Category / Medicare Prescription Drug Plans (PDP)

by Jim Sorrentino

Medicare Advantage Issues you Should Know before Selecting a 2023 Plan.

Use It or Lose It Benefits

As we enter the end of the year, it’s important to check if your health insurance plan has benefits that you need, but have not used and will be erased on New Year’s eve.

This applies to Medicare Advantage (MA) plans as well as some employer and marketplace plans.

Some plan benefits that you may have, but could use or lose, before year-end include:

  • Prescription drugs and vaccines
  • Preventative dental care
  • Contact lens/eyewear allowances
  • Healthy living rewards
  • Over-the-counter medication/supplies
  • Telehealth consults
  • Rides to/from medical appointments

Prescription Medications

The cost of prescription medications can be your highest medical expense each year and its one of the most complicated and least disclosed aspect of your health insurance. There can be considerable differences among private Medicare Advantage plans in their cost, choice & access to the medications that your doctor prescribes. 

To help understand these differences, go to Medicare Plan Finder and enter your medications for Medicare Advantage plans in your area and the program will show the comparative: medical and drug premiums, deductibles, co-pays and co-insurance and optional benefits for all plans. Then, you can select a more detailed comparison of up to 3 plans that you are most interested in buying for 2023, before December 7th.

A couple things of other things that you can do before year-end are to check if your current plan offers discounts for using: 1.a preferred pharmacy 2. a discount for 90-day supplies of your maintenance meds (usually generics) from your plan’s preferred pharmacy. Some plans provide up to a 33% discount for a 3-month supply over the cost of buying medications monthly. In some cases, the cost of your medications from your pharmacy can be cheaper by not running it through your insurance plan, especially if your meds are subject to a high deductible and/or co-payment. So, check with your pharmacy.

If you take Tier 3-5 maintenance medications and have already met your yearly deductible, consider having your prescription refilled with a preferred pharmacy before year-end. If you wait until after the 1st of the year, you’re likely to have to pay another deductible early in the year.

Finally, if you are diabetic and use insulin, you should definitely check to see (using the Medicare Plan Finder) what your current or another MA plans for 2023 charges for the insulin that your doctor prescribes. Some plans may include the insulin that you use for $35 or less a month.

Vaccines 

Many FDA approved adult vaccines are covered in full with no co-pay or deductibles through your plan’s network of providers (PCP, pharmacy). These include flu, pneumonia, Hepatitis B, Covid-19 virus. However, not all plans include other important FDA approved vaccines that prevent illnesses such as shingles, tetanus, diphtheria and pertussis. Many insurers require an out-of-pocket deductible payment and a high-cost Tier 3 co-payment.

This means you can have insurance coverage for vaccines, but you may have to pay up to the full cost for specific vaccines.

Preventative Dental Care

In recent years, a number of MA plans have added preventative and some restorative dental care to their plans. While plans often emphasize two “free” cleanings, x-rays and exams a year. Some plans have also expanded their dental coverage to include other services such as filling, root canals, crowns etc. However, a common limitation to these dental benefits is that there is a maximum fee that the plan will pay participating providers for each service/procedure and often full payment coverage is limited to a low-negotiated fee agreed to by a small group of local dentists. If your dentist does not participate in the plan and accept their fee schedule, you will need to pay for the service out-of-pocket and then submit a claim to your insurance company and request reimbursement up to what they allow, not what you paid. Finally insurance companies commonly don’t provide you with their allowable fee schedule and they usually won’t pay for more than the plan’s negotiated rate with their in-network dentists. So, in most cases you won’t know if your dental work is covered until it is completed, paid and you submit a claim for reimbursements.

If you haven’t used up your dental allowance for the year, check with your dental office and either book an appointment before year-end and/or ask to go on an appointment cancellation list. This is another use it or lose it benefit.

Eyewear/Contact Lens Allowance

Most insurance plans have an eyewear/contact lens allowance. The amount of the allowance varies by insurer from $75 to $300/yr. and is usually tied to the premium that you pay. This benefit is another use it, claim it, or lose it. There is no rollover of the benefit to the next calendar year and you usually need a recent eye exam in order your eyewear or contact lens.

If you have a simple lens prescription, there are many options for ordering what you want/need online at reasonable prices for both contacts & eyewear. Examples can include regular & prescription sunglasses, reading glasses and stocking up on contact lenses.

Healthy Living Rewards

More plans are including incentives for healthy living because they attract healthier customers that use fewer medical services and cost the insurance company less to serve. Some plans offer rewards up to $200/yr. in debit cards for taking brief online classes, getting a flu shot, completing surveys, having an annual physical, mammogram, colorectal & PSA screenings, vision test, use of a gym etc.

As with many benefits, you need to earn the rewards, report them, claim them or lose them. There is no roll-over of unclaimed rewards to the following year.

Over-the-Counter Medications/Supplies

Some MA plans also include an allowance of up to $100 a year for over-the-counter medications and supplies. However, there are a number of procedures to complete along with restrictions and limitations that vary for each plan. For example, some plans advertise a $100/yr. benefit, but the fine print states that it is limited to $25 a quarter with no carry-over of the unused benefit from one quarter to another.

So, check with your insurer for the benefit details, limitations and procedures for claiming your rewards.

Source: https://www.todaysgeriatricmedicine.com

Emergency, Urgent Care and Ambulance Services

Health care systems continue to evolved and there are new services that are available, less costly and more accessible than your doctors office or a hospital emergency room. The first level of service is a call to your primary care provider (PCP) during office hours for a phone consult. The second option is to use a “Telemed Service” affiliated with your PCP for questions and concerns that you may have. Telemed services are often covered by your insurance plans with either a low or no fee. The next level of services is an Urgent Care Center. These centers. are designed to divert people from overwhelmed emergency departments. They can diagnose and treat a limited number of medical conditions. Hospital Emergency Departments and Ambulance Service providers are costly and designed to provide a rapid response to people facing life-and-death crises such as heart attacks, strokes, serious accidents & injuries etc. Ambulance service providers are responsible for assessing, stabilizing and transporting patients experiencing a medical crisis to an emergency department. Insurance companies won’t reimburse ambulance companies for providing transportation to individuals with less acute problems. However, recently some insurance plans have added coverage for a limited number medical rides to and from medical appointments. Check your policy or call your plan’s customer service representative listed on the back of your insurance card for more benefit information.

