Potential gotcha when shopping for Part D plans

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busdriver
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Potential gotcha when shopping for Part D plans

Post by busdriver »

Not sure if this has been brought up before, but when using the medicare.gov site, (https://www.medicare.gov/plan-compare/# ... &year=2022), to compare plans, the least expensive plan by yearly drug and premium may not be the least expensive.

After drugs and pharmacies have been entered, plans that cover those drugs can be displayed by lowest drug and premium cost. What’s figured in the display is if the drug is covered, but not necessarily the quantity called for. In my case, one of my prescriptions is a larger amount than what some plans want to cover.

You can check to see if there are quantity limits for each drug by clicking on “View drugs and their costs” in the lower right corner of the box of each plan, scroll down to click on the blue box “+ View more drug coverage.” Scroll down to the “OTHER DRUG INFORMATION” box. Here it shows among other things, quantity limits. If so, click on the “Yes” to display the amount the plan will cover.

For myself, several plans have a limit on one of my prescriptions that would only cover 2/3 of the quantity called for. As it turns out, the second cheapest plan, (appx $40/yr more), also has a quantity limit, but it is for the entire amount called for.

The gotcha would be for someone in similar circumstance, going with the cheapest policy and not finding out about a quantity limit until after the enrollment period when getting a prescription filled, not to the quantity expected.

As a matter of final verification, I also go to the plan website to find the formulary document and check that all quantities of all my prescriptions will be covered. A bit tedious, but peace of mind for me.

I would suspect this could also apply to Advantage Plans, (Part C), that include drug coverage as well.
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nisiprius
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Re: Potential gotcha when shopping for Part D plans

Post by nisiprius »

Another huge gotcha that is driving me bananas this year, is that I take a prescription drug that is on the formulary for my current plan. But the co-pay at a "preferred network pharmacy" is forty times the price per pill of the same drug bought without insurance at Costco.

I could upgrade to a different part D plan that offers the drug with no co-pay but the difference in monthly premium--in effect, extra premium for the plan with no co-pay--is almost exactly the same as the co-pay.

So your first job before even using the comparison tool is to be sure you know the "going price" of all your drugs without insurance at competitive pharmacies.

My feeling is that This Should Not Happen--but it does.
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BatBuckeye
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Re: Potential gotcha when shopping for Part D plans

Post by BatBuckeye »

I make evaluations on MyMedicare.gov but when I use a GoodRX coupon I receive a significant discount on one med.
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busdriver
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Re: Potential gotcha when shopping for Part D plans

Post by busdriver »

nisiprius wrote: Sun Oct 17, 2021 2:42 pm Another huge gotcha that is driving me bananas this year, is that I take a prescription drug that is on the formulary for my current plan. But the co-pay at a "preferred network pharmacy" is forty times the price per pill of the same drug bought without insurance at Costco.

I could upgrade to a different part D plan that offers the drug with no co-pay but the difference in monthly premium--in effect, extra premium for the plan with no co-pay--is almost exactly the same as the co-pay.

So your first job before even using the comparison tool is to be sure you know the "going price" of all your drugs without insurance at competitive pharmacies.

My feeling is that This Should Not Happen--but it does.
I would be curious to know if the Costco price remains constant throughout the year and how they are able to do it without insurance.
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Re: Potential gotcha when shopping for Part D plans

Post by busdriver »

BatBuckeye wrote: Sun Oct 17, 2021 8:17 pm I make evaluations on MyMedicare.gov but when I use a GoodRX coupon I receive a significant discount on one med.
Just be advised that both GoodRX and SingleCare coupon prices are not indefinite. I have mailed printed coupons to my sister who doesn't have a computer or smart phone only to find out after a period of time they are no longer valid. Perhaps just the coupon code changes, but I suspect the price does as well.
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Re: Potential gotcha when shopping for Part D plans

Post by celia »

busdriver wrote: Sun Oct 17, 2021 2:00 pm In my case, one of my prescriptions is a larger amount than what some plans want to cover.
Have you called one of the drug plans that doesn't cover the higher dosage to confirm that is their policy? Do you have the "typical" dose that is usually prescribed? I've previously found database errors in the Medicare database. For example, one med that we had taken for a long time was suddenly not covered by anyone one year. But the drug plan we were already on confirmed that it was. The drug plan doses didn't match the doses in the Medicare database, because all the doses for the med had disappeared for that med. So I looked up all the possible doses and called Medicare to report the missing dose info. It was soon fixed.

Another thing you may have to ask the drug plan that won't cover all the pills you need (after they say their policy/database is correct) is if you can get a "doctor override" for your dose. [There's an official Medicare term for this.] We have this for one med, as long as we stay at the same carrier. But our doctor would fill out the simple form again for another drug plan. When asked why the patient needs a different dose, they can write one sentence such as "patient's condition will respond best to the higher dose". Doctors already know the verbiage to use.

nisiprius wrote: Sun Oct 17, 2021 2:42 pm But the co-pay at a "preferred network pharmacy" is forty times the price per pill of the same drug bought without insurance at Costco.
Instead of telling us the price can be 40 times as much, can you tell us the prices in dollars. For example, a pill that can be 10 cents or $4 is different than one that cost $3 or $120 per pill.

And, have you called the higher-priced drug plan to confirm that high price?

We wait until near the end of open enrollment and let people like both of you go first, to work out the "bugs"/database typos for us. :D
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celia
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Re: Potential gotcha when shopping for Part D plans

Post by celia »

busdriver wrote: Mon Oct 18, 2021 12:04 am I would be curious to know if the Costco price remains constant throughout the year and how they are able to do it without insurance.
It's probably a commonly-prescribed generic that they buy in bulk. Costco might have a contract with the manufacturer that is better than what the drug plan has.
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Re: Potential gotcha when shopping for Part D plans

Post by busdriver »

celia wrote: Mon Oct 18, 2021 1:56 am
busdriver wrote: Sun Oct 17, 2021 2:00 pm In my case, one of my prescriptions is a larger amount than what some plans want to cover.
Have you called one of the drug plans that doesn't cover the higher dosage to confirm that is their policy? Do you have the "typical" dose that is usually prescribed? I've previously found database errors in the Medicare database. For example, one med that we had taken for a long time was suddenly not covered by anyone one year. But the drug plan we were already on confirmed that it was. The drug plan doses didn't match the doses in the Medicare database, because all the doses for the med had disappeared for that med. So I looked up all the possible doses and called Medicare to report the missing dose info. It was soon fixed.

Another thing you may have to ask the drug plan that won't cover all the pills you need (after they say their policy/database is correct) is if you can get a "doctor override" for your dose. [There's an official Medicare term for this.] We have this for one med, as long as we stay at the same carrier. But our doctor would fill out the simple form again for another drug plan. When asked why the patient needs a different dose, they can write one sentence such as "patient's condition will respond best to the higher dose". Doctors already know the verbiage to use.
I haven't called, just went to the insurance company websites to see their plan's formulary, (list of all drugs covered under plan).

Exceptions to quantity limits can be requested by doctor, but there's no guarantee it will be granted, so I just opted for a slightly more expensive plan that will supply the quantities I need. The additional $40/yr is worth it to me for not having to bet on getting an exception.
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Re: Potential gotcha when shopping for Part D plans

Post by Kagord »

I've found as of late, prescriptions that were $2/3 are now $30-$70. I'm not really understanding how these part D plans really follow what they say for copays, and whereas I used to be under $50 a year, now I'm hitting the $400 or so deductible mid year for the same prescriptions. I still plan to keep, the plan I use went down $5/month (around $32 now), but the deductible and copays went up. So I'm sure I'll spend more.

I guess my point is, there's other variables at play here, if you actually have prescriptions, besides plan cost.
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