With Medicare Part D, the insurance companies are in control of the pricing structure, in short of determining the Formulary categories for drugs, namely, defining them as Tier 1 (generic or the cheapest), Tier 2 (middle of the road), Tier 3 (most expensive) or Specialty Drug (high and sometimes not allowed). The fine print in the insurance literature from my carrier, however, does state that one can apply for a "tier cost sharing exception" if given sufficient cause.

Recently, I felt that I had sufficient cause and applied for a tier cost sharing exception. A drug was prescribed whose stated side effects were already a problem for me; therefore, to avoid exacerbating an existing problem, I wanted to try the lowest possible dosage of the drug to see if it worked. The lowest dosage of the drug was a Formulary Tier 3 drug; another form of the exact same drug by the same company, a longer lasting one, was classified as Tier 2, but its lowest dosage was double that prescribed by my doctor and, a capsule, and couldn't be broken in half. 

Here's the time-consuming scenario that followed:

Me to Insurance: "I'd like to apply for a tier exception."

Insurance: "Your doctor has to call us. Here's the number to call." (Insurance carrier supplies an 800 number.)

Me to MD Office: "You have to call this toll-free number to request a Tier Exception and explain to the insurance carrier why I need to try the lowest possible dosage of this drug."

MD Office to Me: "We can't tie up our phone calling these 800 numbers. Please get their FAX and we'll fax the information to the insurance company."

Me to Insurance: "The doctor's office can't telephone your 800 number. It will send you a FAX. What is your FAX number?"

Insurance: "The FAX # is XXXXX."

Me to MD: "The FAX # is XXXXX."

MD Office to Me: (Next day) "We've had no reply to the FAX we sent your insurance carrier."

Me to Insurance: "The MD office said it hasn't received an answer to its FAX to you."

Insurance: "What FAX number did your doctor's office use?"

Me to Insurance: "FAX XXXXX."

Insurance: "That's the wrong number. Use this FAX." (A different number is supplied.)

Me to Insurance: "Thank you. How long will this request take?"

Insurance: "It could take a week or ten days or so. It has to go to medical review."

Me to Insurance: "What?"

Insurance: "If it's a matter of life or death, it can be faster."

Me to Insurance: "It's not a matter of life or death. It's a matter of money."

Me to MD Office: "You have to send a new FAX and to this new number. The first FAX number wasn't correct." (I give MD office the new FAX number. MD office sends new FAX.)

Me to MD Office: (Several days later) "Have you heard from the insurance carrier?"

MD Office to Me: "No."

I call the insurance carrier again and explain that there has been no reply to my MD office's FAX. The insurance carrier's representative investigates, returns to me, saying that the request has been denied, that there wasn't sufficient cause. I ask why. A long winded answer is given and I say, "Please put all that in the mail to me." Several days later, a denial notice arrived in my mail.

My prescription drug (caps theirs) "...IS DENIED AS A TIER COST SHARING EXCEPTION.  COVERAGE REQUIRES ALL OF THE FOLLOWING: (1) THE PATIENT HAS FAILED OR HAS CONTRAINDICATIONS OR INTOLERANCE TO ALL EQUIVALENT FORMULARY DRUGS IN THE LOWER PREFERRED TIERS (I.E., TIER 1 AND TIER 2). THEREFORE, COVERAGE ADDITIONALLY REQUIRES A TRIAL OF (and two different drugs are mentioned) AND (2) THE DRUG IS FDA APPROVED FOR THE CONDITION BEING TREATED, OR ITS USE IS SUPPORTED BY A CITATION IN ONE OF THE FOLLOWING COMPENDIA: (a) AHFS (AMERICAN HOSPITAL FORMULARY SERVICE) DRUG INFORMATION; OR (b)USPDI (UNITED STATES PHARMACOPEIA DRUG INFORMATION); OR (c) DRUGEX INFORMATION SYSTEM FROM MICROMEDEX. THANK YOU.  (Initials with "PHARM.D." follow.)

"Right to appeal" information "within 60 days...or more time if needed" is included with the above denial which I notice contains no information concerning the specific dosage problem encountered for the Rx my physician prescribed.

Nor does it refer to dosages for the two medications in lower tiers which it suggests. Ironically, I note that the lower dosage for the Rx my physician recommended will be moved to a lower tier in 2008 - another point not mentioned. 

Certain facts emerge.  First, the insurance carrier expects the insured to try supposedly comparable drugs (which may have different side effects and different success parameters and, in my case, different but not necessarily comparable dosages), recommended by its "Pharm.D" who knows nothing about the patient. Second, item (2) above would require considerable research and time, and will discourage most people, as it did me, from proceeding further.

My resolution: I discuss the situation with my MD who has a sample of one of the drugs mentioned by the insurance carrier's "Pharm.D" but it is a higher dosage and I don't want to try it. I decide to save money by trying the stronger dosage for the drug my physician initially suggested, and will try the weaker one when it moves to the other tier.

To sum up, with Medicare Part D (which does have some benefits) and its Formulary program, our Congress has put profit-making private insurance carriers in control of senior citizens' outlay for prescription drug medical needs recommended by patients' doctors. Clearly, the program needs a major overhaul which can only be done through Congress.  The fact that so many insurance carriers solicited seniors before the Dec. 31, 2007 closing date to apply for or change Medicare Part D insurance coverage is testimony to the profit-margin-involved windfall given them by Congress.

The above-described experience confirms another aspect of the complicated logistics involved with the program.