Major Differences among HMO, PPO and Medigap Plans

Unlike original Medicare where you can receive services from any health care provider that has a service and payment contract directly with Medicare, private Medicare Advantage (MA) insurance plans have the primary contract with Medicare and are paid on per capita basis (approx. $12,000/yr./person.) with higher Medicare rates based on the patients’ diagnoses & medical conditions.

HMO plans have well-established provider networks with service contracts and geographical boundaries. Services and use of specialists need to be coordinated and approved by your primary care provider. The patient cost for receiving out-of-network services can be substantially higher than in-network services with the exception of emergency services.

PPO plans also have service and payment contracts with providers that can include broader geographical areas and have less restrictions on prior approval to receive services from speciality providers. However it’s important to note that PPO service providers,who participate in Medicare, are not required to accept all medical insurance plans. This is a common problem for subscribers in small regional MA PPO plans who want to receive services in another state in the absence of a formal contract between the insurance plan and the service provider.

However, a recent development addressing this issue is that national Medicare Advantage insurers such as United Health Care, Humana and Blue Cross affiliates have developed reciprocal agreements among their plans that allow for the acceptance of patients from other affiliated plans at the in-network rates, thereby increasing access to services with lower out-of-pocket expenses. This expanded MA PPO plan coverage can provide a more comprehensive and less costly alternative (for some people) to the option of buying a free-standing Medigap plan and a Prescription Drug Plan along with the cost of your original Medicare.

Medigap plans are private insurance plans used to supplement the coverage of original Medicare including the subscriber responsibilities for deductibles, co-payments and co-insurance. Plans differ based on the comprehensiveness of their coverage, 12 different plan designs and cost of monthly premiums among the different states and regions. If you sign-up for a Medigap plan, you also need to sign-up for a freestanding Prescription Drug Plan (PDP), unless you have credible medication coverage from an retiree employer plan or the VA.

Individuals with high medical expenses, such as renal dialysis and chemotherapy, are good candidates to consider a Medigap plan. MA plans generally require a 20% co-insurance payments for dialysis & chemotherapy until you have paid up to $7,900 -$11,700 in a calendar year, not counting the cost of self-administered medications.

Opportunities to Change Your Medicare Plans

The period of October 15 to December 7th is the annual open enrollment period. If you already signed up for a MA plan, you can still change your plan until December 7th. If you missed this deadline, you can switch from one MA plan to a different MA plan or switch from a MA plan to original Medicare and add a PDP between January 1 and March 31st.

You can make changes yourself by using Medicare.gov, calling the respective plans or calling the State Health Insurance Assistance Program SHIP (877-839-2675)

If you have any comments, or suggestions, please share them with us.

Thanks

Jim Sorrentino

by Jim Sorrentino

Medicare Plans Offer New Discounted Insulin Prices, or Do They?

Medicare Prescription Drug Plans that are sold by private insurance companies in Medicare Advantage Plans and stand-alone Part D plans for people with Original Medicare and Medigap plans are funded largely under contracts with the federal government using taxpayers funds.

Here’s are 3 things in the fine print you need to know.

1. The new pre-election announcement of a “Part D Senior Saving Program” that lowers your out-of-pocket co-payments for insulin, doesn’t begin until January 1, 2021 and doesn’t include the millions of Americans who use insulin every day but are not on Medicare.

2. The progam is optional for government-funded Medicare plans to participate in and the specific insulin that your doctor prescribes for you may not be included in the plan that you select.

To illustrate, in the upstate NY, we have 30 Medicare Advantage plans offered by 5 different insurers. However, in reviewing the details of their plans, only Excellus BCBS and United Healthcare have chosen to participate in this special option that will benefit seniors and disabled people who need insulin to live.

The other insurers who sell federally subsidized Medicare plans but chose not to participate in this insulin option include: Aetna, Wellcare and MVP (a regional insurer).

In drilling down deeper into the participating plans of Excellus and United Healthcare, a few other differences were noted.

Excellus: offers 5 Medicare Advantage plan that have monthly premiums ranging from $0 to $255. However only the three of the higher prices plans ($79, $157 & $255/mo.) are participating in the savings program. The two plans with either $0 or $39 monthly premiums are excluded.

So, individuals who enroll in a $0 or $39 monthly premium plan will be subject to a $380 or $300 deductible and a $42 a month/ $84 for three month supply of insulin from a preferred pharmacy.

By comparison, individuals who enroll in one of the three higher priced Excellus plans will not be subject to a deductible and will pay $25 a month/ $60 for 3 month supply of insulin from a preferred pharmacy.

United Healthcare: offers 4 plans with monthly premiums ranging from $0 to $79 a month. All of their plans include the insulin saving plan with an insulin cost of $35 a month/$95 for 3 months from a preferred pharmacy until you enter the catastrophic phase of medication expenses.

Finally note….always confirm that all your health care providers participate in any health insurance plan you are considering and that the medications that your doctor and you feel work best for you are also included in the plan’s formulary.

And, don’t be distracted with the marketing of $0 premium plans and extra free benefits that you may never qualify for or use. Spend some time shopping and comparing plans based on your most critical health care needs and the cost you’re likely to experience in the coming year.

There are two common problems that I see with clients….some are gamblers and they are under-insured even when they can afford to be safer.

And there are others that are too complacent and continue to stay with the same insurer/plan for 10 plus years even when their needs and income have changed. They are spending too much on insurance and don’t have enough money for other basic needs.

Look at the options that are available to you and make a choice that allows you to sleep at night.

Best wishes and stay safe and well.

