The Med Diva

An insider's guide to Medicare Part D and more

On Medicare and live in the South? Make sure you’re not taking a high-risk drug.

Seniors in the Southeast are more likely to be prescribed at least one one high-risk medication.

Senior Medicare beneficiaries in the Southeast are more likely to be taking at least one high-risk drug.
Source: NPR (Dany Qato and Amal Trivedi/Alpert Medical School, Brown University)

As I mentioned in my last post, recent findings from Express Scripts show that Medicare providers in New York, New Jersey, and several southern states are less likely to prescribe lower-cost generic drugs then their counterparts in Midwestern states.

Now a new study from the Alpert Medical School at Brown University finds that more than 20 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan are taking at least one high-risk medication. And beneficiaries who live in parts of the South are even more apt to be prescribed high-risk medications. In fact, in many parts of the South – especially the Southeast – more than one-third of seniors are taking drugs that, according to Medicare guidelines, are considered high risk for people age 65 and older.

For example, more than 38 percent of Medicare Advantage enrollees in Albany, Georgia, were prescribed at least one risky drug, compared to 10 percent in Mason City, Iowa, the area with the lowest rate. Beneficiaries prescribed risky drugs were also more likely to be poor, white, and female.

So why are Southerners more likely to be prescribed risky meds? According to the authors of the study, it could be that patients are asking their doctors for them. Or it could be that doctors in these regions are more apt to stick with old prescribing habits. Neither one of these reasons is a valid excuse.

Why are some drugs classifed as risky?

Certain medications are associated with a high risk of side effects and drug toxicity in the senior population, and pose a concern for patient safety. Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage plans to report prescribing rates of high-risk medications.

Many drugs are classified as risky because they stay in the body longer, increasing the risk of falls and fractures. Others are classified as drugs to be avoided in people 65 years or older because they are simply not effective enough to be used on a regular basis.

Risky drugs for seniors include amphetamines, barbiturates, muscle relaxants, and narcotics. Old-style sedating antihistamines and medications for depression and anxiety (like long-acting diazepam or Valium®) are also risky, as they can cause sleep apnea or cardiac arrest.

What drugs should be avoided?

The Centers for Medicare & Medicaid Services (CMS) has published a list of high-risk medications to be avoided in patients 65 years and older. Doctors should have this information, but patients and caregivers also need to be aware of this list. The authors of the study — a pharmacist and a medical doctor — suggest that people talk with their doctors about risky medications and make an appointment with their pharmacist to review all their medications to find out if any should be stopped or replaced with a less risky drug.

You should also check the star ratings of your Medicare plan (Part D or MA-PD) if you have prescription drug coverage. CMS awards lower star ratings to Medicare plans if a certain percentage of the plan’s members age 65 and older receive a medication that puts the patient at high risk for an adverse drug-related event, such as a fall or cardiac event. When reviewing Medicare plans, you should ask how the plan scored under “Drug pricing and patient safety.” If you live in the South and your plan has a low star rating in this category, you should definitely be on the alert for prescriptions for high-risk medications.


Live in New York or New Jersey? Better speak up and ask for that generic drug.

Location generic drugsBritish real estate developer Lord Harold Samuel once said, “There are three things you need in property. These are location, location, and location.” Apparently the same is true when it comes to prescribing generic drugs for Medicare beneficiaries, too.

According to the Express Scripts 2012 Drug Trend Report, where you hang your hat will frequently determine how often your doctor will prescribe a generic drug for you: Medicare providers in New Jersey, New York, and southern states such as Texas and Louisiana prescribe fewer cost-saving generics than their counterparts in Midwestern states such as Ohio and Wisconsin.

“A prescriber’s geographic location is a strong predictor of the proportion of generic prescriptions they write,” says Sharon Frazee, vice president, Research & Analysis, Express Scripts. “Location encompasses many features that have a complex influence on prescribing and utilization.” Some of the regional features that influence the prescribing and utilization of generic drugs include income levels, the impact of media markets and advertising dollars, and the proximity to urban centers and healthcare services.

Here are some other interesting trends that can help predict which healthcare providers are more apt to prescribe generics:

• Younger, less tenured healthcare providers, including physicians, nurse practitioners and physician assistants, are more likely to prescribe generic medications to Medicare patients than older providers with more years in practice.
• Prescribers who care for a large number of Medicare patients are more likely to prescribe generics than those with fewer Medicare patients.
• Prescribers who practice in rural areas adjacent to large cities are more likely to prescribe generics than prescribers in metropolitan areas and urban centers.

