Why do I need to review my Part D coverage?
November 1, 2018
You may have seen or heard a lot of buzz about the Open Enrollment Period (OEP) for Medicare Part D. And you may think to yourself, “I am perfectly happy with my current prescription drug coverage and I don’t want to make any changes so I will stay with the plan that I have.” This decision could cost you money and here’s why.
The (OEP) is a six week opportunity for those who have Medicare to review their coverage. Persons who have not had prescription drug coverage may join a plan and those who have prescription drug coverage may change to a different plan. These changes become effective Jan. 1.
The Center for Medicare and Medicaid Services (CMS) provides prescription drug coverage to beneficiaries through contracting with private companies that offer prescription plans from which beneficiaries can choose. In 2018 there were 19 different plans available in Alaska. In 2019, there will be 22 plans available.
Each of the companies that offer these plans must follow Medicare’s rules including a “formulary,” a list of all of the medications covered by the plan. The plan must offer at least two medications in all therapeutic classes, including medications generally needed by populations on Medicare, and insulin preparations. However, the plan gets to choose the specific medications they will provide in each class.
There are certain protected categories that require each plan to offer all available medications. The protected categories are: cancer drugs, HIV/AIDS drugs, antidepressants, antipsychotics, anticonvulsants and immunosuppressants. They must also cover all commercially available vaccines, including the shingles shot, except those vaccines covered under Part B, such as the seasonal flu shot and pneumococcal vaccine.
The coverage and the cost of the plans can vary. In 2019, most people will pay a monthly premium – the range is between $15.50 (WellCare Value Script) and $97 (Express Scripts Medicare – Choice). Eighteen of the 22 plans will charge a yearly deductible ranging from $345 to the cap at $415. Four of the plans have no monthly premium. Beneficiaries will also probably pay a co-pay or co-insurance at the pharmacy as well.
Each year, the plans can make changes to the formulary, in other words, change what medications they will cover that year. Your current plan may be covering a medication this year and choose not to cover that same medication next year. On the other hand, they can cover medications next year that they did not cover this year.
They can also change the tier level of medications. Tier 1 medications are typically lower cost generics and have the lowest cost-sharing amount. Tiers 2 through 5 are for more expensive generics, brand-name and specialty medications. These have higher costs for the beneficiary. The tier level of your medication determines your cost in copays and coinsurance.
Additionally, the plans contract with pharmacies each year. Pharmacies that have agreed to provide members of certain plans with services and supplies at a discounted price are known as network pharmacies. In some plans, your prescriptions are only covered if you get them filled at network pharmacies. If your plan’s network includes “preferred cost-sharing” pharmacies, you can save money by using them. The plan and the pharmacy have agreed to provide certain medications at a lower price. Each plan offers a mail order option. This option may or may not be less expensive than purchasing retail.
As you can see, there are a lot of elements that can affect your medication costs. Things may have changed for you as well.
Perhaps your medications have changed this year or your choice of pharmacies may have changed.
The bottom line is that the coverage you enjoyed this year may change even if you stay with the same plan. So, even if you like your current Part D plan, you still should spend some time during open enrollment comparing it with other plans available in 2019. Here some things to consider when reviewing your coverage: Do you have other current coverage, either through a retiree plan or a working spouse? Is the coverage creditable, which means it is as good as Medicare coverage? Could joining a plan affect your current coverage or a family member’s coverage?
You should also look into being screened for the Limited Income Subsidy (LIS) program, also known as the Extra-Help program. The LIS program is intended to help pay for the costs of Part D for those with limited income and assets. The income limits to qualify for the program are $1,918 per month if you are single, $2,593 per month for couples. The asset limit is $14,100 if single and $28,150 for couples. The asset limit does not count the value of your home, vehicles or personal possessions. However, they do count annuities, investment accounts, and other property. This program can significantly lower your out of pocket costs and gives you other advantages as well. If you think that you may qualify, your Alaskan Medicare counselor can assist in screening you and provide application assistance.
The State of Alaska Medicare Information Office can assist you in finding a Medicare counselor that can walk you through a review of your coverage and comparison of the upcoming year’s choices and offer screening and application assistance for the Extra Help program. The counseling can be done in person or by phone. They can be reached at 1-800-478-6065 Monday through Friday, 8 a.m. to 5 p.m.
If you are on very expensive medications, you may be eligible for a patient assistance program. These are programs offered by pharmaceutical manufacturers and other sources that may provide that medication for you at little or no cost. Each program has different eligibility qualifications. Your Medicare counselor can assist you in researching these programs.
There are almost 100,000 Medicare beneficiaries in Alaska and many of them have Part D coverage, so I encourage you not to delay in making arrangements to review your coverage so that you are assured that you are getting the coverage you need and the lowest cost available in 2019.
Nila Morgan is a Certified Medicare Counselor who works at the Anchorage Senior Activity Center.