Dear Marci,
I might need COVID-19 treatment. Will Medicare cover Paxlovid if I need it?
-Ralph (Indianapolis, IN)
Dear Ralph,
Yes! Good news from Medicare! It is now covering prescriptions for the oral antiviral COVID-19 treatment, Paxlovid, through the end of 2024. You can access it in a couple of different ways.
If your Part D plan participates in the Paxlovid patient assistance program, you can have your prescription filled free of cost at your pharmacy. Contact your plan to find out if it participates.
If your plan doesn’t participate, or you simply don’t have drug coverage, you can still get Paxlovid at no charge. You’ll just need to enroll in the U.S. Government Patient Assistance Program (USG PAP) operated by Pfizer.
If you are choosing a Part D plan, you can search for Paxlovid and add it as prescription drug when comparing drug plan costs on Medicare’s Plan Finder. This will allow you to choose a drug plan that automatically covers the medication.
If you decide on a drug plan that does not cover Paxlovid, you can still obtain the medication through the USG PAP mentioned above.
Stay well!
-Marci
Health Tip!
A survey conducted by the National Academies of Sciences, Engineering, and Medicine suggests that 1 in 3 US adults over 45 feel lonely, despite our ability to reach someone with the click of a button. Social isolation can be harmful to our health, increasing the risk of heart disease, depression, and mental decline. However, people supported by meaningful human connections tend to sleep better, experience less stress, maintain healthy habits, and have a better quality of life. Fortunately, there is a lot we can do to decrease loneliness while improving our overall health.
The CDC provides some useful tips for maintaining healthy social connections and better health:
Take time to nurture your existing relationships
Create new connections by joining a club or taking a class at your local library
Invite a friend to join you for a walk, a meal, or start a new activity together
Provide support to others in whatever ways you can
Reduce or limit your social media use; call a friend instead
The CDC provides some useful tips for maintaining healthy social connections and better health:
Take time to nurture your existing relationships
Create new connections by joining a club or taking a class at your local library
Invite a friend to join you for a walk, a meal, or start a new activity together
Provide support to others in whatever ways you can
Reduce or limit your social media use; call a friend instead
Dear Marci,
Dear Marci,
I received a discharge notice from the hospital, but I need to continue medical care. I think I can appeal but I’m not sure what to do. Please help!
-Lorraine (Buffalo, NY)
Dear Lorraine,
You’re right! If you think you’re being discharged from the hospital too soon, you do have the right to file an appeal.
You should’ve gotten a notice that explains this right titled, Important Message from Medicare, when you were admitted. If you were there more than 3 days, you should receive another copy of the same notice between 4 hours and 2 days before you are to be discharged.
The Important Message from Medicare notice will have instructions for filing a fast (expedited) appeal. This appeal will be sent to the Quality Improvement Organization (QIO), a company that is contracted to evaluate discharge appeals. For a fast appeal, you must appeal by no later than midnight on the day of your scheduled discharge. Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which must explain, in specific detail, why the hospital believes that Medicare coverage for your stay is ending, and that discharge is appropriate. You can also send additional information about why you, and your care team, if appliable, believe the discharge is too soon. The QIO should call you within 24 hours with their decision.
If the QIO agrees with the hospital that Medicare coverage of your hospital stay should end, you have the right to continue to appeal to higher levels of review. If you stay in the hospital after the QIO decision agreeing with the hospital, however, you may be responsible for the full cost of your care from the date of that decision forward if you don’t win at a higher level of appeal. There are five levels of appeal, and instructions for the next steps are included in each decision. Keep in mind that at each level there is a separate time limit for when you must file the appeal and when you’ll receive a decision.
Here are a few tips to help you succeed:
Follow the appeal timelines for each level.
Take good notes throughout the process & keep original copies of all documents.
Include a letter from your doctor or other care-team member explaining why your specific circumstances require additional hospital care to support your appeal.
Contact your State Health Insurance Assistance Program (SHIP) for more guidance on your appeal.
(Later appeals processes differ for Medicare Advantage and Original Medicare. For more information about higher levels of appeal if you are in a Medicare Advantage plan, see: Medicare Advantage appeals if your care is ending – Medicare Interactive. For more information about higher levels of appeal if you have Original Medicare, see: Original Medicare appeals if your care is ending – Medicare Interactive )
Good luck!
-Marci
I received a discharge notice from the hospital, but I need to continue medical care. I think I can appeal but I’m not sure what to do. Please help!
-Lorraine (Buffalo, NY)
Dear Lorraine,
You’re right! If you think you’re being discharged from the hospital too soon, you do have the right to file an appeal.
