The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “prescription drug plan”

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




Why women (and men) with Medicare should know about shrinkage

Important Facts about Medicare Part D for 2013

If you’re a fan of Seinfeld, you must remember this classic dialog from the 1994 Hamptons episode, in which George’s girlfriend catches him naked after he gets out of the cold swimming pool:*

Jerry, George Costanza: Elaine!
Jerry: Do women know about shrinkage?
Elaine: What do you mean, like laundry?
Jerry: No, like when a man goes swimming afterwards.
Elaine: It shrinks?
Jerry: Like a frightened turtle!
Elaine: Why does it shrink?
George Costanza: It just does.
Elaine: I don’t know how you guys walk around with those things.

Although I’m going way out on a limb here, I like to think that the Medicare Part D Coverage Gap is also undergoing shrinkage. Albeit, not quite like a frightened turtle – more like a threatened millipede starting to coil up into a ball.

How the donut hole is shrinking

While the entire country is debating whether or not the Patient Protection and Affordable Care Act (ACA) is constitutional, the Medicare Coverage Gap, also called the donut hole, is getting smaller under the public’s radar.

As a result of the ACA, eligible prescription drug plan enrollees who are not Dual Eligibles will pay only 47.5 percent of the costs of covered brand-name drugs in 2013. That’s down slightly from 50 percent this year. If you use generic drugs in the gap (and you should whenever possible), your cost sharing will shrink to 79 percent, from 86 percent in 2012. The Coverage Gap will continue to close a little bit each year, until beneficiaries will pay only 25 percent for both brand-name and generic drugs if they reach this stage.

2013: Three strikes and you’re out

I’m writing this while listening to the Yankees play Tampa Bay on Opening Day, so I couldn’t resist the headline. Basically, what this means is that in 2013, the Centers for Medicare & Medicaid Services (CMS) will alert plan members if their Medicare Part D drug plan or Advantage (Part C) health plan has failed for three years in a row to receive at least 3 out of 5 stars from CMS. If the plan has three strikes, CMS will offer a special enrollment period to allow those members to move to a higher quality plan.

What you will pay for Part D in 2013

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 directs CMS to update the parameters for the standard Part D drug benefit each year. These parameters include the standard deductible, initial coverage limit, catastrophic coverage threshold, and minimum co-payments for costs incurred in the Catastrophic Stage.

Following are the 2013 Part D parameters for the defined standard benefit:

  • Deductible: $325  ($320 in 2012)
  • Initial Coverage Limit: $2,970  ($2,930 in 2012)
  • Out-of-pocket threshold: $4,750  ($4,700 in 2012)
  • Minimum cost-sharing for generic/preferred multi-source drugs in the Catastrophic Phase: $2.65  ($2.60 in 2012)
  • Minimum cost-sharing for other drugs in the Catastrophic Phase: $6.60  ($6.50 in 2012)

*The Internet Movie Database


Medicare Part D Plans Must Ensure Prescription Drug Access in Disaster Areas

When a disaster is declared, Medicare beneficiaries must have access to their prescription medications.

This week the governors from Kentucky, Ohio, and Indiana all declared a state of emergency in response to Friday’s barrage of deadly tornadoes and widespread storm damage. By requesting the declaration, these states can expedite the process of getting Federal Emergency Management Agency (FEMA) assessment and assistance teams into communities that need it most. It also means that all Medicare beneficiaries who live in these communities will be able to get immediate refills of any prescription drugs lost in the storms.

When disaster strikes, there’s no such thing as “refill too soon”
According to guidelines from the Centers for Medicare & Medicaid Services (CMS), all Medicare Part D prescription drug plans must guarantee immediate refills of Part D medications for any members located in an area that has been declared a major disaster. In addition, because of certain conditions that might exist during an emergency, such as a reduced number of operational pharmacies, limitations on transportation and travel, and the disruption of U.S. mail service, plans must also allow an affected beneficiary to get the maximum extended day supply of the drug, if requested and available at the time of refill.

In other words, any time a disaster has been declared, Part D plan sponsors must remove what is called the “refill too soon” (RTS) edit for affected members, for the period of the emergency declaration.

