2020 is coming to an end. If you’re on Medicare, here are some tips to help ensure you’re on the best track for the new year.
Two things happened during Open Enrollment that merit giving some attention to your drug plan’s network.
One national chain seemed to be out of network in more plans than I noticed in the past. Before dealing with a pharmacy, confirm that it is in the network.
The second event had to do with my exercise buddy Jim. In my November post, I shared his story. He discovered that his health system’s pharmacy would not be in his drug plan’s network in 2021 and figured he should change plans. But in his usual fashion, Jim procrastinated until early December. Checking the Medicare Plan Finder, he found that the pharmacy was indeed listed in the plan’s network. He confirmed that with both the plan and the pharmacy.
We don’t know exactly what happened but it’s likely that there was some last-minute negotiation. It just emphasizes the point to verify a pharmacy’s network status.
The cost differences between pharmacies offering standard or preferred retail cost sharing can be dramatic. In the most recent review I did, the client would pay $108 for his drugs at his regular pharmacy with standard pricing or $14 at a preferred pharmacy.
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In many cases, mail order service can also offer significant cost savings.
Most Medicare beneficiaries grew up during a time when they got milk and bread at the grocery store and pills from the corner drug store. Things certainly have changed. During Open Enrollment, we found that large-chain grocery stores often offer preferred retail cost sharing. If your grocery store has a pharmacy counter, check it out.
There are some medications that can be very costly in Part D drug plans or may not be covered by a plan. In those cases, it pays to look for ways to save.
Some drug companies offer a pharmaceutical assistance program that can help pay for medications for Part D enrollees. Some programs exclude those who are eligible for Medicare drug coverage.
There are drug discount and coupon programs, some of which you’ll see in commercials. A pharmacy may offer a prescription savings club or card with out-of-pocket discounts on selected medications. Know that you cannot combine a drug discount with Part D coverage, and you cannot use a coupon on a medication that will be paid for by the drug plan. In spite of those restrictions, these programs can offer savings.
Prior authorization means the plan requires prior approval of certain services. The plan will either approve or deny a physician’s order and can add limits, such as specifying a number of visits. In 2020, 99% of all Medicare Advantage enrollees were in plans that require prior authorization for some or most services.
It is the plan member’s responsibility to know the plan’s requirements and to ensure that services are authorized. If moving forward with a physician’s order before getting authorization, the individual will likely have to pay the entire bill.
Every new year brings changes in Medicare Advantage plans’ networks, costs and coverage rules. A recent study reported that 57% of Medicare beneficiaries do not review or compare options annually.
In 2021, a significant change that many may have missed is the increase in the maximum out-of-pocket limit. The limit for in-network coverage will increase from $6,700 to $7,550 and for in-and-out of network combined, from $10,000 to $11,300. There is a fair number of plans at the maximum limit.
Whether you get your Part D drug coverage through a Medicare Advantage or a stand-alone Part D drug plan, there can be changes during the year. For example, the plan may drop a brand-name drug if a generic alternative becomes available. Plans can change or add coverage rules for specific medications.
There can be significant changes in a Medicare Advantage plan’s network. Hospitals, doctors, and other providers can come and go from a plan’s network anytime during the year.
Medicare has procedures for addressing changes in drug coverage and networks. The first step is that the plan will send a notice explaining what happened and your options. If you don’t open the mail, you won’t know what’s happening and that could create problems.
For Medicare Advantage beneficiaries who didn’t pay attention during Open Enrollment and now have discovered things about the plan they cannot tolerate, fear not; you have another chance to make things right. Do your research, check out plans on the Medicare Plan Finder and enroll in a new plan. Coverage will begin the first day of the month after you enroll.
This benefit has been around for almost 20 years, but it became a very hot topic during the 2020 Open Enrollment season. With another open enrollment beginning in January, there will be more interest.
As noted in a recent post, this benefit is not available to the majority of beneficiaries. In most cases, it is not the $144 you see in the commercials. And, it’s likely the plans offering this may not work for everyone. The best advice: Look for a plan that meets your medical and drug needs. If it includes the giveback, that’s an added plus.
The government is planning the rollout and distribution of the vaccine. The states have the final word on who gets the vaccine first, but it appears that those over 65 will have high priority.
Not being able to afford the vaccine will be no excuse. Medicare Part B will cover it with no copayments. Just be sure to go to a pharmacy that accepts Medicare payment or, for those with Medicare Advantage, is in the plan’s network.
Inevitably, in spite of our most diligent preparations, something always changes. So perhaps the best advice is to stay on top of things throughout the year.