Jim Sorrentino

by Jim Sorrentino

What to Know When Selecting a Medicare Prescription Drug Plan

Background of Private Medicare Prescription Drug Plans

  • Legislation design by the President G.W. Bush administration and approved by Congress in 2003, resulted in the creation of a new privatized Medicare prescription drug (PDP) and Medicare Advantage (MA) plans for millions of elderly and disabled individuals. However, there was no responsible plan to pay for it. No new federal revenue sources were included nor were there cuts to existing federal expenses. Instead, federal subsidies were authorized for these new privatized Medicare benefits and these private insurers could also retain profits above and beyond their costs.
  • Traditional Medicare insurance which was already serving over 40 millions Americans in 2003, was not allowed to offer prescription drugs or other new benefits that private Medicare Advantage plans included.
  • It should also be noted that private insurers are allowed to pick and choose where and how long they want to sell plans compared to Traditional Medicare that is available to everyone that is eligible in the country.

  • As a result, two new publically funded, private health insurance plans were sold to the public on the assumption that they would cost less than Traditional Medicare and provide more benefits. However, today Medicare Advantage and PDPs cost taxpayers $328 billion/annually in federal subsidies.
  • The 2003 legislation also prohibited Medicare from negotiating drug prices on behalf of subscribers (as is done with the VA and Medicaid) and outlawed the importation of prescription drugs from Canada and other countries where they are sold at lower prices. As a result, prescription drug costs have sky-rocketed over the past 15 years.
  • Today, 43 million people are enrolled in private Medicare Part D drug plans either in stand-alone PDP how many people or integrated within Medicare Advantage plans.
  • In addition, the federal Social Security Administration subsidizes the cost of private insurer PDP premiums, deductibles and medications for 13 million low income individuals. This represents 28% of all PDP enrollees.

Important Facts to Know about PDPs

  • Today, the vast majority of Medicare Advantage Plans today include prescription drug coverage. However, Traditional Medicare and private Medicare Supplemental (Medigap) plans don’t include drug coverage, so a separate private PDP is needed for your medications and to avoid a potential late enrollment penalty.
  • Medicare-approved stand-alone PDPs are sold primarily by large, for-profit insurers such as Aetna/CVS, Cigna, Humana, SilverScript, United HealthCare and WellCare.
  • Private insurers are allowed to charge subscribers plan premiums, deductibles and co-pays/co-insurance for medications in addition to the federal subsidies that they receive.
  • Insurers also exclude specific drugs from their formulary, establish restrictions, such as requiring prior insurer authorization, limit medication quantities and require that subscribers take lower-cost drugs before higher-cost drugs.
  • Each insurer establishes their own drug classifications into pricing tiers and there are significant differences among PDPs regarding the drugs that are excluded/included and the premiums, deductibles, co-pays/coinsurance that subscribers are required to pay.
  • Although PDPs are not allowed to deny coverage or charge higher premiums to subscribers with pre-existing conditions and chronic diseases, insurers have latitude with establishing restrictions and subscriber charges.
  • There are no annual maximum out-of-pocket expenses for prescription drugs in either Medicare Advantage or stand-alone PDPs, so the cost of drugs can create serious financial problems for families.

  • In a 2019 study, reported in Health Affairs Journal, more than half of seriously ill Medicare enrollees face financial hardship with their medical bills with the cost of prescription drugs being the leading problem.
  • Unlike the rest of the developed world, in the US there is no public insurance for medications or government negotiation of drug prices, with the exception of the VA and Medicaid. As a result, the cost of medications to treat millions of Americans with life-threatening and disabling diseases such as diabetes, cancer, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, organ transplants are the highest in the world.
  • The cost of medications has become a huge burden on taxpayers; federal, state and local governments; employers; patients and families. This results in more costly health care with poorer outcomes, increases in disability, reduced work productivity and results a major cause of personal bankruptcies in the US.

A  Review of PDPs Available in Rochester, New York

Popular plans offered by Aetna/CVS, Cigna, Express Scripts, Humana, SilverScripts, United HealthCare (UHC)  and WellCare reveal the following observations.

  • Each insurer generally offers 3 plans with different premiums and deductibles. Premiums range from Humana’s Walmart Value plan $13.20/mo. with a $435 deductible, to SilverScript’s Plus plan $91.20/mo. with a $0 deductible.
  • It is common that low/no premium plans have higher deductibles, co-pays/co-insurance and limitations.
  • Only 3 plans have no deductibles (down from 7 plans in 2019) but all have high premiums. The 3 plans include SilverScript Plus with a $91.20/mo. premium, United HealthCare AARP Preferred with a $85.60/mo. premium and WellCare Value Plus with a $76.60/mo. premium.  These plans are not affordable for most people, since the average annual premium is over $1,000 and doesn’t include the cost of your medication.
  • All insurers have developed strong financial disincentives for subscribers who use “non-preferred” brand name and generic medications by establishing medication exclusions, deductibles and up to 50% co-insurance for non-preferred brand name Tier 4 drugs.
  • Many insurers also charge higher prices for “standard” versus their “preferred” and “mail order” pharmacies. However, insurers are generally weak in informing current and prospective enrollees of the cost differences among pharmacy options.
  • There are significant differences among insurers in specific brand name drugs that are either excluded from their formulary or placed into either Tier 4 or Tier 5. And, there are differences among insurers regarding the price of T4 non-preferred brand name  vs. T5 specialty medications. To illustrate, it is not uncommon that T4 non-preferred drugs are billed at a high rate of 32%-50% compared to T5 speciality drugs that are billed at 25%-33%. 
  • An insurer’s “Preferred generic and brand name” medications are not the most cost-effective medications with the least side-effects. “Preferred” medications reflect the deals that the insurers have made with the pharma companies to push their drugs over their competitors drugs.
  • This often occurs with medications for common conditions including rheumatoid arthritis, multiple sclerosis, diabetes and various neurological, cardiovascular, inflammatory, autoimmune and respiratory diseases and cancer.

