The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “PDP”

28% of #Medicare #partD plans receive poor star ratings from CMS

You probably wouldn’t choose a 2-star restaurant or a resort hotel that has only earned 3 out of 5 stars. You shouldn’t choose a Medicare Part D or Medicare Advantage plan with low star ratings, either. And for pretty much the same reason: Low star ratings mean lower quality and poor customer service.

Each year, the Centers for Medicare & Medicaid Services (CMS) rates how well health plans and prescription drug plans perform in different categories, such as customer service, prescription drug safety, and member satisfaction. The Medicare star ratings are important because they help you compare the overall quality of plans. Star ratings range from 1 star (poor) to 5 stars (excellent), so look for a plan with high ratings (4 or 5) to ensure you get the level of service and safety you deserve.

Now here’s the catch (there’s always a catch with Medicare!). This year, 28 percent of rated prescription drug plans (PDPs) that will be available in 2012 scored poorly (fewer than 3 stars). No national PDPs received a perfect 5-star rating this year, and one only national PDP—Medco Medicare Prescription Plan—received 4 stars. Although a few smaller, regional plans did receive 5 stars, the chance that one of these plans is in your region and meets your needs is very slim. 

The good news for beneficiaries is that CMS is telling these poor-performing plans that unless they take steps to improve their performance over the next few years, they face losing their Medicare sponsor status.

One of the main reasons that many plans’ ratings fell from last year is a shift in the way CMS rates Medicare drug plans. This year, the criteria changed to focus more on clinical outcomes, such as whether patients with diabetes, hypertension and high cholesterol are taking their medications as directed by their doctors.  Although some plans do have very effective medication management tools in place—such as pharmacist outreach calls—it’s not an easy or inexpensive task for plans to ensure their members are following doctor’s orders and taking their drugs as prescribed.

Like last year, the ratings also consider member experience, such as how long a patient is kept on hold when calling the plan, the number of complaints lodged against plans, and the number of people who choose to leave plans.

How does your state rate?

On a national level, 24 percent of the 557 rated drug plans get the top ratings of four or five stars, and about half fall in the middle with three stars. Another 28 percent score below three stars. From Kaiser Health News, here is the percentage of rated Part D plans in each state that get fewer than 3 stars on a scale of 1-5.:

Alabama 50%
Alaska 40%
American Samoa 0%
Arizona 48%
Arkansas 47%
California 42%
Colorado 46%
Connecticut 43%
Delaware 42%
Florida 42%
Georgia 47%
Guam 0%
Hawaii 40%
Idaho 40%
Illinois 44%
Indiana 48%
Iowa 42%
Kansas 39%
Kentucky 48%
Louisiana 50%
Maine 46%
Maryland 42%
Massachusetts 43%
Michigan 44%
Minnesota 42%
Mississippi 47%
Missouri 50%
Montana 42%
Nebraska 42%
Nevada 48%
New Hampshire 46%
New Jersey 43%
New Mexico 43%
New York 31%
North Carolina 43%
North Dakota 42%
Northern Mariana Islands 0%
Ohio 48%
Oklahoma 43%
Oregon 40%
Pennsylvania 39%
Puerto Rico 81%
Rhode Island 43%
South Carolina 53%
South Dakota 42%
Tennessee 50%
Texas 42%
Utah 39%
Vermont 43%
Virgin Islands 0%
Virginia 50%
Washington 40%
Washington D.C. 42%
West Virginia 39%
Wisconsin 45%
Wyoming 42%


Countdown to Medicare Part D Open Enrollment: Day 7

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

Day 7: The Medicare Part D Coverage Gap Discount Program helps you save when you’re in the donut hole 

 The Affordable Care Act, otherwise known as Obamacare, includes provisions to close the Medicare Part D Coverage Gap (aka “donut hole”) to help lower prescription drug costs for Medicare beneficiaries. One of the major provisions is the Coverage Gap Discount Program, which went into effect January 2011. According to the Centers for Medicare & Medicaid Services, more than 1.7 million Medicare beneficiaries had taken advantage of program through August 31, 2011, resulting in a total savings of almost $930 million.

