Coverage of Current AD Drugs

Which drugs are covered?

In general, you and your loved one will have numerous drug plans from which to choose, but the exact number of plans will depend on your city and state. You can choose which plan is best for your loved one by simply completing a form online. This form will ask you which drugs your loved one is currently taking and what pharmacy he or she uses, and will show you all of the insurance plans that currently cover that drug. From those choices, you can then narrow down the choices of which plan would be best for your loved one.

So, for example, if your loved one is taking Aricept® (donepezil), you would indicate that on the form, along with all of the other drugs he or she may be taking for other conditions (eg, high cholesterol, high blood pressure, depression, etc.). If possible, you should choose a plan that covers all of your medications.

The CMS requires that each plan cover at least 2 drugs in each drug category. They are strongly encouraging plans to cover a majority of medications in the following categories: anti-psychotics, anti-depressants, and anticonvulsants. This is true for 2006, and may be re-evaluated in 2007. However, benzodiazepines (eg, Ativan®) are not currently covered.

A Plan Comparison Web Tool is available. The tool will help you pick the drug plan that’s right for your loved one. Otherwise, you can call Medicare directly and someone at Medicare will fill out the form for you to determine your options. There are also local Medicare-related events in which Medicare representatives are available to explain this drug plan and help you complete the form.

If your loved one currently does not have coverage for some of their drugs, they may now be able to get coverage, depending on what plans are available locally. You can quickly find that out by completing the form.

Can a Medicare drug plan change their formulary?

Plans are allowed to make changes to their approved drug list at any time. However, they must give 60 days’ notice of these changes to enrollees who are taking that medication or provide enrollees with a 60-day supply of the medication they are removing from the approved drug list. The plan must also notify prescribing physicians and the Centers for Medicare and Medicaid Services (CMS).

The CMS requires that the plans include medications in a wide range of therapeutic categories.

What if the doctor changes my medication(s)?

That will depend on the specific insurance plan. You can complete the online plan comparison tool (described above) or call Medicare to find out what other plans would cover the new medication. You can switch to a different plan between November 15 and December 31. Your new Medicare prescription drug plan will then begin January 1 of the following year. However, please remember to list all of your loved one’s drugs when using the plan comparison tool. So, even if the new drug is covered by another plan, another drug that he or she is currently taking may not be.

Which drugs are excluded?

Some drugs are currently not included in the new Medicare prescription drug benefit. These include: benzodiazepines (eg, Ativan® [lorazepam], Klonopin® [clonazepam], Valium® [diazepam], Xanax® [alprazolam]), barbiturates, and drugs to treat eating disorders. If your loved one takes these medications, you should either find another patient assist program, which are available from private organizations and drug manufacturers, or talk with your doctor about other possible medication options.