  • Issues of drug cost, insurance prior approvals and access to treatment is a major source of conflicts among insurers, physicians and patients. So, it is very important to compare plans to understand the differences in coverage, restrictions and cost among plans that you are considering.

In summary, in considering PDPs it is important to confirm if the plans:

  • Do they include your medications and at what cost?
  • Is there a deductible expense on your drugs?
  • What restrictions are imposed on your prescribed medications?
  • Does the plan have preferred retail and mail-order pharmacies?
  • What is the reputation of the insurer with your doctors and pharmacies?

And finally, what is the total annual cost to receive your medications from each plan and the comparative differences in the PDP quality, costs and benefits.

Resources

Free resources are available to help you in comparing costs, coverage and quality ratings among plans. These include:

Medicare Plan Finder

Provides detailed information from Medicare to compare Quality Star ratings, your estimated annual and monthly cost (premiums, deductibles, co-pays/co-insurance) for your specific medications and pharmacies among available Prescription Drug Plans and Medicare Advantage Plans sold in your community.

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State Health Insurance Assistance Program

Provides free personal and group information/assistance with Medicare issues and questions.

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MedicareRights

Helps people with Medicare understand their rights and benefits, and navigate the Medicare system

References

Congressional Budget Office, 2019 reports

Center for Medicare & Medicaid Services (CMS)

Health Affairs Journal

Kaiser Family Foundation, 2019 Data Briefs and Fact Sheets

Medicare.gov

Medicare Rights Center

Medicare Trust Fund Board of Trustees, 2019 Annual Report

 

 

by Jim Sorrentino

How to Avoid Costly Mistakes in Choosing a Medicare Plan

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Medicare’s annual open enrollment runs from October 15th to December 7th. During this time, Medicare subscribers can join or change plans including:

  • Medicare Advantage plans:
  • Return to the original Medicare coverage
  • Medicare Supplemental (Medigap) plans;
  • Part D Prescription Drug plan

It is very important to make an informed choice of the best insurance plan for your medical needs, preferences, and budget. A bad choice can cost you thousands of dollars and prevent you from receiving services that you need from your preferred providers.

Medicare Insurance Options for Seniors

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Original Medicare is the government-run health insurance for seniors and disabled people that use private doctors, hospitals and other healthcare providers.

By comparison, Medicare Advantage (MA) plans that often include a prescription drug plan, stand-alone Prescription Drug plans (PDP) that are used with original Medicare and Medigap (Supplemental) plans are all sold by private insurance companies that are subsidized and regulated by Medicare.

These plans are offered by a variety of large for-profits (eg. United Healthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some seniors are eligible to receive their health insurance through their current or former employer.  And most Veterans are eligible to receive their health care and medications through the Veterans Administration.

Common Problems to Avoid

Your plan doesn’t include your preferred service providers.

If you don’t verify that your health care providers have a network contract with the insurer that you are considering, you could be facing huge bills. You could be responsible for paying the full cost of expensive services from health care providers or declined service.

Out-of-Network does not mean out of your area. Your preferred health care provider could be next door, but may not have a contract with your insurance company.

Be especially cautious of PPO plans, often sold by national insurers, that lead you to believe that you can go to any doctor anywhere. This is not accurate. Many times national insurers have not developed local provider networks or formal contracts. They often pay commissions to insurance agents to sell policies but do not have local staff to resolve provider and subscriber issues and concerns. These are often handled by central call centers.

The fine print in PPO plan documents includes this disclaimer: “Out-of-Network/non-contracted providers are under no obligation to treat plan members, except in emergencies”

This means that while you may have insurance, you may not be able to find a provider that accepts your plan, for a variety of reasons.

You Didn’t Anticipate High Deductibles and Out-of-Network Costs

Some plans, such as the Aetna Elite PPO are advertised as a $0 premium plan, however you need to pay the first $1,000 for many medical services plus an additional $350 deductible for Tier 3,4 & 5 drugs  including vaccines that do not have a generic equivalent. In HMO plans, you could be responsible for the full cost of “out-of-network” services.

Consumers need to be aware that each insurer decides what drugs to include and exclude, and what they will charge subscribers. Generally, you will be responsible for the full cost of medications that are not included in the plan’s formulary.  Drug prices can also vary by the pharmacy that you choose and if you choose a 90 day mail-order supply versus a more costly monthly supply.

In considering plans, you should not focus solely on the advertised premium cost, but rather your medical, drug, out-of-network needs and your projected out-of-pocket expenses including premiums, deductibles, co-pays, out-of-network charges and drug costs.unknown-1

Medicare.gov provides a  “plan finder” that helps you analyze medical & drug expenses among various plan options that are available where you live.

 

 

You Didn’t Consider Medigap Plans for High Medical Expenses and Maximum Choices

Many Medicare Advantage HMO plans have little or no out-of-network coverage and you may have to pay for the full costs of services that you receive. If you have serious medical conditions that require costly tests, hospitalization, nursing home rehabilitation, outpatient

surgery and intensive outpatient treatment such as cancer, heart disease, renal disease and/or you would like the freedom to select specialty providers outside of your plan’s network, you’ll need good coverage at an affordable price. “Original Medicare” has no limit on your annnual expenses. And, Medicare Advantage plans have a high annual maximum out-of-pocket limit of $6,700 but there is an alternative–Medigap plans.

As a general guide, if your projected annual out-of-pocket medical expenses (premiums, deductibles & co-pays – excluding your prescription drug expenses) exceeds $3,000/yr. and/or you want Medicare coverage across the country, you should explore a Medigap plan.

Medigap plans provide supplemental coverage to original Medicare and pays for deductibles and copays. All healthcare providers who participate in Medicare across the country are included and there are no out-of-network exclusions or surcharges.

Medigap plans are regulated by each state and you can receive information on the availability of plans and their premiums by contacting your state insurance department medicare.gov/contacts.