 Under the Discount Program, if you have Part D coverage but don’t get Extra Help from Medicare, you get a 50 percent discount on “applicable” brand-name drugs if and when you reach the Coverage Gap.  This discount applies at either retail or mail-order pharmacies, but does not include the cost of the pharmacy dispensing fee.  Another good thing is that the full cost of the drug counts toward your out-of-pocket spending, which helps you move out of the Gap and into the Catastrophic Coverage stage.

 In addition, this year you’ll pay only 86 percent of the total cost of generic drugs and supplies used for the delivery of insulin when you’re in the Gap.  

How the Coverage Gap Discount Program works

 Let’s say you have reached the Coverage Gap and go to your pharmacy to fill a prescription for a brand-name drug, such as Diovan®. The full price of Diovan at this pharmacy is $50 and the dispensing fee is $2. Once the 50% discount is applied, the price of Diovan is now only $25. The pharmacy charges a $2 dispensing fee, so your total cost for the medication would be $27. The entire amount, however–$52–will be counted as out-of-pocket spending and will help you move out of the Gap.

Who is eligible for this savings while in the Coverage Gap?

You must meet all of the following criteria to be eligible for discounts under the Medicare Coverage Gap Discount Program:

  • You are currently enrolled in a Medicare prescription drug plan (PDP) (including employer-sponsored plans called Employer Group Waiver Plans), or a Medicare Advantage Plan that includes prescription drug coverage.
  • You do not get Extra Help from Medicare for your prescription drug costs.
  • You have reached the Coverage Gap stage of your benefit.
  • You fill a prescription for a covered brand-name drug.

If you are fortunate enough to be enrolled in a Part D plan that don’t have a Coverage Gap stage, you’ll still be eligible to get a discount on brand-name prescriptions once you reach the defined standard initial coverage limit (ICL). In 2012, the standard ICL is $2,930

In coming weeks I’ll explore the Discount Program further, and tell you some things the drug makers don’t want you to know about it.

Countdown to Medicare Part D Open Enrollment: Day 13

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

 Day 13: Ensuring that your plan still has you covered in 2012

If you are currently enrolled in a Medicare prescription drug plan, one of the first things you should do sooner than later is confirm that your current plan is going to continue covering your medications in 2012. You should also make sure that your drugs will be in the same cost-sharing tier next year.  If your plan is not going to cover one or more of your medications next year—or your drug is being moved to a higher cost-sharing tier (for example, it’s switching from a Tier 1 to a Tier 2 drug), you may want to shop around for a new plan during the Open Enrollment period.

Although Medicare requires all Part D plans to cover at least two drugs in each therapeutic drug category, each Medicare prescription drug plan has its own list of covered prescription drugs, which is called a formulary. Formularies include both generic drugs and brand-name drugs.

 Pay Special Attention to the Annual Notice of Change

All Part D plans can make changes to their formulary for the coming year, so you should never assume that your current plan will have you covered in 2012 just because it covers all your drugs this year. That’s why it’s critical to review your plan’s Annual Notice of Change, which you should have received by September 30.  

 Take a moment now to review the plan’s formulary, which should have been included in the Annual Notice of Change documentation. Ignoring the formulary now and not double-checking that your drugs will be covered  in 2012 could leave you stuck in a plan that may not be right for you—and may end up costing more than you should have to pay for your Medicare prescription drug benefit.

Countdown to Medicare Part D Open Enrollment: Day 15

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

 Day 15: Premium price hikes are just one reason to shop around (carefully) for a new Med D plan

Source: Avalere Health analysis. “New Avalere Analysis of Medicare Prescription Drug Data Shows Commercial Plans Aggressively Positioning for Membership in 2012.” Available at:

Two days ago, I referred to an eHealth study that found that 65 percent of seniors were unaware the dates for Medicare Open Enrollment (for coverage effective January 1, 2012) were changing this year. In the same study, 63 percent of respondents said they didn’t expect their prescription drug plan to change–or didn’t know if it would change—in 2012.

This figure is alarming, because most plans do make changes that can affect your pocketbook—or your health.

