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Medicare guidance: Navigating the maze of prescription drug coverage

By Scott Welsh

Eileen Swenson has a drug problem. Like tens of thousands of other Americans, she suffers from Type 2 diabetes, and is treated with injectable insulin.

The costs of the drugs she needs to control her diabetes has skyrocketed in recent years. She fears, like many others, what the new year will hold for her drug co-pays and overall costs. In 2019, she paid $70 per month on average, then hit the coverage gap, in October.

Her monthly costs then rose to $160 per month for the remainder of the year. This year, she hit the coverage gap in June, and her monthly drug co-pays rose to $210.

Her challenge is chasing the cost sharing and co-payments due to the rapidly rising amounts pharmaceutical companies and pharmacy benefit managers charge retailers and Medicare beneficiaries for prescription drugs every year.

“I get anxious at the end of each year when it comes time to renew my health insurance,” she said. “I feel like I will really have to make lifestyle changes. I never thought I would have to choose between groceries and medications, but I am close to that. I don’t have more income each year, but my drug costs keep rising. It’s a daunting issue.

“I really have to stay on top of every drug. If my doctor wants to prescribe something new, I have to find out the costs at the pharmacy.”

Drug costs continue to be the hot button for Medicare beneficiaries. It’s a complicated issue, but there are some solutions and guidelines to help you. There are two primary ways Medicare beneficiaries can have Part D prescription drug coverage: either it is included in a Medicare Advantage plan, or it is purchased as a standalone plan.

Medicare recently announced the Part D Senior Savings Model, which will allow Medicare beneficiaries to choose a Medicare drug plan that provides access to a broad set of insulins at a maximum $35 co-pay for a month’s supply.  Starting Jan. 1, 2021, beneficiaries who select these plans will save, on average, $446 per year, or 66 percent, on their out-of-pocket costs for insulin.

In any given zip code in Southern California, there can be more than 30 different standalone prescription drug plans available, and 40-plus Medicare Advantage plans that include Part D coverage.

Each plan that offers Part D drug coverage is contracted with multiple preferred pharmacies. When you fill your prescriptions at a preferred pharmacy as opposed to a standard contracted pharmacy or a non-contracted pharmacy, you are sure to pay the lowest amount for your medications.

You can locate the preferred pharmacies associated with your plan by calling the customer service number on your health plan card.

Each plan has a different formulary, or covered drug list, and different cost sharing associated with each medication. Talk to your doctor about your medications. Bring your drug plan’s formulary to your doctor visits to make sure you are being prescribed medications that are approved.

Medicare requires that each drug plan have two medications in each therapeutic category. If your doctor feels it is necessary for you to take a medication that is not listed on the formulary, he or she may request a formulary exception from the plan that could result in a lower cost to you.

Dr. Gaja Andzel, an endocrinologist at Beaver Medical Group in Yucaipa, is an example of a doctor who is actively involved in prescribing medications that are the most affordable, without compromising the quality of care.

“You have to shop every year, you have to stay on top of it,” Andzel said. “The rules are changing, and plans change some of the drugs they are covering each year. And prices always go up. Some patients become complacent and let their current plans renew without considering the formulary changes. I feel that we have to help the patient reach their goals, but also prescribe drugs they can afford.

“The problem is that some of the new medications that are prescribed are just not worth the price. Some of the patients are having a hard time affording food. It’s sad. How can we ask them to pay for the more expensive drugs?”

Some Medicare recipients may qualify for a federal drug cost savings program called Low Income Subsidy, or Extra Help. This program can dramatically reduce prescription drug costs. Those who do qualify experience greatly reduced co-pays, and no coverage-gap increases.

The gross monthly income guidelines are $1,595 for an individual, with resources (savings, etc.) of $14,610, or $2,195, with resources of up to $29,160 for a couple.

A Medicare beneficiary can call 800-MEDICARE almost any day of the year to determine if they qualify and receive information. Health plans regularly report that about 60% of the people who are qualified don’t know the program exists. This can be a game changer.

Other ways to seek help are to recruit a local licensed Medicare insurance broker. There are hundreds of brokers available — at no additional cost to you — who will find the right plan to fit your financial needs and lowest out-of-pocket costs. A broker can compare many different plans to help solve your medication puzzle.

Often, your primary care medical office will be able to recommend local brokers who can help you find the proper plan.

In addition, HICAP is a group of volunteers who are focused on Medicare advocacy and Medicare education, and is able to provide free and objective information about Medicare health plans and prescription drug cost comparisons.

Scott Welsh and his wife, Sarah, own and operate Welsh Insurance Services, Inc., a Medicare advisor/broker in Southern California. More information at

Medicare Part D: Consumer tips

  • Shop every year.
  • Use preferred pharmacies associated with your plan.
  • Involve your doctor when choosing medications by showing him/her your drug formulary.
  • Apply for Extra Help with Medicare.
  • Seek help from local brokers to compare plans.

Source: Orange County Register

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