Why you must look at your Part "D" Plan Today

Your work on part "D" is not over yet!  You have until March 31 to act.

February 1, 2008 - - Robert Fassbach, editor, www.seniorark.com

 

So now it's February, and you think your worries about Part "D" are over. Not so fast. What you do right now can determine how well you do for the rest of the year in getting the medical care and prescriptions you need.

I turned 65 the day before Christmas, about 5 weeks ago, so this is my second month living under Part "D". Getting here has been an experience. I have been studying and writing about the nuances of Part "D" for over two years on SeniorArk, and in various other publications. But until I entered the scene myself, I had no idea of the extreme confusion surrounding the process. Even now, having made an "informed" decision for 2008, I am not completely sure I have made the best choice for my needs. I have a plan that will work, but Pennsylvania has some 150+ plan possibilities out there, all being offered by private insurance companies interested more in my money than my health. During insurance company  plan presentations I heard misrepresentation, half-truths, and outright misinformation. But a choice was needed, so one was made.

Years ago, when I managed a real estate office in suburban Washington D.C., my boss, Bill Ellis, told me, "I just sold my Bethesda home after several years, and have moved to another one in Potomac. I had no idea what our buyers and sellers go through every time they move. I think every manager in our company ought to be required to move every 5 years just to keep the memory fresh."  He was right. And I just found that out when I turned 65. Now I get it. What we are put through as we decide on Medicare and Part "D" is a serious trauma.

So then, if our decisions on Part "D" were made between November 15 and December 31, what is there to do between now and March 31? Well, here goes..

(1) If you have "traditional Medicare", and a "stand-alone" Part "D" plan, get out all those papers from your Part "D" insurance carrier and really read them. Get on- line, or on the phone and make sure you have a plan that will cover the drugs you anticipate needing. Review the co-pays and other details of the plan. Ask questions of your insurer if there is ANYTHING you don't understand. You are the customer. They want your business. They must be clear. And don't assume that everything is the same as last year if you have continued the same policy. Insurance carriers are subtly  eliminating everything possible within the law, and are not standing on the rooftops shouting out the news. You must dig for it.

(2)  Now let's assume that you have reviewed the details again, and have decided that you are in the right plan. Then today we need to think about the doughnut hole. The best time to begin avoiding it is right now. This week I met with my doctor to go over the salad of drugs that seem necessary to keep me going each month. I told him I wanted to find a generic for every one of them. He was willing to do that with one exception, and I may still decide to change that one. It is a statin, and I'm not convinced that Lipitor is necessarily better than several others out there. I will need to do a little research on that. 

Here are some examples of the savings when switching from Brand to Generic:

  • Celebrex 200mg, a medication used for arthritis, costs about $100 for a one-month supply. Replace with Meloxican 15 mg (generic for Mobic) costs about $8. Cost difference,$1100/yr.

  • Lipitor 20mg, used for cholesterol, costs about $111 for a month's supply.  Simvastatin, (generic for Zocor) cost $11. Savings, $1200/yr.

  • Prevacid 30mg, a medication for heartburn, costs about $144 for a one-month supply. Omeprazole 20mg (generic for Prilosec) costs about $27, or a savings of $1400/yr.

  • Tricor 145mg, a medication for triglicerides, costs around $100/mo. Fenofibrate (generic for Tricor) costs $37, for a savings of about $750/yr.

Remember, in the "stand-alone" Part "D" plans, you are paying the first $275 of annual drug costs, and then 25% of the next $2,235 ($558.75). After that, you will pay 100% of the next $3216.25. This is the doughnut hole. (see chart) How fast you reach this expenditure level is determined by what your pharmacy bills your insurance company, not what the insurance company pays your pharmacy. If you are using generics, it will take much longer to reach the doughnut hole than if you are using brand  name drugs. The average stand-alone premium is somewhere around $40 per month. Some with higher premiums may be more generous.

(By the way, this is also a good time to go over your medications to determine if you still need every one of them. Over time, medications are prescribed that should be given for a limited time, but they are never stopped. Several doctors, including your specialists, may have written prescriptions that just keep refilling automatically long after their need ends. Doctors are so busy these days, that many overlook this. Make them look.)

