Maximizing Your Medicare Part D Prescription Drug Benefit
by Susan R. Tolbert, Licensed Health Agent
Prescription drug plans in the Medicare market, known as Part D, tend to be more complex in their structure. A review of the overall components of Part D plans can assist in maximizing the full benefit of your Part D Prescription Drug Plan.
Know your pharmacy Network Options
Within each Medicare Part D plan there are preferred pharmacies, standard pharmacies, and non-network pharmacies. Members are going to receive the lowest co-payments at preferred pharmacies.
Consider options within your plan that may reduce your cost
If your physician will write your prescription for 90 days versus 30, there could be cost savings at pharmacies that fill 90-day prescriptions. All mail order service options for maintenance medications are automatically set up to dispense at a 90-day supply and usually offer a cost savings over pharmacy store pick-up.
Your pharmacist, physician, or plan sponsor should be able to inform you about available medications that treat the same conditions. New medications or generic equivalents of certain brands may be options that you can compare in efficacy and cost to your current treatments. Recently a Medicare beneficiary who was spending thousands of dollars annually on a medication tried a different medication with successful results at a fraction of the cost.
Pharmaceutical Assistance Programs or State Pharmaceutical Assistance Programs
Many pharmaceutical manufacturers offer Pharmaceutical Assistance Programs on their high priced and specialty medications. Acceptance into a Pharmaceutical Assistance Program could allow for complete coverage of the medication or substantial savings. Applicants to programs must meet established criteria related to income and current health insurance coverage to be accepted. Individuals interested must reach out directly to the pharmaceutical manufactures to see what programs they offer.
Using your plans’ formulary
You should easily be able to access the formulary on your plans’ Part D website or your broker can send you an electronic copy. As well Part D plan sponsors will often mail a hard copy if it is requested. In addition to containing a list of all the medications on your plan, formularies will show which tier medications fall into from levels 1-5 as designated below.
Tier 1 Preferred generic Commonly prescribed generic drugs
Tier 2 Generic Generic drugs a little more costly than Tier 1 drugs
Tier 3 Preferred Drug Brand name drugs that do not have a generic equivalent.
Drugs in this tier are at the lowest cost for brand name drugs.
Tier 4 Nonpreferred drug Higher priced brand name and generic drugs.
Tier 5 Specialty drug The most expensive drugs on a formulary used to treat complex conditions and could be generic or brand name.
Tier 6 Select Care Generic drugs used to treat diabetes and high cholesterol. Drugs in this tier are usually $0 – $5.
Note: Only about 5% of Part D plans currently have a Tier 6.
The formulary will also show any limitations on medications. These can be any one of the three listed below. Knowing ahead of time if your medication will fall into one of these requirements can help in being prepared for the process that will be involved if you are prescribed a medication with a limitation.
Quantity Limits – usually designated by QL – this means there is a restriction on the quantity of medication that you can received in a specified time period
Prior Authorization usually designated by PA – this means that the Part D plan must grant authorization of the coverage before it can be received.
Step Therapy – usually designated by ST- this means that one or more medications must be tried first and fail to treat a condition before the preferred usually more costly medication can be obtained.
If you have been prescribed a medication that is not on your plan’s formulary, reach out to your plan sponsor
Let your Medicare Part D plan sponsor know if you have been prescribed a medication that is not on your plan’s formulary and make a request for an exception. Part D Plans have a form that will need to
be completed by your physician. When an exception is granted, it usually goes in covered at a higher tier level, but this allows for coverage and most importantly starts counting toward your total drug out-of-pocket calculation. If your formulary exception is denied, you have the right to appeal your plan’s decision.
Understanding the Part D drug stages
Be aware of the Medicare Part D drug stages that are required on all plans and the monetary
thresholds required at each stage. This means you may not always pay the same amount for a medication during the year. Depending on your overall total drug cost you will pay different amounts based on whether you are in the deductible, initial coverage, coverage gap, or catastrophic stage. Your monthly Part D plan statements will show which stage you are in based on your medication purchases. Knowing the stages and how they work can help you to strategically plan for the year. For example, if you have entered the coverage gap stage you may find that your prescription cost will be lower using a Rx discount card, not associated with insurance, than the cost on your Medicare plan. While the cost of your medication using a discount drug card could initially be lower out of pocket cost to you; do not forget to calculate the number of times you need to fill it before the end of the year as using the Part D plan may propel you into the catastrophic stage allowing you to get your remaining medications at a lower copay. A detailed description with the monetary thresholds on the Part D stages is available at www.newbrookeinsurance.com/articles/MedicarePrescriptionDrugPlans.
Taking medications for more than 1 medical condition
Part D plans are required to implement a program called Medication Management Therapy (MMT) for members that are taking medications to treat multiple medical conditions as well as above average prescription drug utilization. The qualifications for each MMT plan may vary slightly but the goal is the same in working with providers and pharmacists to ensure medications are working optimally to improve members’ health. Please reach out to your plan sponsor if you would like to learn more about Medication Management Therapy Programs.
Evaluate your plan and compare options annually
Each fall Medicare beneficiaries have the opportunity to select a different Part D plan during the Annual Enrollment Period, which runs from October 15 – December 7. Part D and Part C plans must send members an Annual Notice of Change with any changes to your current plan. Use this time to evaluate your medications and cost by shopping the market in your area for the best fit for you.
Please feel free to reach out to Newbrooke Insurance at info@newbrookeinsurance.com for assistance with plan comparisons and to learn about new products in your area.
Need Extra Help
If you experience financial hardship or income reduction and need help paying for medications, speak to your pharmacist and/or your broker about programs from drug manufactures, and/or non-profit organizations. Federal and State programs use the Federal Poverty Level Guidelines to determine Extra Help income limits. Please contact your local Medicaid office or the Social Security Administration for more information on their programs.