Part d question

[melmadhav]

Hoping someone can help with a question I have about Part D. If a medication is not on the formulary and no exception has been made by the carrier as an approved drug does it still track toward the TROOP and the ICL?

 

[Bob_The_Insurance_Guy]

The answer to your question is No.

If it is not an approved prescription medication on the formulary, nor is it an exception medication, then the costs involved will not go towards the Donut Hole.

With Part D coverage, there is no OOP, there is only amounts going towards the Donut Hole, and therefore the Catastrophic Coverage portion.

 

[unic.consulting]

Hoping someone can help with a question I have about Part D. If a medication is not on the formulary and no exception has been made by the carrier as an approved drug does it still track toward the TROOP and the ICL?

If the pharmacy can submit the medication to the insurance company and get a paid claim (even if the insurance pays no money towards the medication), it will be picked up by the system towards the TROOP, etc. If the claim is simply rejected by the insurance, it will not count towards those totals.

 

[melmadhav]

Thank you for your help!

 

[G.Gordon]

If the pharmacy can submit the medication to the insurance company and get a paid claim (even if the insurance pays no money towards the medication), it will be picked up by the system towards the TROOP, etc. If the claim is simply rejected by the insurance, it will not count towards those totals.

That is correct, but I've seen it go the way of "not applying" more often than not.

 

[unic.consulting]

That is correct, but I've seen it go the way of "not applying" more often than not.

Yeah, 95% of the time they'll get a straight rejection, but there's always prayer.