What the “refill too soon” edit means to you
Even if your community has never been declared a disaster area, it’s important for you to know about the RTS edit and how it can affect your access to your prescription drugs. Most people outside of the insurance or pharmacy benefit industry don’t know about this edit, but I think it is very worth sharing this inside information with you.

If you’ve ever tried to refill a prescription for a long-term drug a few weeks early, your claim was probably rejected at the pharmacy. Your pharmacist would have told you to come back in a week or so, because your Medicare Part D plan wouldn’t pay for a refill yet. This is the RTS edit in action.

When your pharmacist receives the “refill too soon” message from your Part D plan, it means you are trying to refill a prescription before a certain percentage of your current medication has been used. For example, let’s say your Part D plan requires that at least 75 percent of your medication from the previous order be used before you can get a refill. If you order a 30-day supply (30 pills) of a certain medication every month, you must wait at least 23 days—in other words, you must have already taken 23 pills or 75 percent of your medication—before you can order another refill. 

The rationale behind the RTS edit is that it is an effective way for prescription drug plans to minimize excessive use, waste, and stockpiling of medication. I do agree that the RTS edit is a good rule to help prevent people from hoarding bottles of pills or using more drugs than their doctor has prescribed. But I’m also glad that CMS had the good sense to recognize that when disaster strikes, some rules must be broken.

Pharmacist groups says CMS, “restricted network” Medicare Part D plans, deceived seniors

The local community pharamcy is often a "non-preferred" phamarcy in Medicare Part D plans.



As if Medicare Part D wasn’t confusing enough, beneficiaries now have to make sure they watch out for the terms “preferred network” or “restricted network” when choosing a prescription drug plan (PDP).

According to the National Community Pharmacists Association (NCPA), restricted network pharmacy plans are centered on national pharmacy chains (such as CVS or Walgreens) 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 is often the small community pharmacy in your town.)

There are several national restricted network Part D plans, 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.

Last week, the NCPA asked the Centers for Medicare and Medicaid Services (CMS) to create a special enrollment period that would allow members of these plans to enroll in a new Medicare Part D prescription drug plan. The group says this action is needed for patients who believe that “material misrepresentations” led them to sign up for a “preferred network” plan with inadequate pharmacy access.

According to the NCPA, many people have claimed that they relied on CMS’ Medicare Plan Finder, as well as online advertising and/or enrollment agents, to help them find the best plan. They chose a plan based on the low, advertised co-pays, only to find out later the advertised co-pays were only for “preferred network pharmacies.” Now these members may have to travel 20 miles or more to a large chain pharmacy to get that advertised price.

Back in November, NCPA sent a letter to CMS urging the agency to modify the Medicare Plan Finder tool so it is perfectly clear that the lower co-pays are only available at a preferred pharmacy. They also asked CMS to require restricted network plans to clearly state in all communications that members must use a preferred pharmacy to get the lower advertised drug costs.

In a January 19, 2012, press release, NCPA Chief Executive Officer Doug Hoey, RPh, stated, “Every day about 10,000 Americans turn 65 and are eligible to enroll in a Medicare drug plan. Medicare should allow seniors who feel that they’ve been duped the same choice as those just entering the program. In addition, CMS should implement preventative steps to avoid a repeat of this situation next year.”

NCPA is asking community pharmacists to assist their patients in filling out a CMS complaint form, calling 1-800-MEDICARE, or filing a complaint via NCPA’s website if patients feel they were mislead and are experiencing pharmacy access issues.

Five-star special enrollment period for Medicare will help seniors in only 8 states

Although Medicare Open Enrollment officially ended on Wednesday, a new Special Enrollment Period (SEP) has now kicked in for beneficiaries who would like to enroll in a five-star Part D (prescription drug) or Medicare Advantage plan. This SEP theoretically extends the Open Enrollment period for the 2012 plan year to December 31, 2011, which had always been the deadline in the past. The problem is, most seniors will have a hard time finding a five-star plan, since very few plans received this top-quality rating from the Centers for Medicare & Medicaid Services for 2012.

According to an analysis conducted by Allsup, a Medicare plan selection service, as of November 30, there was only one five-star prescription drug plan available in just eight states:  Iowa, Minnesota, Montana, Nebraska, New York, North Dakota, South Dakota and Wyoming.