One possible explanation for these findings has to do with habit and experience: Some healthcare providers have been practicing medicine longer than many generic drugs have been on the market. They may prescribe the brand drugs with which they are familiar and that have worked well for their patients out of habit, without giving any thought to the cost. If their patients don’t speak up and ask about generic drugs, they’ll immediately fill out the script for the brand-name drugs they know the best (this is especially true if the physician has pre-printed scripts for certain popular brands).

As I have mentioned in previous posts, brand-name drugs, especially “blockbuster drugs” like Lipitor® and Plavix®, are often a lot more expensive than their generic counterparts. And if pricing trends from 2011 to 2012 are any indication, I wouldn’t expect prices on brand-name drugs to come down anytime soon.

The increasing availability of lower-cost generic drugs offers significant savings opportunities for Medicare beneficiaries – but unless you speak up and specifically ask your healthcare provider to prescribe generics whenever possible, you may never enjoy these added savings. Especially if you live in New York or New Jersey.

Finding a Doctor Who Accepts Medicare | PBS NewsHour

Finding a Doctor Who Accepts Medicare | PBS NewsHour.

Read the Fine Print Before Getting Locked Into a Restricted Network Part D Plan

Don't get locked into a Part D plan with a restricted pharmacy network unless it's right for you.

Don’t get locked into a Part D plan with a restricted pharmacy network unless it’s right for you.

As I’ve mentioned several times before, Medicare beneficiaries should always read the fine print and watch out for the terms “preferred network” or “restricted network” when choosing a Part D prescription drug plan (PDP).

Restricted network pharmacy plans encourage members to use national pharmacy chains (such as CVS or Walgreens), which are called preferred network pharmacies. These preferred pharmacies offer covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy. A non-preferred network pharmacy, on the other hand, is often the small community pharmacy in your town.

Many of the largest Part D plans have restricted networks, including Humana Walmart-Preferred Rx Plan, Aetna CVS/pharmacy PDP, First Health Value Plus PDP, Rite Aid EnvisionRx Plus, AARP Medicare Rx Preferred, and CVS Caremark Plus. Beneficiaries are attracted to these plans because of the low premiums and copays.

In its 2014 Call Letter, the Centers for Medicare & Medicaid Services (CMS) remind plan sponsors that beneficiary communications regarding preferred networks must be “clear and unambiguous.” In addition, CMS reminds Part D plans that the plans can never–under no circumstances–require beneficiaries who get Extra Help from Medicare and qualify for low-income status (LIS) to use a preferred network pharmacy in order to get their LIS copays.

According to groups like the National Community Pharmacists Association and the Indo-American Pharmaceutical Society, many Medicare beneficiaries are confused by Part D marketing activities that led them to sign up for a “preferred network” plan, only to later find out that the closest pharmacy in the preferred network is 20 miles from their home.

This week, the IAPS posted a sample letter to CMS on its website, and asked that every independent pharmacy owner cut and paste the letter and send it to CMS. Here is a portion of that letter:

I am writing in response to the release by CMS of the Medicare Part D draft Call Letter for 2014. I applaud CMS for addressing certain issues in the Call Letter that have concerned independent community pharmacies and our patients for many years. As an independent community pharmacist, I wish to voice my support for the following provisions that focus on eliminating abusive practices by Part D pharmacy benefit managers (PBM’s) that have disadvantaged patients and independent community pharmacies. I respectfully ask that CMS include these provisions in the agency’s final Call Letter for 2014:

Preferred Pharmacy Networks: We support the fact that CMS addresses some of the improprieties regarding so-called preferred Part D pharmacy networks. My pharmacy is not offered the chance to participate in the vast majority of these networks, which negatively impacts many of my patients who are forced to pay higher co-pays to continue to fill prescriptions at their pharmacy of choice. Plans should be required to offer any pharmacy willing to accept a plan’s terms and conditions the chance to participate in the preferred network per statute (42 U.S.C. § 1395w-104(b)(1)(A)).

In addition, CMS hits the nail on the head when it says that some of these networks require pharmacy “pay to play” in these networks. Where do these reverse pharmacy payments to the plans go? To the beneficiary? To Medicare? Or to the bottom line of the plans? Why should I have to pay a plan to serve my patients?

