To lower costs, many plans offering prescription drug coverage place drugs into different “tiers" on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

Here's an example of a Medicare drug plan's tiers (your plan’s tiers may be different):

Tier 1—lowest copayment: most generic prescription drugs
Tier 2—medium copayment: preferred, brand-name prescription drugs
Tier 3—higher copayment: non-preferred, brand-name prescription drugs
Specialty tier—highest copayment: very high cost prescription drugs
In some cases, if your drug is in a higher tier and your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) thinks you need that drug instead of a similar drug in a lower tier, you or your prescriber can ask your plan for an exception to get a lower coinsurance or copayment for the drug in the higher tier. Plans can change their formularies at any time. Your plan may notify you of any formulary changes that affect drugs you’re taking.

Anonymous wrote:

Anonymous wrote:Call Medicare on the back of her card and they will look at the prescriptions and help you choose a better plan. Also, get her a supplement.

She has Part D supplement. She pays $104 a month for that, and takes no other medications. So basically she's paying for nothing at this point. In terms of getting a better plan, we've already discussed this - she would have to wait until the end of the year, and even then she's not sure if there is a plan that will solve this issue.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

How do you think the immigrant parents of wealthy Silicon Valley workers qualify? No assets in their name. They don’t get retirement beyond SSI though, that’s why I am suggesting to add a zero income “household member” in the mix (may require some creativity).

Anonymous wrote:What is the good Rx price. You can’t use it with insurance (including Medicare), but is it cheaper? Is there another covered drug that is similar? Has she tried it? A lot of time, if you demonstrate the covered drug doesn’t work, insurance will cover the one that does work. But you need fry and fail first.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

This is the way to go. Or she needs to give you her assets and add someone with zero income to her household (jut on paper) so that she becomes low income herself.

Doing this without competent legal advice is a recipe for disaster.

I think reading the rules on asset transfer and household eligibility should suffice.

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

This is the way to go. Or she needs to give you her assets and add someone with zero income to her household (jut on paper) so that she becomes low income herself.

Doing this without competent legal advice is a recipe for disaster.

On February 11, 2022, the U.S. Court of Appeals for the 11th Circuit reversed a lower-court decision and found that Medicare must provide coverage for a beneficiary’s off-label use of a medication in Dobson v. Secretary of Health & Human Services, No. 20-11996, 2022 WL 424813 (11th Cir. Feb. 11, 2022). Florida resident Donald Dobson contacted the Center for Medicare Advocacy because his Medicare Part D plan denied coverage for dronabinol. He could not afford the medication without coverage, but he needed it critically. Since he suffered a spinal cord injury and underwent related surgeries, Mr. Dobson has experienced intractable, severe nausea and vomiting that interfere with his ability to function and other aspects of his health. After standard anti-nausea medications failed to alleviate his symptoms, Mr. Dobson’s physicians prescribed dronabinol (brand name Marinol), which worked immediately.

However, when Mr. Dobson became eligible for Medicare based on his disability, his Part D plan denied coverage of dronabinol. The denial was based on the prescription being “off-label,” meaning it was for a non-FDA approved use. Off-label prescribing is a routine, legal practice, frequently used when medications are needed to treat less-common conditions. But Medicare Part D requires more than a doctor’s prescription for off-label coverage. The program allows for coverage only if there is “support” for a particular off-label use in one of the “drug compendia” specified by Medicare law. The drug compendia are essentially reference books that summarize information on prescription medications, including chemical ingredients, potential side effects, clinical studies, and different uses for the drugs. (The compendia are also commercial publications, available only to paid subscribers, so it can be very difficult for Medicare beneficiaries to access the information they need to argue for off-label coverage of needed medications.)

Medicare agreed that dronabinol was medically necessary for Mr. Dobson. There is also a compendium entry indicating dronabinol’s off-label use for intractable nausea and vomiting that is disease-related – his very condition. Yet Medicare denied coverage on the grounds that his use was not “supported by” that compendium entry because Mr. Dobson did not share exactly the same underlying diagnosis as the patient described in the entry’s cited case study.

Conducting a thorough analysis of the Medicare Part D statute, the 11th Circuit decided that Congress’s intent was clear. For an off-label use to be “supported by” a compendium citation, the citation “must tend to show or help prove the efficacy and safety of the prescribed medication.” Furthermore, “[n]othing about the common meaning of ‘support’ means that a compendium citation must hyperspecifically identify a prescribed off-label use to tend to show or help prove its efficacy and safety.” Using this commonsense meaning of the word “support,” the court concluded that the listing in question requires Medicare to cover Mr. Dobson’s off-label use of dronabinol.

Anonymous wrote:
OP here - I am 100% certain my mom won't transfer her assets in order to accomplish getting this medication. It's too complex and too many things can go wrong. It is not a life-saving medication rather one that improves the quality of her daily life. The other issue is that because she doesn't have a diagnosis getting any kind of assistance with this just won't happen. I appreciate all of the feedback I've received with my question. Such a great knowledge base!

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

Again, attempting to shift assets to qualify for Medicaid is not for amateurs and if done incorrectly can leave the person with neither the assets nor the Medicaid. Get your legal advice from a competent elder law attorney, not some poseur on a discussion board who doesn’t have a clue.

Oh - with no diagnosis, is it the case that Medicare just won't cover the cost? In that case it might be worth fighting for Medicare coverage of the medication in this specific instance.

OP here - I am 100% certain my mom won't transfer her assets in order to accomplish getting this medication. It's too complex and too many things can go wrong. It is not a life-saving medication rather one that improves the quality of her daily life. The other issue is that because she doesn't have a diagnosis getting any kind of assistance with this just won't happen. I appreciate all of the feedback I've received with my question. Such a great knowledge base!