There were only eight five-star Medicare Advantage contracts (14 total plans) available 10 states, with one available in each of the following seven states: California, Colorado, Hawaii, Illinois, Maine, Massachusetts and Oregon; two available in Iowa and Washington; and three available in Wisconsin.

How the Special Enrollment Period works

Starting December 8, you can make the switch to a five-star Medicare Advantage plan or Part D prescription drug plan that serves your area. You can make this switch only one time through November 30, 2012. 
• If you enroll December 8 – December 31, 2011, your coverage will begin January 1, 2012.
• If you enroll January 1 through November 30, 2012, your coverage will begin on the month following the month in which you submit your enrollment request.

Consider other factors when switching to a five–star plan

If you are fortunate to live in one of the eight states that offer a five-star plan, you may want to consider it if you are not pleased with your current Part D plan. But remember, while the star ratings are important, there are many other factors to think about, such as total plan costs based on all the drugs you are taking and the plan’s formulary (list of covered drugs.) And should you switch to a five-star plan, there’s no turning back: You only get to switch once, so you’ll have to stick with that plan until the next Open Enrollment period in 2012.

Spread the Word: Only 2 Shopping Days Left for Medicare Part D Open Enrollment

There may still be 19 shopping days left until Christmas, but this year the shopping season for Medicare Part D ends on December 7. That means there are only 2 more days (after today) in which you can switch your prescription drug plan for 2012.

You can thank Healthcare Reform for the early deadline this year: The 2010 Patient Protection and Affordable Care Act mandated the earlier enrollment period to give you more time to weigh your plan options and the drug plans more time to complete paperwork and get membership cards and plan materials to beneficiaries by January 1, 2012. The intention was good, but unfortunately, the execution has been poor.

In fact, one recent survey shows that almost 20 percent of seniors are still unaware of the Wednesday deadline.

According to the survey conducted by Opinion Research Corporation and sponsored by PlanPrescriber, one in five seniors 65 years of age and older with Medicare prescription drug coverage were still aware that the Open Enrollment period ends December 7. The national phone survey was conducted between October 28 and October 31, 2011.

Please spread the word

Hopefully, this number has improved during the past month. Ideally, 100 percent of seniors are now aware of the early deadline. However, it’s more likely that a small percentage of beneficiaries are still in the dark about the deadline – which means we must still work hard to get the word out. That’s why I’m asking all of my readers, Facebook friends, and Twitter followers to talk to all the seniors in your lives and remind them that the last day to switch their Medicare Part D plan is Wednesday, December 7.  Thank you everyone!

When to enroll in a Medicare Part D prescription drug plan

Today I spent the day monitoring phone calls from my company’s Medicare Part D plan enrollment call center. Several seniors who called to enroll in our plan said they were very confused about the Open Enrollment deadline, especially those people who are eligible for both Medicare and Medicaid.

To help clear up some of this confusion, here is some basic information about when you can enroll in a Part D plan or switch Part D plans. In a nutshell:

• Most people can enroll in a Part D plan when they first become eligible for Medicare and then once a year after that during Open Enrollment if they want to switch plans.
• People who receive both Medicare and Medicaid can enroll when they first become eligible and then once a month after that if they want to switch plans.

Enrolling for the first time: Turning 65 or new to Medicare

If you are new to Medicare, it’s important to enroll in a Part D plan as soon as you become eligible (during your Initial Enrollment Period) to avoid paying any late-enrollment penalties. When first eligible for Medicare, you have a full 7 months to enroll in a Medicare Part D plan:
• Up to 3 months before you turn 65
• During the month of your 65th birthday
• Up to 3 months after you turn 65

If you join a prescription drug plan during the 3 months before you turn 65, your coverage will start on the first day of your birth month. If you join during or after your birth month, your coverage will begin on the first day of the next month.

Here are 3 examples to show you when your coverage will go into effect:
Let’s assume your 65th birthday is May 3, 2012. That means your Initial Enrollment Period is from February 1 – August 31, 2012 (3 months before to 3 months after your 65th birthday).

