28 North Shore Towers Courier n August 2015 BY FELICE HANNAH Tips on How to Appeal If Your Part D Plan Refuses to Pay for Your Prescription Drug If a Pharmacist states that your prescription is denied, you or the prescribing doctor should contact your Part D Plan to find out why the Plan refused to pay. You will find the number on the back of your card. Questions to Ask: 1. Is the drug on the plan’s formulary? This means is the drug covered by your plan. You or the doctor has a right to request an exception to have a drug on formulary. If the request is granted, the drug will continue to be covered by your plan through the end of the calendar year, resetting in January. 2. Are there restrictions on coverage. What are they? Restrictions include: a. Prior Authorization—This means that the prescribing doctor must contact the Drug Plan for authorization to show that the drug is ‘medically necessary’ before prescribing the drug b. Quantity Limits—Limits the amount of drugs that you can get at one time c. Step Therapy—The Plan may require that another drug is used before granting approval. You or your doctor can ask for an exception NOTE: When filling a prescription, if you find that the cost for a drug has increased, it may be that the pharmacy is not a Preferred (or Participating ) Pharmacy or the Part D Plan has the drug on another tier since you last had the prescription filled. The cost of a drug is usually lower when using a pharmacy, which is “Participating” or “Preferred,” meaning they participate with your Part D Drug Plan. If the Part D Plan changes your prescribed drug tier during the year, you have the right to have the drug remain on the same tier for the rest of the calendar year. NEW IN 2015 Your prescription drug prescriber must be enrolled in Medicare or have an opt out request on file in order for your drugs to be covered by your Drug Plan. Managed Long Term Care (MLTC) Plans and Fully Integrated Dual Advantage (FIDA) Plans If you are enrolled in a MLTC Plan, you received a notice regarding enrollment in FIDA. For Dual Eligibles, MLTC is mandatory. FIDA is not mandatory. You will be passively enrolled in FIDA, if you do not respond to notices received. If you have questions regarding your MLTC or FIDA status, contact New York Medicaid Choice at 800-401-6582 Elderly Pharmaceutical Insurance Company (EPIC) You may be eligible for lower drug costs by enrolling in the New York State Drug Plan known as EPIC. EPIC supplements your Medicare Part D coverage to lower your drug costs. To be eligible for EPIC, you must be a resident of New York State, 65 years of age or older, with income levels not exceeding $75,000 single/$100,000 married couples. Call Epic for enrolling or to get additional information: 800-332- 3742. Felice Hannah’s MEDICARE CORNER NST Car Butler Professional Car Care Services 718-224-2525 Under New Mgmt-Better Service, Better Value Full Service Auto Detailing Fully Insured Pick Up & Delivery Minor Mechanical & Body Repairs 270-10 Grand Central Parkway, Floral Park North Shore Towers; Building 3, Garage Level 3 TOWERS Restaurant at North Shore Towers 27248 Grand Central Pkwy, Floral Park, NY 11005 718-819-8228 Legally Speaking By: Scott Baron, Attorney at Law HOIST ME NO MORE Q: At a construction site, a contractor had installed a temporary personnel lift, to ferry us workers to our various work locations. The lift became stuck, and we were directed to exit this hoist through an exit in the top. As I emerged onto the top, I was struck by a piece of guide rail that was part of the hoisting mechanism. The rail had broken off and fallen to where it struck me. I have since learned that the contractor had used recycled parts – despite the fact that its contract required the contractor to put up the hoist using new and firstquality Advertorial The law responds to changed conditions; exceptions and variations abound. Here, the information is general; always seek out competent counsel. This article shall not be construed as legal advice. Copyright © 2015 Scott Baron & Associates, P.C. All rights reserved. 159-49 Cross Bay Boulevard, Howard Beach, New York 11414 • 718-738-9800 1750 Central Park Avenue, Yonkers, NY 10710 • 914-337-9800 1-866-927-4878 parts. A: Under section 240(1) of the Labor Law, you appear to have an excellent case. The hoist is a safety device specified in the statute. It failed. In addition, the guide rail was required to be kept secured. It was not. These failures were the proximate cause of your injury. Under section 200 of the Labor Law, and also as a matter of common-law negligence, you also seem to have a very strong case. When a contractor launches a force or instrument of harm, he potentially has tort liability even to third party, like you. Under a third section of the Labor Law – 241(6) – you would need to prove a violation of a specific applicable industrial code section in order to succeed. While nothing you have told me points to such a section, perhaps your attorney can identify one, upon learning about this mishap in greater detail.
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