You should’ve gotten a notice that explains this right titled, Important Message from Medicare, when you were admitted. If you were there more than 3 days, you should receive another copy of the same notice between 4 hours and 2 days before you are to be discharged.
The Important Message from Medicare notice will have instructions for filing a fast (expedited) appeal. This appeal will be sent to the Quality Improvement Organization (QIO), a company that is contracted to evaluate discharge appeals. For a fast appeal, you must appeal by no later than midnight on the day of your scheduled discharge. Once you file the appeal, the hospital must give you a Detailed Notice of Discharge, which must explain, in specific detail, why the hospital believes that Medicare coverage for your stay is ending, and that discharge is appropriate. You can also send additional information about why you, and your care team, if appliable, believe the discharge is too soon. The QIO should call you within 24 hours with their decision.
If the QIO agrees with the hospital that Medicare coverage of your hospital stay should end, you have the right to continue to appeal to higher levels of review. If you stay in the hospital after the QIO decision agreeing with the hospital, however, you may be responsible for the full cost of your care from the date of that decision forward if you don’t win at a higher level of appeal. There are five levels of appeal, and instructions for the next steps are included in each decision. Keep in mind that at each level there is a separate time limit for when you must file the appeal and when you’ll receive a decision.
Here are a few tips to help you succeed:
Follow the appeal timelines for each level.
Take good notes throughout the process & keep original copies of all documents.
Include a letter from your doctor or other care-team member explaining why your specific circumstances require additional hospital care to support your appeal.
Contact your State Health Insurance Assistance Program (SHIP) for more guidance on your appeal.
(Later appeals processes differ for Medicare Advantage and Original Medicare. For more information about higher levels of appeal if you are in a Medicare Advantage plan, see: Medicare Advantage appeals if your care is ending – Medicare Interactive. For more information about higher levels of appeal if you have Original Medicare, see: Original Medicare appeals if your care is ending – Medicare Interactive )
Good luck!
-Marci
Dear Marci,
Dear Marci,
I heard there are a few changes to Medicare costs this year. What should I expect?
-Marco (Chattanooga, TN)
Dear Marco,
Yes, that’s right! Here’s a breakdown of the costs you can expect in 2024:
Part A (Hospital Insurance)
Premium:
Free if you’ve worked 10 years or more
$278 per month if you’ve worked 7.5 to 10 years
$505 per month if you’ve worked fewer than 7.5 years
Deductible:
$1,632 each benefit period
Coinsurance:
$0 for the first 60 days of inpatient care each benefit period
$408 per day for days 61-90 each benefit period
$816 per lifetime reserve day after day 90 in a benefit period (You have 60 lifetime reserve days that can only be used once. They’re not renewable.)
Skilled Nursing Facility:
$0 for the first 20 days of inpatient care each benefit period $204 per day for days 21-100 each benefit period
Part B (Medical Insurance)
Premium: $174.70 is the standard premium
Deductible: $240 per year
Coinsurance: 20% for most services Part B covers
Part D (Prescription Drug Insurance)
National Average Part D Premium: $32.74/month
Maximum Deductible: $545 per year
Coverage Gap Begins: $5,030 (you and your plan together)
Catastrophic Coverage Begins: $8,000 (your costs, including brand coverage gap discounts)
Costs after catastrophic limit: $0
For more details, check out our Guide to Medicare Costs in 2024 here: Medicare Costs in 2024.
You can also review your Medicare & You 2024 handbook (contact 1-800-MEDICARE (633-4227) to receive one) if you have Original Medicare. If you have a Medicare Advantage Plan, contact your plan directly to learn about changes in 2024 that might affect you.
I hope this helps!
-Marci
I heard there are a few changes to Medicare costs this year. What should I expect?
-Marco (Chattanooga, TN)
Dear Marco,
Yes, that’s right! Here’s a breakdown of the costs you can expect in 2024:
Part A (Hospital Insurance)
Premium:
Free if you’ve worked 10 years or more
$278 per month if you’ve worked 7.5 to 10 years
$505 per month if you’ve worked fewer than 7.5 years
Deductible:
$1,632 each benefit period
Coinsurance:
$0 for the first 60 days of inpatient care each benefit period
$408 per day for days 61-90 each benefit period
$816 per lifetime reserve day after day 90 in a benefit period (You have 60 lifetime reserve days that can only be used once. They’re not renewable.)