1. If you join a Part D plan before your birth month (February 1 – April 30, 2012)
Your coverage will begin the first day of your birth month: May 1, 2012

2. If you join a Part D plan during your birth month (May 1 – May 31, 2012)
Your coverage will begin: June 1, 2012

3. If you join a Part D plan after your birth month (for example, July 1 – July 31, 2012)
Your coverage will begin: August 1, 2012

When you can switch Part D plans

If you are already enrolled in a Part D plan, you can generally switch plans only once a year during Open Enrollment (also called the Annual Election Period). Open Enrollment runs from October 15 through December 7 for the 2012 plan year. Outside this time period, you may make other changes during the year only if you qualify for a Special Enrollment Period (SEP).

For example, you may qualify for an SEP for the following reasons:
• You lose creditable coverage (that is, coverage as good as or better than Medicare) through no fault of your own  (for example, your former employer or union stops providing coverage for retirees)
• You move to a new permanent address that is not in your current plan’s service area
• Your current plan no longer offers Part D coverage
• You receive Medicaid or get Extra Help with Part D costs
• You are enrolled in a State Pharmaceutical Assistance Program (SPAP)

Dual Eligibles can switch plans once a month

If you have both Medicare and Medicaid, you are considered a “dual eligible” individual. “Dual eligibles” may change plans once every thirty days. You can ignore the Open Enrollment dates and the December 7th deadline because they do not apply to you.

No “Oops” Allowed: 3 Facts to Remember About Medicare Part D Open Enrollment

In honor of Texas Governor Rick Perry’s most recent gaffe during the CNBC Republican presidential debate, I want to briefly review three questions about Medicare Part D Open Enrollment that seniors have often asked me. You don’t want to go “oops” when it comes to something as important as your health, so please remember the answers!
1. Do I have to re-enroll every year if I want to keep the same prescription drug plan?
No, if you are happy with your plan and it is meeting your needs, you do not need to do anything – your coverage will automatically continue each year. However, if your current plan has earned less than 4 stars from Medicare, or will no longer cover one or more of your medications in 2012, you should consider switching to another plan that is better suited for you.

It’s also a good idea to use the Medicare Plan Finder tool each year to make sure you’re not paying more than you have to for your prescription drugs. Recent studies show that seniors can save a few hundred dollars or more by doing some research and switching Medicare Part D plans.

2. My spouse and I use the same insurance company for our health coverage. Is it a good idea for us to enroll in the same prescription drug plan, too?
For most couples, it is not a good idea to choose the same Medicare Part D plan. Chances are you have different health needs and take different medications, so picking the same plan is usually not the best option.

For example, you may take only one generic medication, so your needs are minimal. Therefore, you would probably choose an inexpensive plan that has a low monthly premium but no extra bells and whistles. Your spouse may be taking several medications for a chronic condition such as diabetes or asthma, and therefore needs a plan that offers better coverage, a higher star rating, and a mail-order pharmacy for extra savings. It does not make sense for you to pay more for coverage you don’t need, or for your spouse to be enrolled in a plan that does not meet his or her prescription drug needs.

3. If I sign up for a Medicare Part D plan today, will my coverage start immediately?
When you join a Medicare plan during the Open Enrollment period, your new coverage will not begin until January 1st of the following year. So if you join a plan on November 15, 2011, your coverage will begin January 1, 2012. You will continue to be covered under your current prescription drug plan through December 31. You will be automatically disenrolled from your current plan as soon as your new coverage begins on January 1st.

And don’t forget: Open Enrollment ends early this year on December 7!

’Tis the season to shop: Seniors could save hundreds of dollars by switching Medicare Part D plans

Don’t Miss Your Chance to Save: Open Enrollment Ends December 7

Whether you’re a senior on Medicare, a caregiver for a Medicare beneficiary, or just helping your parents with their money matters, ’tis the season to go shopping. Even if you are satisfied with your current prescription drug plan, you could save a few hundred dollars or more by comparison shopping and choosing a plan that better meets your needs.

According to a recent survey of 71,000 people enrolled in Medicare prescription drug plans, 81 percent lowered their costs by an average of $298 by switching plans from 2006 to 2007. This number is promising, because it shows that even though Medicare Part D is complex and often confusing, seniors are using available tools and services to choose plans that cost them the least based on their prescription drug use.