You Didn’t Think You Needed or Understood Differences in Prescription Drug Plansmed prices

Most Medicare Advantage plans include prescription drug (Part D) coverage. However, if you have “Original Medicare” with/or without a Medigap plan, you will also need to purchase a prescription drug plan (Part D) unless you have an approved employer drug plan or receive your medications from the VA.

If you don’t have a an approved drug plan and you want to purchase one at a later date, you are likely to be subject to a late enrollment penalty.

Part D plans are sold by private insurance companies and vary from state to state. For example, in New York State 27 plans are available from 10 different insurers. The premium and deductible cost of plans in New York varies widely from a Humana Walmart plan that costs $13 a month with a $435 deductible to a SilverScript plan that costs $91 a month with no deductible.

It is also important to check plans that you are considering to confirm that the medications that you need are included and what your co-pays and total annual expenses will be before enrolling in a plan.

Medicare.gov has a planfinder that compares the different cost of the various Part D plans based on the medications that you use and where you live.

You Didn’t Expect a Medicare Enrollment Penalties

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Medicare rules require that if you want to receive Medicare benefits, you need to enroll and pay your Medicare Part B (outpatient) and Part D (prescriptions) premiums when you are first eligible. There are a few penalty exceptions, for example, if you receive creditable medical and drug insurance from you or your spouse’s employer, if you receive your medications from the VA.

Medicare penalties can be significant. The Part B (outpatient care) late enrollment penalty is 10% for each year, from the date of your initial Part B eligibility. The Part D (prescription drugs) penalty is 1% for each month from when you were initially eligible, or June 2006, the start of the program. There are a few circumstances when penalties can be reduced or eliminated.

The Importance of Having a Good Medicare Plan

Selecting the best plan for you or your family member is a very important responsibility since the consequences can be significant, both to your pocketbook and your ability to receive needed health care from your preferred providers.

Investing time in planning and seeking objective advice in selecting a plan, can save you a lot of time, money and headaches. The following is a list of free resources that are available to help you.

Resources

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Social Security Administration, socialsecurity.gov, 800-772-1213

The Social Security Administration is the agency that you need to contact to apply for your Social Security benefits and enroll in Medicare Part B and D., In addition, you can be screened for eligibility (income and resources) and apply for “Extra Help” with your Part D premium and cost of your medications

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Medicare: Medicare.gov – 800-633-4227

An excellent resource with Medicare information and specific help in comparing Medicare Advantage and Prescription Drug Plans in your area.

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State Health Insurance Assistance Program  SHIP 877-839-2675

Medicare contracts with states, counties and nonprofit organizations to provide individuals with personalized education, support, and assistance with Medicare.

These free services include comparative plan information, eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.

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Partnership for Prescription Assistance

 This is an online information resource tool. You can learn about assistance programs that are available for specific medications, along with the eligibility criteria and program applications.

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Medicare Rights Center, medicarerights.org , Helpline: 800-333-4114

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.

 

This article was updated in October 2019 from an earlier post.

by Jim Sorrentino

Shingrix – The CDC Recommended Vaccine that Most Medicare Plans Cover, But Few will Pay for it.

Background

Shingles affects nearly 500,000 of Americans over 60, every year. It can be a very painful and debilitating condition. However it can be prevented with a vaccine. Shingles causes a rash with itchy blisters on your body along with shooting nerve pain. It can attack older adults’ as well as individuals with weakened immune systems as a result of chemotherapy, long-term use of steroids and other conditions.

Shingles can be contagious to people who have never had chickenpox or have not been vaccinated. People especially at-risk are pregnant women, newborns and children who have not been vaccinated.

The Center for Disease Control (CDC) has recommended Shingrix as the preferred vaccine because it is 90% effective in preventing shingles. The average cost of Shingrix is $300 for the two required vaccines and it’s effective for the rest of your lifetime.

In my work as a Medicare counselor in Rochester, NY (Upstate New York), I have reviewed the formularies of all 24 Medicare Advantage (MA) plans and 27 stand-alone Part D prescription drug plans (PDP) in Rochester service area.

And, here is what  I learned…….

  • All the MA and PDP include Shingrix in their plan’s formulary.
  • However, only one MA plan (nonprofit Excellus Blue Cross/Blue Shield), classified Shingrix as a Tier 1 vaccine with no premium, deductible or co-pay.
  • Other MAs offered by: Aetna/CVS, nonprofit MVP, United HealthCare and WellCare that have monthly premiums ranging from $0 to $350 and deductibles ranging $0 to $395 listed Shingrix as a Tier 3 drug
  • All of the 27 PDPs offered by: Cigna, Emblem, Envision, Express Scripts, Humana, Magellan, JourneyRX, Silverscript, United HealthCare and Wellcare also classified Shingrix as a Tier 3 vaccine with monthly premiums ranging from $13.20/mo. with a $435 deductible to a plan with a $91.20/mo. premium and no deductible.

Conclusion

The bottom line is (with the exception of Excellus Blue Cross) 50 private Medicare drug plans that are under contract with Medicare and receive generous subsidies, include Shingrix in their formulary, but classifying it as a Tier 3 drug make it subject to a deductible that is equal to the price of the vaccine. As a result, you are paying for the full cost of the CDC recommended vaccine and these 50 insurers are paying nothing.

At the same time, The President and Congress give away $95 billion a year of taxpayer’s money to subsidize private insurance companies that sell private Medicare policies. In return, the insurance and pharmaceutical companies pay over $ 9 million a year in campaign contributions to candidates and members of Congress.

Final Thoughts

This is just one of many examples, that illustrates how American health care services are the most costly in the world with the poor outcomes due to unethical practices that have become commonplace on the part of elected and appointed officials, insurance and pharmaceutical companies.

Medicare insurance policies and contracts need to be reformed to make them rational, sustainable and cost-effective. And meaningful ethical standards need to be established, monitored and enforced. Science and accepted clinical evidence needs to replace the dominance of the financial self-interest of elected and appointed federal office holders and the billion dollar insurance and pharmaceutical industries.