As I explained yesterday, Part D plan sponsors contract on a yearly basis with the Medicare program, so more often than not plans do make annual changes to their formulary (list of covered drugs), co-payments or coinsurance amounts, or monthly premiums. In 2012, for example, average premiums across all prescription drug plans are decreasing by about 4 percent. However, an Avalere Health analysis found that 6 of the top 10 plans are increasing premiums, including UnitedHealthcare (14 percent) and BravoRx (10 percent).

 I know if I found out my insurance coverage was going up 10 or 14 percent, I’d start shopping around. But–there’s always a big “but” with Medicare—here’s a very important caveat: Never choose a Part D plan based solely on the lowest premium. Do shop around, but do so carefully, and arm yourself with helpful tips so you can make an informed decision.

Helpful plan shopping tip #1

The first tip I want to share with you is as follows: Look for a plan with low total costs, which include not just the monthly premiums but also the yearly costs for all your medications. Please keep in mind that plans with low monthly premiums could have higher total costs when you consider how much your drugs will cost. Plans with super-low premiums may also have low customer satisfaction ratings or low Medicare star ratings—or even worse, they may not cover the drugs you are currently taking.

One of the first tools I suggest you use to compare plans is the Medicare Plan Finder on the Medicare website. Just enter your Medicare number and drugs you’re taking, and the tool will display a list of possible plans, estimated costs, premiums, deductibles, covered drugs, and star ratings. You should also download Medicare’s free guide to benefits, Medicare & You, if you don’t already have copy. It’s easy to read, has everything you ever wanted to know about Medicare (or not), and can be very helpful with your decision-making.

 Stay tuned for tomorrow’s tip, plus important information about Medicare star ratings.

Countdown to Medicare Part D Open Enrollment: Day 16

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

  Day 16: Let the Medicare Part D Marketing Begin

If you’re currently enrolled in a Medicare prescription drug plan (PDP), Medicare Advantage (MA) plan, or Medicare Advantage with Prescription Drug Coverage (MA-PD) plan, you should have already received your Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) documents. The Centers for Medicare & Medicaid Services requires plans to ensure that current members receive the ANOC/EOC by September 30, 2011. If you haven’t received your documents yet, call your plan immediately to make sure they have your correct address on file.   

The ANOC and EOC will tell you what your new monthly premium and annual deductible (if any) will be for 2012. They will also procide information about the drugs covered and the co-payments or coinsurance amounts that you will pay in each stage of your benefit.

Even if you are satisfied with your plan in 2011, you still need to review your plan options for 2012

It’s important to carefully review your ANOC and EOC as soon as possible to determine if you want to stay with your current plan or make changes for the coming year. All plan sponsors must contract on a yearly basis with the Medicare program, which permits changes to formulary lists (the list of drugs covered by the plan), restriction and limitation requirements, monthly premium payments, and co-payments or coinsurance. So, for example, if your plan no longer covers a drug that you take on a regular basis, or if the monthly premium has increased more than you expected, you may want to look for a plan that better meets your health and financial needs.

If you do decide that you need to change plans, remember you can only enroll in a plan or switch plans between October 15 and December 7.  After December 7, you will not be able to change yourMA,MA-PD, or PDP plan for 2012 unless you qualify for a Special Enrollment Period.

Starting October 1, 2011, plan information for 2012 will be available on the Medicare Plan Finder on Medicare’s website. MA and PDP plan sponsors can also start marketing their plans on October 1, so expect to get inundated with marketing materials over the next two months. Please keep in mind that Medicare plan sales agents can not do the following: 

  • Come to your house without an invitation from you
  • Approach you in parking lots, hallways, or lobbies
  • Offer you a gift worth more than $15 to join their plan
  • Provide free meals at Medicare sales presentations
  • Try to sell you a plan at educational events and seminars

Over the next few weeks I will be giving you lots of helpful tips, money-saving suggestions, and important things to consider when comparing Medicare Part D coverage.  I’ll also cover Special Enrollment Periods, Medicare star ratings, the Coverage Gap, and other Medicare topics that may not make a lot of sense to you right now, but are nonetheless important to understand in order to make the most of your benefit.



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