Despite the results of this one survey, however, advocates like me still have a long way to go to convince Medicare beneficiaries that it’s a good idea to compare plans every year during the Open Enrollment period. According to the Centers for Medicare and Medicaid Services, only about 7 percent of the 17 million seniors on Medicare drug plans switch plans each year. Another survey conducted by KRC Research confirms CMS’s findings, with two out of three seniors stating they are unlikely to shop around for Med D plans. Medicare experts say this suggests that millions of beneficiaries could be paying more than they have to for prescription drug coverage.

Top 5 Reasons Why Seniors Don’t Make a Switch

According to senior advocates and insurance advisors, there are several reasons why people are hesitant about switching their drug plans:

1. Many believe that once they join a drug plan, they should stick with it long term, just as they stayed with the same private health insurance plan for many years before enrolling in Medicare.
2. A lot of seniors aren’t as aware as they should be of changes to the Part D benefit or of the opportunity to change plans during the Open Enrollment period.
3. With up to 30 or more drug plans on the market in each state, many seniors get overwhelmed or frightened at the thought of changing plans, even if another one would better suit their prescription drug needs and lower their costs.
4. Although Medicare’s easy-to-use Plan Finder tool allows beneficiaries to enter their medications to find a plan with the lowest overall annual costs, many seniors are uncomfortable going online or unable to use computers.
5. Many seniors are very satisfied with their current plan—even if it does cost more—and feel that “if it’s not broken, why fix it?”

Yes, shopping around and switching plans does take some time and can be a bit daunting.  But keep in mind these two good reasons for adding this annual task to your “to do” list:

• Medicare plans can and often do make annual changes to their offerings or formulary (list of covered drugs), which can increase drug costs by thousands of dollars, or make it more difficult for you to get certain drugs.
• If your drug needs have changed since you last enrolled in a Part D plan, your current plan may not be meeting all of your needs.

Remember, the Medicare Part D open enrollment season, which began October 15, continues only through December 7. If you need more information on Medicare Part D coverage, visit the Medicare website or call 1-800-MEDICARE.

Popular brand-drug patent expirations represent $9 billion+ in savings for Medicare beneficiaries

You probably already know that the standard Medicare Part D benefit includes a 50% discount on most brand-name drugs during the Coverage Gap stage.  What you may not know is that even with the discount, lower-cost generic drugs could still help you save more all year long.

Using generic medications instead of brand-name drugs is one of the best ways to lower your overall costs. And here’s even better news: Frequently used brand-name drugs such as Lipitor®, Lexapro®, Seroquel®, and Singulair® are expected to come off patent in 2012. These drugs currently account for more than $31 billion in retail sales. The new generic versions of these drugs could represent more than $9 billion in incremental savings opportunities for Medicare beneficiaries.

Generics are a great choice for savings and quality 

If you’re like me, when you think “generic” you may not always think “quality.” Given the choice of my favorite brand of raisin bran cereal for $3.99 or the generic no-name brand for $2.99, I’ll pay the extra dollar any day. Same goes for brand-name yogurt, shampoo, bread, or body lotion. The brand-name product just seems to taste or work better than the no-name versions.

 But FDA-approved generic drugs have been tested for quality and strength, and are as safe and effective as their brand-name counterparts. Generic drugs look different, but you can expect them to provide the same health benefits as their brand-name counterparts—often at a lower cost to you.

 I always ask my doctor to prescribe the generic drug if it’s available, because I know it will work just as well but cost so much less. In fact, according to the Food and Drug Administration, generic drugs can cost 30 percent to 80 percent less than brand-name drugs.

So if you’re taking a brand-name medication, ask your doctor whether a lower-cost generic drug could work for you. Keep in mind there are two types of generic drugs:

• A generic equivalent contains the same active ingredients as its brand-name counterpart and works the same way in your body.

• A generic alternative may contain different active ingredients, but is used to treat the same condition.

Remember, your doctor wants to help keep your medications affordable, so it’s always okay to ask if the prescription can be written for a generic drug. You deserve to save money, so don’t be afraid to just ask!

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