UHC prescription plan

@DeborahK861663 

• Prescription Drug plans do not tell a doctor what to prescribe.  You don’t give any details so I will only have to guess.

PDP work very simply - you pick the plan that best suits your health needs.  This means, you pick the plan that has the meds that you take on their formulary.   Their formulary has been created on a yearly basis by the rules under Medicare which is enforced by the Center of Medicare and Medicaid Services (CMS) CMS provides the guidelines and requirements to ensure formularies are based on scientific and economic considerations, and that they meet specific coverage requirements.

• Within CMS guidelines, plans have some flexibility in determining which drugs to cover and how they are tiered (e.g., preferred vs. non-preferred). 
• Plans must consider the therapeutic equivalence of different drugs when making formulary decisions. 
• Plans must balance the cost of drugs with the need to cover a wide range of medication
• Plans may use utilization management tools, such as prior authorizations or step therapy, to control drug costs and ensure appropriate use.
• Medicare PDP insurers must include drug classes covering all disease states, and a minimum of two chemically distinct drugs in each class. Part D plans are required to cover all drugs in six “protected” classes: immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.

They may have meds on the formulary that require step therapy(ST) - meaning if a doc prescribes this med, you have to try the others that also may work before trying those up the scale.  

STEP THERAPY:  If this particular drug is on their formulary and listed as “ST”(step therapy), they have others the doc can pick from to see if it works for you..  These have been also proven to be effective.  That is the step therapy.  If the lower cost one does not work you move to the next one until you find the one that works.

If the medication is NOT on the formulary at all, and if it is a new medication for you, you and your doc will have to put in for a formulary exception with the insurer to add it to your plan, usually at a higher price.  If this permission is given by the plan, hen it is covered until next enrollment and it will count towards your plans out of pocket max for the year.

Then when open enrollment start in October, you review your plan at that time and pick the one that is most beneficial for your medication needs at that time.  If your meds are on the expensive side - you should look at both the basic and enhanced plans and decide which is the one best for your needs and also your pocketbook.

EVERY PDP works the same way even though each  may have different drugs covered in their formulary because it is the insurer that is responsible for negotiating their own prices with the drug manufacturers and creating their own formulary under the guidelines that CMS has put out. 

I have family members with HCM - one has had it for a very long time and has used several different meds thru the years -

Of course you are free to buy and pay for out of pocket  the drug that your doc wants you to be on - bypassing the PDP all together.  You might be able to find it someplace else although if you are on Medicare you might not be  able to participate in the manufacturers patient program because you are on Medicare and have access to it threw that program.  But you can always check.

If somebody else is helping you pay for your meds as a PDP insurance program is, then you have to play by the rules of the Medicare PDP program.

Just telling you how it is -

Other plans do it also. I have been taking a medicine for over a year, and they have been paying for it. Last week I got a letter saying they were denying the prescription. I took the letter to pharmacy, and they read it over and explained it to me. My plan said that I needed to try another drug before they would pay for this one. The one they had been paying for since 2023. Go figure. Went to doctor with the name of the one they would approve, same drug, different name. Sounds like "kick back" to me.

DeborahK861663 We're sorry to hear you're having trouble with United Healthcare. We are listening and would like the chance to help as soon as possible. Please visit https://help.aarp.org/s/article/contact-aarp to chat, text, or speak with a representative who can get you in touch with our Member Relations team. - Christy C.