheap. , You can get 1 kadian capsule per day. The two formularies I have seen are extremely limited. I should have looked a liitle closer. Benzos will be the least of our problems if you are paying cash for your meds and are disabled but make more than 600 a month. I entered the 4 meds I take and the only thing out of the projected 11k a year that was covered was my BP med, Lopressor which only cost 13 bucks a month anyway. What a joke. I guess aids patients, cancer patients, heart patients or transplant patiients, etc etc etc aren't worth saving, But if I ever get strep throat I think I can get trimox for less than the monthly premium. :rolleyes:

      At least we don't have to worry about the script plan bankrupting social security.

      Go ahead and panic.

      Dave

      #6; Sun, 16 Dec 2007 15:03:00 GMT
    • The whole medicare drug plan "thing" is making me nervous in general (good thing I still have my xanax for now). But if you don't mind me asking, shore, where did you get the information regarding which specific drugs are covered by the plan you're talking about? I thought that info on specific drug formularies for each plan was not available yet. I checked the medicare website, and the drug search option is not up and running yet. (who knows when the govt will ever get its act together enough to help people make an informed choice??) I'm sorry to be the person to start the panic, that wasn't my intent at all, but the info coming out about this medicare plan speaks for itself, and if it starts a panic, well what can I do because, unfortunately, its all true. Shore, let me know if you find out any other tidbits of info on this depressing "benefit".
      #7; Sun, 16 Dec 2007 15:04:00 GMT
    • Hey Wirry, I called medicare and they don't have specific drug info to tell you who might be covering what you take. 3 people have told me to call back in a couple weeks. But I have sent off and recieved info packets and and checked the web sites of two companies seen on TV as medicare part D providors and checked their forumularies on their sites.Then I ran a checker when you punch in your meds and I included meds I would take if I could, the only thing covered "formulary" is my cheap BP med and it's cheap because that's what I can afford not due to any special quality I bothered to research. Cheaper than the monthly premium for meds that aren't covered. I don't think I can advertiise a particlur providor and they will be different in each area. For example XYZ well known insuance is available in northern Va but not in southeastern Va.

      I called every providor in my copy of "Medicare and you 2006." They must print them acording to the state you live in because I had a list of about 6 providors that had confirmed prescription plans that you didn't have to go with their existing HMO or PPO plans. Some were waiting aproval so I called the ones offering script plans only with formularies ready. None of my drugs are covered. I have a much better understanding of what formulary means and prefered means.

      Without the medicare formlary and being able to say if a drug isn't even on medicares', I can't say there aren't any good deals out there if your needs are minimal and morphine SR and percocet works for you.

      I'll keep checking for more info is it becomes available from medcare and new outside souces and have a complete list of every source in my area. Maybe I can get the OK to openly discuss company names and who is offering and covering what in your area. It's something we are going to have to call each and every company and ask for a formulary or their web site, and ask them if they cover your meds, then ask what it takes to get a non formulary aproved. FRom what I heard today, IT aint looking good.

      I'll write a mod and ask if we can discuss the pros and cons of each individual plan and help each other some.

      Take care, Dave

      #8; Sun, 16 Dec 2007 15:05:00 GMT