In addition, many of my patients are confused by these preferred pharmacy networks’ marketing activities. Because of the marketing, patients may believe that they can use any pharmacy in a “preferred” plan and get lower prescription co-pays. Patients may only learn that this is not the case when they come to my pharmacy, and then have to drive long distances to a remote preferred pharmacy in the network to get the lower co-pays.

Finally, there is evidence from the Part D plan finder tool that these preferred networks are charging beneficiaries higher prices (or the same price) for medications than they can obtain at non-preferred pharmacies like mine. It is not clear to me why a pharmacy would be designated as preferred if they are not lowering prescription prices for beneficiaries. In fact, if a my pharmacy is being paid less for the medications than a preferred pharmacy, and the beneficiary is paying more in co-pays at my pharmacy, how can it be that Medicare is actually saving money?

Don’t Settle for Lousy Customer Service in Your Medicare Plan.

Don't settle for a bad Medicare plan

Don’t get stuck in a jam if you don’t like your Medicare plan.

I recently came across a slew of complaints about the SilverScript Medicare Part D plan on the Complaints List website. (SilverScript is sponsored by the SilverScript Insurance Company, which is an affiliate of CVS Caremark.) The majority of complaints were about the drug plan’s customer service – or alleged lack thereof.

For example, Rita posted this complaint:

I’ve been treated rudely, after waiting on hold for an hour plus, sent to someone else after another 45 minutes, then that person said to hold and hung up on me. There should be a law about these customer service people treating the disabled elderly with more respect. Their day will come too. I feel as if they don’t care if we live or die and if we die without our meds they would be happy.

Now, I need to point out that last month the Centers for Medicare and Medicaid Services took action against SilverScript for issues related to claims processing (for example, some claims for new members were being rejected at pharmacies). Many of the complaints on the Complaints List website may be tied to this claims processing issue; however, it appears that the SilverScript customer service reps have not been properly trained on how to help people and treat them with respect.

No one should have to deal with horrible customer service. That’s why Medicare has established a 5-star special enrollment period.

Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans. As I’ve mentioned before, low star ratings typically mean lower quality and poor customer service.

Last year SilverScript earned only 3 stars from Medicare. This was the lowest star rating among the top 10 Medicare Part D plans in 2012. Based on all the complaints I’ve read, it won’t surprise me if the plan’s ratings drop even lower for 2013.

Here’s the good news for Rita and everyone else who has complaints about his or her Medicare plan: You may not have to settle for a plan with bad customer service all year long. That’s because you can switch to a 5-star Medicare Prescription Drug Plan or Medicare Advantage Plan if you are not happy with your current plan. The Special Enrollment Period for joining a 5-star plan runs from December 8 through November 30 every year.

Although very few plans have earned a 5-star rating from CMS this year, if you’re fortunate enough to find one that serves your area, you can disenroll from your current plan if you’re not satisfied and join a plan that has earned 5 stars.

Use the following resources to get plan ratings:
• The overall plan star ratings are available at the Medicare Plan Finder.
• You can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
• You can download the Medicare fact sheet, which has additional information about star ratings.

Don’t Accept a Provider That Doesn’t Accept Medicare: No Exceptions

Medicare home health representativeI received an e-mail from my cousin Michelle about one of her clients, who had a very uncomfortable experience with a Medicare provider. According to Michelle, her 85-year-old client, Bill, had just undergone some surgery and was now recovering at home. He received an unwelcome – and surprise – visit from a woman who said she was from a home healthcare agency.

The woman told the man that she was sent by the hospital, and that her agency worked with Medicare. She also told him that he had to sign some papers authorizing the agency to provide his home health services.

“My client did not know anything about this woman or her agency, and the woman was very rude to him when he questioned her,” Michelle wrote to me. “He refused to the sign the documents. Was that the right thing to do?”

