Drug coverage changes — how to find out

“My 49-year-old son is on SSDI and Medicare. He has a chronic condition for which he takes Clozapine, and has been taking it for many years. My worry is that it will not end up in the basket of allowable medications! How can we find out?”

 Crossing Fingers in Maryland

Dear Crossing Fingers in Maryland,

You need not worry that health reform (“Obamacare”) will change which drugs your son’s plan covers.  Health reform does not affect services or drugs for Medicare or Medicaid.

Your son’s drugs are covered either by a “Part D” drug plan or by a Medicare Advantage plan.  An Advantage plan simply puts together regular Medicare coverage with the drug coverage.  These plans can change their list of covered drugs – also called a “formulary” – from year to year.

The drug your son is taking is an atypical anti-psychotic medication used for schizophrenia and bipolar disorder.  Plans will not generally take someone off of a medication he has been taking, and certainly not an anti-psychotic medication.  The impact of changing drugs on a person who has a serious mental illness is too unpredictable and, potentially, too expensive since they may need hospital care or may harm themselves or someone else.

So, even though it is highly unlikely that your son’s plan will stop covering his drug, you can call the plan to find out.  If he has a Part D plan, he will have a separate ID card for pharmacy.  If he has a Medicare Advantage plan, he will have just one ID card.  Either way, call the telephone number on the back of the card.

The plan would have to notify him about any changes to the drug list.  They would send a letter specifically to the people taking the drug that was going to be changed.  Make sure that you see all the letters sent from the plan.

My guess is that you will find that no changes will be made to his particular drug.  But it never hurts to check!

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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.