Rick – Vt.: One of my drugs, eszopicolone, is not covered on my plan or any other plan for 2016. I had them send the complete formulary for 2016, which said it is covered. This was dated Oct. 1, 2015. But as of today, the web listing on Medicare.gov says it is not covered. Can the company decide to not cover the drug before or after Jan. 1?
Phil Moeller: Unfortunately, it can. Medicare drug plans have many grounds for changing their formularies on short notice. Perhaps a cheaper generic version of the drug becomes available. Or the drug’s maker raises its price, causing the plan to favor a cheaper alternative. Or supplies of a drug are in short supply. Pick your poison. And while the formulary may have been dated Oct. 1, odds are it was filed with Medicare last spring.
However, you have the right to appeal this change. Should your prescribing physician attest to the clinical need for you to continue taking this particular drug, the plan may have to cover it, even if it’s been removed from its formulary. Further, plans just can’t cut you off cold turkey. They are supposed to provide you at least a 60-day supply of any drug that has been removed from the plan. Eszopicolone is the generic name for Lunesta, the sleeping aid medication that went generic in the spring of 2014. It can sometimes take time for drug plans to formally replace branded drugs with cheaper generics. It wasn’t clear from your question whether you have been taking Lunesta or its generic equivalent. Given the popularity of this drug, I’d be surprised if it’s not available in generic form. I checked for it on Medicare’s Plan Finder, and it popped right up.