(3) Go online, or call your state's agency on aging, or the equivalent department, to determine if you may actually qualify for additional prescription help. There is a lot of it out there. My state, Pennsylvania, has 2 tremendous plans for couples earning less than $31,500, and individuals below $23,500. You may be passing up help that is staring at you. See our "Surviving the Doughnut Hole" page for 14 ideas on dealing with the doughnut hole.

(4) Let's assume that you looked over your paperwork, and decide that you may have made a Part "D" mistake. Now there are two choices: live with it until next year (changing to something else between November 15 and December 31, 2008), or switching NOW to a Medicare Advantage Plan, occasionally  called Medicare Health Plan, and also called Medicare "C". (see simple description)  Open enrollment has not ended for these plans. Open enrollment for Medicare Advantage plans goes until March 31.  This plan is not administered by the government, but is handled by private insurance companies. It combines Medicare A, B and D. There are a wide variety of plans, and types of Medicare Advantage Plans.   If you take a number of prescription drugs, however, it gets more difficult to choose. Certain plans might cover some of the drugs you need but not all of them. But there are a number of resources to help you choose. At Medicare's website, you'll find a plan finder that will help you choose a plan based on a number of factors, such as what drugs are covered, how much you can afford to pay, and what pharmacies participate. Another tool lets you enter the drugs you need and then shows you what plans cover them.

Here are the different coverage scenarios permitted during Medicare Advantage open enrollment:

  • If a person on Medicare currently has coverage in a Medicare Advantage Plan with prescription drug coverage, they can use open enrollment to select a different Medicare Advantage Plan with prescription drug coverage, Original Medicare and a stand-alone prescription drug plan, or a Medicare Advantage Private-Fee-For-Service Plan and a stand-alone prescription drug plan.

  • If a person on Medicare currently has coverage in a Medicare Advantage Plan with no prescription drug coverage, they can use open enrollment to select a Medicare Advantage Plan or Original Medicare without prescription drug coverage.

  • If a person on Medicare currently has coverage in Original Medicare with a stand-alone prescription drug plan, they can use open enrollment to select a Medicare Advantage Plan with prescription drug coverage or a Medicare Advantage Private-Fee-For-Service Plan with the same stand-alone prescription drug plan.

  • If a person on Medicare currently has coverage in Original Medicare without a stand-alone prescription drug plan, they can use open enrollment to select a Medicare Advantage Plan without prescription drug coverage.

Be aware that if you switch to a Medicare Advantage Plan, you must review much more than just the Part "D" portion of the policy. That insurance carrier takes over your "full care", and provides the features of Parts A, B, and D. Study which doctors, hospitals, and other types of care are included with the policy. Medicare pays the Medicare Advantage insurance provider  around $650/month for every month you are in their care, whether you need them or not. 

We hope all of this adds to your options, and not to your confusion, If questions remain, you can always contact Medicare at www.medicare.gov, or call 1-800-MEDICARE. There may also be a state representative available to give you some help.

So what was my choice with Part "D"? I opted for a Medicare Advantage plan through Health America Advantra. Monthly premiums $42. No initial deductible. Most of my doctors are in the program, as is my hospital. With minimal co-pays they include some generic drugs through the doughnut hole. I have already had blood work done this month, and find that they require me to go to a lab that I consider third rate in its appearance and speed. Not the hospital lab I was accustomed to seeing. Am I recommending Advantra? Not a chance. You must make your decision, with your needs, in your state. I'll let you know how it goes for me this year.

A final comment. I think it is obscene that our government puts us through this traumatic, risky, confusing process. I totally support a "single-payer" system, run by the highly competent Medicare section of the Department of Health and Human Services. They can administer the program more cheaply, and would have huge negotiating power with drug and other suppliers. The only thing standing in the way has been Congressional backbone, and Presidential consent. Insurance and drug lobbyists have wielded enough power to control these programs up to this point. What may happen after this coming November MAY be another story. Until then, we must sift through this program as best we can. Best wishes.