If you want to see the Medicare insurance system change, let your elected federal representatives and candidates running for office in 2020 know your views. Remember you pay their generous federal salaries and benefits and it is their job to represent the common good of the people that they are expected to represent.

And, if you plan to get a Shingrix vaccine soon, first check the coverage and cost of your current plan and other available insurance plans in your area. You have the opportunity to change your Medicare plan for next year by December 7th.

Be the change you want to see.

In the interest of full disclosure, I am not compensated or have a relationship with any insurance or pharmaceutical company mentioned in this article.

 

 

 

by Jim Sorrentino

What to Look for in a Medicare Prescription Drug Plan

 

Background

  • Approximately 43 million or 72% of the people on Medicare are enrolled in Medicare-approved Prescription Drug Plans (PDP)
  • If you have Original Medicare (with or without) a Medigap plan, you likely need a PDP to have drug coverage and avoid a future penalty.
  • You need to have a PDP from the month that you were initially eligible for Medicare, or 2006 when PDPs were first established or you have subject to a penalty.
  • Most Medicare Advantage Plans include prescription drug coverage along with medical coverage.
  • There are no annual maximum out-of-pocket prescription drug expenses for either Medicare Advantage or stand-alone PDPs. Original Medicare & Medigap plans do not cover prescription drug expenses, you need to buy a separate PDP.
  • Medicare-approved stand-alone PDPs are sold primarily by large, for-profit insurers such as Aetna/CVS, Cigna, Humana, and United HealthCare. Medicare enters into contracts with private insurers to provide PDPs that meet specific requirements.
  • Private insurers are also allowed to charge subscribers plan premiums, deductibles and co-pays/co-insurance for medications. They can also exclude specific drugs from their formulary, establish restrictions: such as requiring prior insurer authorization, limit medication quantities and require that subscribers take lower-cost drugs before higher-cost drugs.
  • Each insurer establishes their own drug classifications into pricing tiers and there are significant differences among PDPs regarding the drugs that are excluded/included along with the premiums, deductibles, co-pays/coinsurance that subscribers are required to pay.
  • Although PDPs are not allowed to deny coverage or charge higher premiums to subscribers with pre-existing conditions and chronic diseases, insurers have latitude in establishing restrictions and subscriber charges.
  • Private insurers receive over $95 billion a year in taxpayer subsidies for PDPs. This represents 71% of the total prescription drug plans costs.
  • Unlike the rest of the developed world, in the USA there is no public Medicare insurance for medications or government negotiation of drug prices with the exception of the VA. As a result, the cost of medications in the United States, to treat millions of Americans with life-threating diseases such as diabetes, cancers, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, organ transplants are the highest in the world.
  • The cost of medications has become a huge burden on taxpayers; federal, state and local governments; employers; patients and families. This results in more costly health care with poorer outcomes, increases in disability, reduced work productivity and becomes a major cause of personal bankruptcies in the USA.
  • Medicare Quality Star Ratings -Medicare uses a Quality Star Rating System to measure how well Medicare Advantage and Part D plans perform. Medicare scores how well plans perform annually in several categories including quality of care and customer service. Ratings range from Poor (1 star), Below Average (2 Stars), Average (3 Stars), Above Average (4 Stars) and Excellent (5 Stars). Details of specific PDP and Medicare Advantage plan ratings are published on Medicare.gov.

A review of major insurers and their 23 PDPs in Upstate New York including plans by Aetna, Cigna, Express Scripts, Humana, SilverScripts, United HealthCare (UHC)  and WellCare reveal the following observations.

  • Each insurer generally offers 3 plans with different premiums and deductibles. Premiums range from $15.50 a month with a $415 deductible (WellCare Value Script) to $92.50/mo. with a $350 deductible (Express Scripts Medicare Choice)
  • Seven plans have no deductibles with premiums ranging from $39.70/mo.                    (SilverScriptsChoice) to $80./mo.(Humana Enhanced & SilverScript Allure).
  • The Medicare Quality Star ratings of plans vary from 3.5/5 Stars ( 3 SilverScript plans & UHC AARP Preferred) to low-rated plans (EnvisionRx Plus 1.5/5 & three Cigna plans 2/5 Stars). Other plans offered by Aetna, Humana, WellCare, and two UHC plans each received a 3 Star rating.
  • All insurers have developed strong financial disincentives for subscribers who use “non-preferred” brand name and generic medications by establishing medication exclusions, deductibles and up to 50% co-insurance for Tier 4 drugs.
  • Many insurers also charge higher prices for standard pharmacies and 30-day supplies with lower prices for “preferred” retail and mail-order pharmacies. However, many consumers and health care providers are unaware of what pharmacies are preferred and the cost differences that can be substantial.

PDPCostChronicDiseases

  • There are significant differences among insurers in the number of brand name and specialty drugs that are excluded in their formularies. Some diseases including rheumatoid arthritis, multiple sclerosis, diabetes and various neurological, cardiovascular, inflammatory, autoimmune and respiratory diseases have higher-cost Tier 4 & 5 medications and more excluded drugs than other conditions. This creates major conflicts among insurers, physicians and patients.
  • The co-insurance rate for Tier 4 “non-preferred generic and brand” medications in many cases is double the co-insurance rate for more costly Tier 5 specialty drugs. Many plans exclude specific medications or place them in Tier 4, that are used to treat common conditions such as diabetes, inflammatory, autoimmune and cardiovascular diseases in favor of other specific drugs sold by competitor drug companies. Insurers have increased “excluded medications” by 160% in the past 4 years and boast about saving billions of dollars each year by reducing access to treatment and raising patient expenses.

Differences in Subscribers Satisfaction with Plans

One dimension of Medicare’s quality ratings is the analysis of subscribers’ level of satisfaction with their specific PDP or Medicare Advantage plan. Medicare looks at a number of areas including quality of services and customer service. Two area that are important to look at include turnover rates (the percentage of subscribers who leave the plan) and the major reasons for leaving. The following analysis focuses on 23 PDP plans sold in Upstate New York.

SilverScript

  • SilverScript’s three plans: Choice ($37.90), Plus ($73.80) and Alure ($80/mo.) stand out from other plans in that they all have a 3.5/5 Star rating; none have deductibles and they have a low subscriber turnover rate of 6%  but 34% of subscribers who left complained about costs.

UHC

  • UHC AARP 3.5 Star Preferred plan ($77.70) with no deductible) and had a low 7% turnover rate but 56% of the people who left, complained about the high costs.
  • UHC other two plans: AARP Saver Plus ($59.90/mo. + a $415 deductible) and AARP Walgreens ($28.10/mo. + $415 a deductible) have a lower, 3 Star rating and 15% turnover rate with 45% of subscribers who left, complained about costs.

Humana

  • Humana‘s three plans earned 3 star Medicare ratings including its Walmart Rx ($35.70/mo.+ $415 deductible), Preferred Rx ($37.40/mo. + $415 deductible) and Enhanced ($80.50/mo. with no deductible. The plans all had 11% turnover and 31% subscriber complaints regarding costs.

WellCare

  • WellCare’s plans all were rated 3 stars rated and ranged in price from Value Script ($15.50/mo.+ $415 deductible), Classic ($37.90/mo.+ $415 deductible) and Extra ($81.50/mo. with no deductible) all had consistent turnover rates of 13% and 33% complaints about costs.

Aetna

  • Aetna’s 3 star Select ($17.70/mo. + $330 deductible) had 12% turnover and 33% complaints about costs while their 3-star Value Plus plan ($58.80/mo. with no deductible) had 24% turnover and 53% complaints about costs.

In summary, in considering PDPs it is important to confirm if the plans:

  • Include your medications and at what costs
  • Have a deductible expense on your drugs;
  • Have restrictions on access to your medications,
  • Have preferred retail and mail-order pharmacies,
  • Have high subscriber turnover and/or have other significant negative issues identified by subscribers and/or Medicare.

And finally, what is the total annual cost to receive your medications from each plan and the comparative differences in quality, costs and benefits.

Resources

Free resources are available to help you in comparing costs among plans. These include:

Medicare Plan Finder

Provides detailed information from Medicare to compare Quality Star ratings, your estimated annual and monthly cost (premiums, deductibles, co-pays/co-insurance) for your specific medications and pharmacies among available Prescription Drug Plans and Medicare Advantage Plans sold in your community.

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State Health Insurance Assistance Program

Provides free personal and group information/assistance with Medicare issues and questions.

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MedicareRights

Helps people with Medicare understand their rights and benefits, and navigate the Medicare system

References

Congressional Budget Office, 2018 reports

Kaiser Family Foundation, 2018 Data Briefs and Fact Sheets

Medicare.gov

Medicare Rights Center

Medicare Trust Fund Board of Trustees, 2018 Annual Report

The Doctor-Patient Rights Project

 

 

by Jim Sorrentino

10 Things You Didn’t Know about EPIC -NYS’s Prescription Assistance Program for Seniors

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NYS, like 15 other states, has a wonderful prescription assistance program for seniors called EPIC. It can make a huge difference for seniors, if they only knew about it.

10  very important things that you probably never knew about EPIC

1.The EPIC plan is used by more than 300,000 New York seniors who are over 65. However, EPIC members only represent 10% of New York’s 3 million seniors and there are many more people who are eligible and could benefit from the program.

2. EPIC is not a substitute for a Medicare Part D drug plan, but rather a supplement for low to moderate income individuals. In many cases, EPIC will actually pay for part or all of your Part D premium.

3. The EPIC program income eligibility is $75,000 for an individual and $100,000 for couples. Income is based on your last year’s federal 1040 tax return, line 22 (total income). EPIC does not look at your assets (cash, investments, property etc) or your expenses, only your reported income and they verify what you report with your tax return.

4. EPIC provides financial assistance in two areas- it provides a subsidy for individuals who’s income and resources are above Medicare’s Low-Income Subsidy (LIS) criteria but below EPIC’s limit of $23k (ind.) and $29k (couple), to pay for the cost of your Part D premium (up to $39/mo. in 2018). Secondly, EPIC subsidizes the cost of of your prescription drugs (after any deductible in the plan has been met). Your cost of medications with the EPIC subsidy will range from only $3 to $20 per monthly prescription.

Medicare DrugCost

This benefit can be worth tens of thousands of dollars for people with expensive medications to treat chronic diseases such as hepatitis B, diabetes, inflammatory diseases, multiple sclerosis and various form of cancers. This includes medications that may be excluded from your Part D’s formulary.

5. EPIC can pay for either part of your Medicare Advantage’s drug component or a stand alone Part D plan that is used with original Medicare and Medigap plans

6. EPIC can even pay for Part D penalties in some cases if your drug plan premium is under $39/month

7. If you are eligible for an EPIC Part D subsidy, don’t quickly sign up for a zero premium Medicare Advantage plan. You should look at better plans with lower co-pays and added benefits- dental, health club that may cost you little or nothing to upgrade your health plan coverage and may not have a deductible.

8. Applying for EPIC is easy- just complete the half page application and mail it in.

9. EPIC has a small annual member fee for low-income people (under $20k (i) and $26k (c) who are eligible to receive the Part D premium subsidy up to $39/mo. For people with income over $20K (i) or $26k (c), there is no program fee but rather a deductible that needs to be met based on your income. The annual deductible starts at $62 (i)  and $182 (c) and increases with your income. The deductible needs to be met before you’re eligible to receive the subsidized prescription rates..

10. EPIC members are entitled to a Special Enrollment Period once a year, if they want to change their prescription drug plan. This could result in better medical and drug coverage or lower premiums.

For more information and an EPIC application call 800-332-3742

by Jim Sorrentino

Buyer Beware in Selecting a Medicare Prescription Drug Plan (PDP)

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Individuals who use original Medicare A & B for their medical care, with or without a Medigap Plan (not a private Medicare Advantage plan), need to check the formulary and costs of various private insurer PDPs that are available in your area very carefully. And, don’t assume that an insurer that provides a good value for one type of plan (eg. MA or Medigap) provides the same quality, value and coverage in their PDPs. Unlike MA plans that include the same medication formulary, PDPs often have different medications, deductibles and co-pays among their various plans, so check carefully.

