Eight Things You Need Know about Medicare Prescription Drug Plans before Enrolling

 

  1. Medicare pays private insurance companies $95 billion each year in subsidies for Prescription Drug Plans (PDP) in addition to what enrollees pay in plan premiums, deductibles and co-pays for your medications.
  2. There is no annual limit on your out-of-pocket prescription drug expenses that are sold by private insurers.
  3. Private insurers control their drug expenses by restricting your access to medications that your doctor prescribes through: their drug formularies that exclude specific drugs, require prior authorization, limit quantities, require you to take lower cost drugs before higher cost drugs are approved and by establishing their own drug price tiers, annual deductibles and the amount that you are required to pay for prescriptions.
  4. There are significant differences among Medicare Part D plans including: the drugs they include, what Tiers they assign to their included drugs, and the premiums, deductibles, co-pays and coinsurance that subscribers are required to pay.
  5. Although Medicare Part D plans are not allowed to deny coverage or charge higher premiums to people with pre-existing conditions, their prescription drug policies provide a clear message of who they want, and don’t want as subscribers.
  6. The cost of medications in the US to treat millions of Americans with life-threating diseases such as diabetes, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, various cancers, organ transplants are the highest in the world.
  7. Big Pharma and the insurance industry have been very successful in controlling Congress and the Executive branch with the millions that they pay each year in political campaign contributions and lobbying.
  8. In return, Big Pharma and the insurance industry has insiders working in key executive positions in government, such as the White House advisors, Congressional committees staff, Departments of Health and Human Services (Alex Azar), Center for Medicare & Medicaid Services (Seema Verma) and the Food & Drug Administration (Scott Gottlieb) where they use their industry special interest in writing federal legislation, establishing policies, regulations, administrative practices and weakening regulatory compliance and sanctions for violations.
  9. This situation results in higher taxes, huge goverment debt and the highest prescription drug costs in the world for life-threatening conditions that many Americans can’t afford.

Medicare DrugCost

A review of four major Medicare Advantage plan insurers in Upstate New York including for-profits: Aetna, United HealthCare and WellCare and regional non-profits: MVP and Excellus Blue Cross revealed the following observations.

  • All insurers target enrolling healthy seniors and provide incentives with low or no monthly premiums along with gym memberships.
  • All insurers have developed financial disincentives for individuals that are prescribed: “non-preferred” brand-name and generic medications, specific medications that they have excluded, requiring deductibles up to $380yr., medications that require co-pays up to $100 mo. and co-insurance charges of up to 33%.

In summary, you may have insurance for your prescription drugs in your private Medicare Part D Plan, but you may not have coverage or the ability to pay for your critically needed medications for life-sustaining treatment.

As result,  it is very important that you that you educate yourself and confirm that the Medicare drug plans that you considering meets your needs and budget during this Medicare open enrollment period that ends, December 7th.

It’s Not Too Late to Change your Medicare Advantage plan

As a result of new federal legislation, subscribers of Medicare Advantage Plans will have three additional months (January-March each year) to change their plan. 

Why would you want to change plans now?

Some reasons could include:

  •  You missed the Annual Fall Open Enrollment period (October 15-December 7)
  • You didn’t realize your plan doesn’t include your medications, preferred doctors, hospitals, pharmacies, etc.
  • Your health condition has changed and you want better coverage.
  • Your financial situation has changed and you can’t afford your current plan.
  • You or your relative didn’t understand the limitations, cost or consequences of their current plan

Normally, you wouldn’t be able to change plans for these reason during the calendar year, except in special circumstances. However, now you will have 3 additional months to make a change each year.

To be eligible to make a change, you must currently be a subscriber of a Medicare Advantage plan (as opposed to being a subscriber to Original Medicare).

What are Some Permitted Changes?

  • You can change from one Medicare Advantage plan to another (from the same or a different insurer)
  • You can select a new plan that either increases or decreases your coverage and/or cost.
  • You can terminate your Medicare Advantage plan and switch to Original Medicare and buy (or not buy), a stand-alone Prescription Drug Plan (PDP).
  • In some states, like New York, you can also choose to purchase a Medicare Supplemental (Medigap) plan for added coverage to Original Medicare, with or without purchasing a PDP.

Is there anyone who can help you look at your options and their consequences?

Yes, there are a number of free independent resource people that don’t receive any sales compensation that can help you understand these complex issues.  They include:

SHIP connects you with local individual and group information/assistance regarding Medicare issues and questions.

 

https://www.medicarerights.org

National Helpline: 800-333-4114

MRC helps people with Medicare understand their rights and benefits, and navigate the Medicare system.