Skilled Nursing Facility:
$0 for the first 20 days of inpatient care each benefit period $204 per day for days 21-100 each benefit period
Part B (Medical Insurance)
Premium: $174.70 is the standard premium
Deductible: $240 per year
Coinsurance: 20% for most services Part B covers
Part D (Prescription Drug Insurance)
National Average Part D Premium: $32.74/month
Maximum Deductible: $545 per year
Coverage Gap Begins: $5,030 (you and your plan together)
Catastrophic Coverage Begins: $8,000 (your costs, including brand coverage gap discounts)
Costs after catastrophic limit: $0
For more details, check out our Guide to Medicare Costs in 2024 here: Medicare Costs in 2024.
You can also review your Medicare & You 2024 handbook (contact 1-800-MEDICARE (633-4227) to receive one) if you have Original Medicare. If you have a Medicare Advantage Plan, contact your plan directly to learn about changes in 2024 that might affect you.
I hope this helps!
-Marci
Dear Marci,
Dear Marci,
My pharmacist said my Part D plan won’t cover my medication. Why would this happen?
-Tony (Plano, TX)
Dear Tony,
There are several reasons that your Part D plan might refuse to pay for your drug. Some of the most common reasons are:
Your drug is off formulary: The drug is not on your plan’s list of covered drugs.
Prior authorization: You must get approval in advance from your plan before it will cover a specific drug.
Step therapy: Your plan requires you to try a different (usually less expensive) drug first.
Quantity limits: Your plan only covers a certain amount of a drug over a certain period (like 30 pills per month).
To find out the reason, you can contact the plan and request a coverage determination, or a formal decision about paying for the drug. Once you know the reason that your drug has been denied, you’ll be able to work with your doctor to communicate with the plan. Your doctor may need to submit additional evidence or information. For example, if your drug is denied because of a step therapy requirement, your doctor may need to submit documentation that you’ve already tried the other, drugs the plan covers to treat your condition. If you and your doctor think that trying the alternative drugs would be dangerous or ineffective for you, you can request an exception to the step therapy rule by filing an appeal. Similarly, if the drug is denied because it is off formulary, you can ask your provider whether the formulary alternatives would be appropriate for you, and, if not, you can request a formulary exception.
There are some reasons that your drug might be denied where you are less likely to obtain a favorable decision through an appeal. In these situations, you still have the right to appeal, but the odds of a successful outcome are lower.
Your drug has been prescribed for an off-label use: “Off-label” is a term used to describe situations where a doctor has prescribed a drug for a reason other than the use(s) approved by the U.S. Food and Drug Administration (FDA) or listed in certain medical reference texts. If your doctor prescribes a medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless it fits into certain narrow categories.
Your drug is excluded from Medicare coverage: Some drugs or specific uses of drugs are excluded from Medicare coverage.
Again, your first step should be to contact your plan to learn why it isn’t covering your medication. Learning the reason for denial is important as you consider your next best step.
I hope this helps!
-Marci
My pharmacist said my Part D plan won’t cover my medication. Why would this happen?
-Tony (Plano, TX)
Dear Tony,
There are several reasons that your Part D plan might refuse to pay for your drug. Some of the most common reasons are:
Your drug is off formulary: The drug is not on your plan’s list of covered drugs.
Prior authorization: You must get approval in advance from your plan before it will cover a specific drug.
Step therapy: Your plan requires you to try a different (usually less expensive) drug first.
Quantity limits: Your plan only covers a certain amount of a drug over a certain period (like 30 pills per month).
To find out the reason, you can contact the plan and request a coverage determination, or a formal decision about paying for the drug. Once you know the reason that your drug has been denied, you’ll be able to work with your doctor to communicate with the plan. Your doctor may need to submit additional evidence or information. For example, if your drug is denied because of a step therapy requirement, your doctor may need to submit documentation that you’ve already tried the other, drugs the plan covers to treat your condition. If you and your doctor think that trying the alternative drugs would be dangerous or ineffective for you, you can request an exception to the step therapy rule by filing an appeal. Similarly, if the drug is denied because it is off formulary, you can ask your provider whether the formulary alternatives would be appropriate for you, and, if not, you can request a formulary exception.
There are some reasons that your drug might be denied where you are less likely to obtain a favorable decision through an appeal. In these situations, you still have the right to appeal, but the odds of a successful outcome are lower.
Your drug has been prescribed for an off-label use: “Off-label” is a term used to describe situations where a doctor has prescribed a drug for a reason other than the use(s) approved by the U.S. Food and Drug Administration (FDA) or listed in certain medical reference texts. If your doctor prescribes a medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless it fits into certain narrow categories.
Your drug is excluded from Medicare coverage: Some drugs or specific uses of drugs are excluded from Medicare coverage.
Again, your first step should be to contact your plan to learn why it isn’t covering your medication. Learning the reason for denial is important as you consider your next best step.
I hope this helps!
-Marci
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