For the first three months of 2006, Medicare required that Part D plans provide a special transition period to allow beneficiaries time to work with their doctors to find solutions for any coverage problems that existed on any of their drugs. Through the end of March, beneficiaries could still receive coverage for most drugs not on their plans' lists of covered drugs (non-formulary drugs) and those requiring limitations of step therapy (trying less expensive drugs first), prior authorization, or quantity limits.

While new members will continue to have a one-month transition period when they first join, the extended transition period that was in effect to try to ease difficulties with the start-up of Part D ended March 31. If a drug you take is not covered by your Part D plan, or requires limits that don't work for your needs, you have a couple of options.

1. Your plan must cover at least one other drug that can be used in place of the drug you take. Talk to your pharmacist or call your Part D plan to find out names of other drugs that may work for you. Then talk to your doctor about trying one of the other drugs. If you have already tried similar drugs that are covered by your plan with no limitations and they didn't work well for you, move on to the next option.

2. If your physician believes that you need the specific drug you are taking now, ask your doctor to work with your Part D plan to request an exception to stay on your original drug. If the request is approved, your plan will cover your drug. 

For those of you who have just enrolled in Part D, find out right away if any of your drugs are not covered by your plan, or if any have limitations that will create difficulties for you. If you do have a non-covered or limited drug, you should still be able to get a one-month supply of your drug while you work with your physician on the steps above. If you and your physician decide to ask your plan to cover your drug as an exception without special limitations, your plan must make a determination within 72 hours of receiving your standard exception request (24 hours for an urgent request). If the plan does not make their decision in 72 hours, your request is automatically forwarded to an independent review organization.

If your exception request is denied and your plan decides that it will not cover your drug as a covered drug with no special limitations, you can appeal the plan's decision. Have your doctor ask for an "expedited redetermination," if waiting for a decision during the standard time period (seven days) would jeopardize your health. For more information on requesting an exception, or a redetermination of a denied exception request call 1-800-MEDICARE (800/633-4227) or call your Part D plan.

Some of you enrolled in Part D early in 2006 are on drugs that are not covered or are limited by your plans, and did not know that you needed to use the first few months of the year to either transition to similar covered drugs or have an exception approved to cover your specific drug. Your non-covered drug will not be paid for by your plan; it will not even count toward meeting deductible or out-of-pocket maximum amounts. You have the same two options above as new Part D members, but will want to be sure all requests for exceptions and redeterminations are made by your physician on an "urgent" and "expedited" basis, respectively.  Your use of option 1 or option 2 earlier in this article will need to be done quickly, since your plan is no longer covering the drug in question.

People who are beyond their first month of coverage in a Part D plan who are requesting an exception may need to pay for their own drugs in April. If your exception request is approved, you will be reimbursed your portion of the drug cost.

Whether you're a new Part D member or you joined early in 2006, if your plan will not cover your drug and none of their alternative drugs will work for you, you may be able to change Part D plans once before May 15, 2006. If you joined one plan and have not yet changed plans this year, you may change plans one time before May 15. (Beneficiaries with Medical Assistance or other Part D "extra help" may be able to change plans after May 15.) Call the plan you want to switch to in order to find out if they cover your drugs with no limitations.

Unless you have more than one drug that is not covered or has limitations, switching to a different part D plan may not be the best option. Plans can change their lists of covered drugs (formularies), so that a drug that is covered today may not be covered later in the year. It may be wise to consult the Senior Linkage Lineª (800/333-2433) or the MnSF Health Plan Information Center (800/783-5045) to review your options and be fully informed.