Caution needs to be taken with the Medicare Part D plan. It requires, not requests, but requires all Medicare participants wanting prescription coverage to seek it through a private insurance agency. These agencies must follow federal guidelines, but for the consumer, the challenge to getting prescriptions just got tougher. In most cases, you will be responsible for part of the cost, whether it is a premium, co-payment, or deductible. The best advice before going any further is: Get as much information as possible before deciding to sign up for any one plan.
The information you will find here is just that, information. Because everyone has different needs, I will not presume to point to any one plan. Every situation is unique, but the items below will pertain to almost everyone. If you’ve had private insurance before, some of this information will be review. Take each area seriously. They will help you ask the right questions to meet your needs.
Formulary vs. Non-Formulary
No matter what company you go with, know up front that they have a specific drug list, also known as a formulary, of specific prescription medications that they will cover. Compare the list of your medications you?re currently with their list. If it?s not on their list, it may still be covered, but you will have to do more legwork.
Private insurance companies can also have a tier structure set up where certain medications like brand medications can be at one copay level and generic medications at a separate copay level. These tiers can be set up in many different styles. Beyond knowing if your medication is on their formulary, you should find out what tier it is on. It will determine how much more money you may be responsible for each month.
Limited Quantities
Admittedly, insurance companies will limit the quantity of medication because of safety reasons (addictive medication) or cost reasons. Another good question to ask about your medications is if any of them have a dispensing limitation.
Step Therapy
Some insurance companies may require you to go through step therapy before paying for a certain medication. Step therapy is where you have to try a lower cost alternative first to see if it works. If it fails, then you would have to try another, before the insurance company would pay for a higher cost prescription. Each insurance company has different requirements for step therapy, so this is something you should inquire about as well.
Prior Authorization
Beyond step therapy, some medications may need prior authorization before a prescription drug plan will pay for them. If you purchase the medications BEFORE the authorization is in place, you will be responsible for the entire cost of the medication. Also keep in mind that authorizations take time. So don?t wait till you have one pill left.
If a prior authorization is not obtained, then you have the right to appeal the decision. Again, this takes time. Appeals go by state standards that could be, on average, 30 days. There are expedited policies as well, but again, inquire with the individual insurance company to see how they handle these requests.
Participating Pharmacies
Just walking into the drug store and getting your prescriptions is a thing of the past. Each insurance company has specific pharmacies that they call in-network. In order to get the benefits from the insurance company, you need to go to one of their in-network pharmacies. While most insurance companies have a huge list of participating pharmacies, it is still important to keep this in mind.
Along with participating retail pharmacies, most insurance companies have mail order companies available so you can get 60 or 90 day supplies of your medications. This is convenient for maintenance medications. The major drawback is that again you have to use their in-network mail order companies. So if you?ve used certain online companies or mail order services like Liberty Medical or drugstore.com, you will need to find out if the insurance company uses them as participating pharmacies. Unfortunately, in a limited search, not many do.
Costs
Each insurance company will have different costs for premiums. The estimated average, quoted by Medicare, is $37 a month. The premium is just the start. Some plans will also have a deductible. This is the amount you have to pay out of pocket before the insurance kicks in. Then there is also a possibility of paying a copay on each of your medications. This is like cost sharing. You would pay a set copay based on the drug list and the insurance company would pay the rest. Check out each plan to find out what your costs will be.
Extra Help through the Social Security Administration
Costs can be hard to handle if you have low income. The Social Security Administration does have a program in place to help with some of the costs if you qualify. You will need to fill out the application form to find out if you qualify for this program.
Dual Eligibility, Long Term Care Facility, and more.
There are many categories that people using Medicare fall into. For those who have dual coverage of Medicare and Medicaid, you will automatically be enrolled in a prescription drug plan. You will have the option to change this plan, if you feel it does not meet your needs. Please research eligibility carefully with your caseworker.
Long term care facilities also have special rules with the new prescription drug plans. They will still be subject to using participating pharmacies.
Yes, there is a lot to digest with this new prescription drug plan. For many, it will help with controlling costs on prescriptions. But, it is recommended to get as much information BEFORE signing up as possible. Below are some links to some sites. Inquire with caseworkers or other organizations in your community that can help decipher this information. Even if you don?t take a lot of medications now, you never know when your needs will change so plan for the future as you?re looking at the different plans.
Links
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