I had a lot of concerns about this scenario, so I immediately replied to Michelle. Here is a summary of my email to her:

• It was definitely Bill’s right to question the woman, especially since he didn’t know anything about her or her company.
• He was also right to refuse to sign any paperwork.
• Bill should contact the hospital or his doctor to confirm that the hospital had in fact contracted with the woman’s agency to provide home health care. If so, he should let the hospital or doctor know that he is not pleased that this decision was made without his consent or knowledge.
• Bill should tell the hospital or physician that the woman who came to his home was very rude, and that he would not be comfortable receiving services from this agency.
• Finally, should Bill decide to use this agency for home health services, he must first confirm that the agency is a Medicare participating provider – or in other words, accepts Medicare assignment. Just because the woman said her agency works with Medicare doesn’t automatically mean the agency is a Medicare participating provider.

What is a Medicare Participating Provider – and Why is it Important?
Participating providers have signed an agreement to accept assignment for all Medicare-covered services. In simpler terms, it means they agree to accept the Medicare-approved amount as payment in full, and will not charge patients any more than the approved amount. They also agree to charge you only the Medicare deductible (if applicable) and coinsurance amount.

Non-participating providers, on the other hand, can charge you up to 15 percent more than the Medicare-approved amount. They can also request that you pay the full cost up front at the time of service, which means you will have to wait for Medicare to reimburse you.

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Medicare offers a search tool on its website that I suggest you use each time you see a new doctor, or, like in Bill’s case, a strange woman comes to your door and wants you to sign some papers.

Switching from Lipitor to a generic should be a no-brainer for Medicare members…or so I thought!

Brand drugs like Lipitor cost much more than genericsOn November 30, 2011, the first generic version of Lipitor® (atorvastatin) hit the market. A few months prior, my company asked me to write a letter to all the members in our Medicare Part D plans who were taking Pfizer’s top-selling cholesterol medicine. In the letter, I advised our members that less expensive generic versions of the drug would be soon be available. I also reminded them that not only do these generic drugs cost less than Lipitor, but copayments are also generally lower for generics than for brand-name drugs.

This is a no-brainer, I thought to myself. Everyone is going to take advantage of this savings opportunity, provided their doctors say it’s okay to switch to the generic.

I was wrong.

I just found out that less than 3 percent of the members who received this letter switched to a generic version of Lipitor. I find this very surprising.

Brand-name drugs, especially “blockbuster drugs” like Lipitor and Plavix®, are often a lot more expensive than generic drugs. And if pricing trends from 2011 to 2012 are any indication, I wouldn’t expect prices on brand-name drugs to come down anytime soon.

According to an Express Scripts report based on 2012 drug claims data, prices for brands increased 13.3 percent while generic drug prices decreased by 21.9 percent. The report states that the price differences between brand-name and generic drugs is more than 35 percent, which is “the largest widening of brand and generic prices since Express Scripts began calculating its Prescription Price Index in 2008.”

Granted, Pfizer did make a lot of efforts to hold onto its customers–for example, they offered insured patients a discount card to get Lipitor for $4 a month–but I know Pfizer didn’t reach everyone, because about 97 percent of our members are still getting Lipitor through their Medicare Part D plan. So about 97 percent of our members are not only paying more than they need to, but they are also approaching the Coverage Gap stage of their benefit a lot faster than those beneficiaries who switched to the generic drug.

Let’s compare Mr. Smith’s costs for Lipitor with Mrs. Johnson’s costs for the generic version of Lipitor as an example:

Mr. Smith always uses brand-name drugs
• During the Initial Coverage period, Mr. Smith has a 25 percent co-payment on brand-name drugs. He pays $32.25 for a 30-day supply of Lipitor. His plan pays the remainder, or $96.75.
• Mr. Smith always uses brand-name drugs, so he reaches the Coverage Gap in July. (Remember, it’s the total amount that both you and your plan pays that advances you to the Coverage Gap.)
• Now he has to fork over $61.25 for Lipitor (the full cost of the drug minus the
47.5 percent discount) for the rest of the year.
Mr. Smith’s total annual cost for Lipitor is $561.

Mrs. Johnson always uses generic drugs
•During the Initial Coverage period, Mrs. Johnson has a 25 percent co-payment on generic drugs. She pays $3.27 for a 30-day supply of atorvastatin, which is a generic version of Lipitor. Her plan pays the remainder, or $9.81.
• Mrs. Johnson always uses generic drugs whenever possible, so she never reaches the Coverage Gap.
Mrs. Johnson’s total annual cost for atorvastatin is $39.24.

I know I’d much rather pay $3.27 for a generic that’s just as safe and effective as a brand-name drug that costs 10 times more!