An example is United HealthCare, who is a leader in sales and value for their Medigap plans in NYS, ranks much lower in sales & value for their MA and PDPs. There are also dramatic differences in the drug formularies and subscriber cost among the 3 different UnitedHealthCare PDPs that are offered.

The UHC Rx Preferred plan includes over 3,500 drugs on their formulary and has their most expensive premium ($91/mo. but does not include a deductible). By comparison, the RX Savers Plus plan excludes over 400 drugs that are included in the Preferred plan for $55/mo. and includes a $405 deductible. And their lowest cost premium plan is the UHC RX Walgreens plan for $26.50/mo. with a $405 deductible, but it doesn’t cover 500 medications that are included in the high premium cost UHC Preferred plan.

Other popular insurers such as SilverScripts, Humana and Cigna that offer multiple PDPs in NYS also share similar issues which makes it difficult for an individual to clearly understand and choose a plan that includes their medications at a price they can afford.

Medicare.gov provides a valuable, free Plan Finder service that allows you to anonymously enter your medications and your preferred pharmacies and then compare the total cost of different plans (including MAs and PDPs) from different companies that you are considering.

Once you enter your medications You will also see differences in:

  • Your medications that are not included on the plan formulary.
  • Your medications that have restrictions.
  • Your brand named medications that have generic alternatives.
  • Your cost or a one month or a 3 month supply of medications from different pharmacies.
  • And, finally the total comparative cost differences of each plan including their premiums, deductibles and co-pays that you are considering.

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Another nice added feature is that your Plan Finder medication data can be printed and is stored anonymously online. It can be retrieved (with your assigned Drug List ID number and Password date for your future review and updating.

Investing some time in objectively comparing coverage and costs differences of your Medicare plan options can save you money and problems in the future.

If you or your family members needs assistance, you can contact the free State Health Insurance Assistance Program at http://www.shiptacenter.org or 800-Medicare.

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by Jim Sorrentino

Four Strategies for Reducing your Medicare Drug Costs

Why is the Cost of Medications so High?

Medications are a major out-of-pocket expense, especially for anyone with acute or chronic medical conditions. Unlike other countries with national health insurance systems, our Congress has supported the financial interests of Big Pharma and themselves and over interests of citizens to have access to affordable health care.

In return,Big Pharma has been a major source of more than $10 million a year in political contributions. In addition, they spend more on marketing to health care providers and  consumers than they spend on research and development of new medications to safely treat serious health conditions.

Medications that are critical to individuals’ health and well-being, are substantially more expensive in the US than in Canada, Europe and other countries.

Pharmaceutical companies are free to establish high prices for their government-protected patented drugs and this results in high consumer and government debt due to taxpayers subsidizing Big Pharma.

The US spending on pharmaceuticals is approximately $300 billion dollars a year. Political efforts to reform these  out-of-pocket expenses for medicare recipients have been very limited primarily to pharma companies agreeing to offer discounts to Medicare patients once they exhaust their initial Medicare coverage limits.

However, there are some strategies that consumers can use  to reduce and control their  medication expenses.

Strategies for Lowering Your Drug Costs

1. Know The Differences in Medication Cost and Coverage Before you a Select a Plan.

Medicare Advantage (MA) and stand-alone Prescription Drug Plans (PDP) are difficult to compare and can be very confusing for most people. However, not knowing the consequences of the plan that you select can be very costly.

Use Medicare’s Plan Finder at http://www.medicare.gov to compare the cost of medications among the different plans available in your service area. If you are changing insurance plans, don’t assume that the plan that you are considering includes the same medications and pharmacies.

Plans can often differ in their restrictions (eg. prior approval, quantity limit & step therapy) that they place on medications as well as the significant differences in Tiers and associated  co-pay/co-insurance that they establish for each medication.

Insurance companies and their pharmacy benefit managers (PBM) establish the plans detailed policies and procedures including:their drug formulary, medication restrictions, negotiated prices paid to pharmaceutical companies and pharmacies,  preferred medications and pharmacies, and the co-pays and co-insurances that consumers will pay.

2. Use your Plan’s Preferred and Mail Order Medications along with in-network, Preferred Pharmacies, Costco & Sam’s

Consumers can experience considerable savings by using your plan’s generic and preferred brand name meds whenever possible; making use of your plan’s mail order pharmacies for maintenance drugs and using your plan’s in-network and preferred pharmacies. And don’t forget to check with Costco and Sam’s. Many people don’t realize, you don’t have to be a club member to benefit from their low drug prices.

3. Check your Eligibility for Financial Assistance Programs.

If your income is low enough, your medical expenses are high enough or you meet other special criteria, you may be eligible for low or no cost medications.

Financial assistance can come from the federal (e.g.. Medicare’s Extra Help, Medicaid, Veteran’s Administration), state (State Pharmacy Assistance Programs such as NYS’s EPIC), private (Pharmaceutical Assistance Programs) or from specific clinical research programs.

4. Make Lifestyle Changes and Reduce Your Need for Medications

While you don’t have control of your genes, there are many things you can do for your health and reduce your risk of medical problems and need for medications.

Eating a healthy diet, exercising, getting adequate sleep, managing your stress, not smoking, limit your intake of alcohol, caffeine, sugar, salt, fat and processed foods will go a long way in reducing your risk of diabetes, cardiovascular diseases, hypertension, cancer and many other debilitating conditions can substantially reduce your quality of life and increase the need for costly medications.

When it comes to your health care, ‘buyer beware”.

Remember, no one has a greater interest in your health  or your pocketbook than you.

Feel free to share your comments and general questions.We all can learn from one another. Go to http://www.healthplanadvisor.org for more articles.

Thanks

Jim Sorrentino