So is there anyone out there who can tell me why a large majority of Medicare beneficiaries are paying so much more than they have to for their medications? What am I missing? Surely not my brain!?

Dear Medicare, We’re not Dead Yet

In Monty Python’s Spamalot, there is a scene with Robin and Lance and a supposed dead man who suddenly rises from a cart singing, “I am not dead yet; No need to go to bed; No need to call the doctor; Cause I’m not yet dead.”

Arnold Ross of New York also sang this song—although not to an audience, but to Medicare. Unfortunately, the people at the Centers for Medicare & Medicaid Services apparently had their ears plugged.

According to this report I came across on Eyewitness News, ever since Arnold’s wife passed away in July, Medicare has declared Arnold dead. “They said I’m deceased. I was dead in their computers,” he tells the reporter. “Look at me, do I look dead?” he said.

Weeks after his wife’s death, Medicare sent Arnold a condolence letter for his own death. Medicare also stopped paying his doctor bills. Arnold says he made many calls to Medicare, but nothing was ever resolved. Eyewitness News made one call and the problem was resolved in a few hours.

Medicare said the initial confusion happened because Arnold and his wife’s Medicare numbers were very similar (in other words, a computer error). They apologized to him for the problem, but couldn’t explain why it took so long to pay attention to his pleas and get it fixed.

A few years back I ran into a similar problem with Medicare — they had accidentally attempted to enroll people into a Medicare Part D plan even though these people had passed away. (Imagine getting a letter thanking your late spouse for joining a Medicare plan.) I had to write a letter to their loved ones expressing condolences for this error.

Unfortunately, because Medicare relies on enormous computer systems to operate, mistakes do happen often. But there was no excuse for the real people at Medicare to ignore Arnold’s calls when their computer system made an error. Talk about Medicare fraud, waste, and ABUSE. If I were in charge, a lot of people would be fired right now for their incompetence.

What They Won’t Tell You about the Medicare Coverage Gap Discount Program

Generic drugs in Coverage Gap

Generic drugs are the best value in any stage of your Part D benefit.

Although many people are opposed to the Affordable Care Act (aka Obamacare) for one reason or another, the law is making Medicare prescription drug coverage more affordable by slowly closing the Coverage Gap.  

This year, if you reach the gap (also called the donut hole), you will get a 52.5 percent discount on brand-name drugs. That’s up slightly from the 50 percent discount on brands in 2011 and 2012. So if your copayment was $50 for a $100 drug last year, your copay will be just $47.50 for the same drug in 2013.

But here’s the catch: Although the Coverage Gap Discount Program is certainly helpful if you reach the Coverage Gap and use brand-name drugs, what you may not know—and what the big drug companies won’t tell you—is that even with the 52.5 percent discount on brand-name prescription drugs, lower-cost generic drugs are still the best bang for your buck in most cases.

For the past few years, the government and the media have all been touting the brand discount as a great way to lower drug costs when you’re in the Coverage Gap. What they should be telling you, however, is although the discount is helpful, the real savings lie in generics, no matter what stage of the benefit you’re in. Using generic drugs whenever possible will not only delay your entry into the gap, but it can even keep you out of it.

I’ve always recommended FDA-approved generic drugs as one of the best ways to lower your drug costs and delay entering the Coverage Gap. Not only do they generally cost up to 80 percent less than brands to begin with, but this year you get an additional 21 percent discount on generics when you’re in the gap (that’s up from 14 percent in 2012). So even with the 52.5 percent discount on brand-name drugs, generics still provide more value for your Medicare dollars.

Closing the Medicare Part D Coverage Gap

You will continue to save on covered brand-name and generic drugs while in the Coverage Gap until the gap is closed in 2020. Here is what you’ll pay for drugs while you are in the gap:

  • 2013: 47.5% for brand-names and 79% for generics
  • 2014: 47.5% for brand-names and 72% for generics
  • 2015: 45% for brand-names and 65% for generics
  • 2016: 45% for brand-names and 58% for generics
  • 2017: 40% for brand-names and 51% for generics
  • 2018: 35% for brand-names and 44% for generics
  • 2019: 30% for brand-names and 37% for generics
  • 2020: 25% for brand-names and 25% for generics



The Med Diva 2012 in review

The stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 6,200 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 10 years to get that many views.

Click here to see the complete report.

Post Navigation

%d bloggers like this: