The 2023 Medicare open enrollment officially kicks off on October 15th and ends December 7th. You can expect the usual plethora of TV Ads extolling the virtues of Medicare Advantage plans. Be careful . . . reality may not match perception.

Hospitals & Advantage plans

Kroger and GoodRx changes.

MEDICARE PART B 2023

NEW TO MEDICARE 2022

2023 DRUG PLAN SUMMARY

Non-US Pharmacy

In addition to Broadway Joe Namath, Jimmie “Dynomite” Walker and William “Captain Kirk” Shatner . . . you may also see Lionel “Dancing on the Ceiling” Ritchie pitching Medicare Advantage plans.

Pitches like Namath’s can be misleading or downright deceptive, starting with the red, white and blue colors that insinuate the ads are from the government, as do the state logos on some mailers. While the plans themselves are perfectly legal and may be great for many of the 27 million Americans enrolled in them, they often don’t deliver everything those pitches seem to promise. Plus, those pitches don’t come close to telling the full story of the benefits of those plans – many of which aren’t even offered in your area.

For instance:

Unlike original Medicare, which is accepted by virtually all doctors and hospitals, Medicare Advantage plans include a network of doctors and hospitals you must visit to be insured. So if you hear about a great gastroenterologist in New York City and she isn’t in your Advantage plan’s network, your insurance may not cover your visit. Plus, unlike original Medicare, you may need prior approval for coverage of a medical procedure or equipment such as insulin pumps.

https://www.recordonline.com/story/opinion/2021/11/05/steve-israel-celebrities-pitching-medicare-plans/6297275001/

If you use a non-network provider, and they want to be paid by your Advantage carrier, they must sign an agreement stating they agree to comply with the stipulations and fee schedule required by the carrier.

If they fail to agree, your carrier may not pay the claim.

Most folks who have a Medigap plan keep it, but if you are tempted to call the 800 number and inquire about these “free” plans, keep this in mind.

If you leave a Medigap plan and enroll in an Advantage plan, it may not be possible to return if you cannot pass the underwriting process. Like the Hotel California, you can check out but you may never be able to leave.

Advantage plans are required by CMS to accept anyone, regardless of health. Medigap plans will issue a policy to anyone, even those with pre-existing conditions, only during the first 6 months after your Medicare Part B is effective. After that, if you want a Medicare supplement plan, you must qualify medically.

If you still think you want to change to an Advantage plan, do this.

Ask your doctor(s) if they participate in Medicare Advantage plans, and if so, which ones. Don’t assume that they take ALL plans offered in the area, very few do.

Ask your friends, who have had a serious illness or accident, what kind of Medicare coverage they have. Someone who is healthy has no idea if their plan is good or not. The REAL test of a Medicare plan is how they work when you have a large claim.

This last year, two of my clients have been treated for cancer at MD Anderson. In each situation, they had no trouble being admitted nor did they have problems with claim denials and all claims were paid.

MD Anderson accepts original Medicare and a supplement plan without challenge . . . but don’t try to check in there with an Advantage plan.

Other hospitals that generally do not participate in Advantage plans include Mayo Clinic, Cleveland Clinic.

You may not know this, but Kroger & GoodRx dissolved their relationship a few months ago. If you are using GoodRx at Kroger, consider changing to this SINGLECARE discount card.

https://www.singlecare.com/prescription-discount-card/kroger

Each year the Medicare Part B premium, deductible, and coinsurance rates are determined according to the Social Security Act. The standard monthly premium for Medicare Part B enrollees will be $164.90 for 2023, a decrease of $5.20 from $170.10 in 2022. The annual deductible for all Medicare Part B beneficiaries is $226 in 2023, a decrease of $7 from the annual deductible of $233 in 2022.

https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related-monthly

If this is your first time on Medicare, please allow me to review your drug plan and compare it to the 2023 offers.

Original Medicare and your Medigap plan usually does not change that much from year to year . . . but drug plans can have SIGNIFICANT changes that impact how much you pay for your plan, and medications, in 2023.

Even if your coverage begins in December, your plan can change in January to something that will not please you.

To properly review and compare your coverage, I need the following:

Exact name & dosage of each medication

(I should have your current information stored, so ask for a printout before compiling a new list from scratch)

How often filled and quantity

Preferred pharmacy

Name of your current carrier and premium

Sometimes medication is prescribed as a pill or a capsule. Pills are usually a lower copay, so if you take a capsule, please indicate.

Drugs can be a pill, capsule, time release, lotion, cream, spray, suppository, patch, etc.

Also, without your input, I have no way of knowing if you have added or subtracted a medication or dosage. 

All of these things can impact your plan. As they say in the computer world, GIGO (garbage in, garbage out).

Late last year I signed up for a drug plan finder that allows me to store useful information about your medications. This finder is more current than formulary’s that are on Medicare.gov . . . many times the formulary on Medicare is 3 months old and won’t be updated again until January!

2023 DRUG PLAN CHANGES

Aetna, 3 plans  . . . premiums $7 to $69*

Anthem, 2 plans . . . premiums $85 to $93*

Cigna, 3 plans . . . premiums $12 to $65

Clear Spring, 2 plans . . . premiums $19 to $26

Elixir, 2 plans . . . premiums $33 to $52

Humana, 3 plans . . . premiums $35 to $86

Omaha, 3 plans . . . premiums $20 to $93

UHC, 3 plans . . . premiums $28 to $118*

Wellcare, 3 plans . . . premiums $11 to $71*

*higher premium plan has $0 deductible

Initial deductible for most plans, $505

Deductible GENERALLY applies to tier 3 and higher drugs (may vary by carrier and plan)

Coverage gap (donut hole) begins when your ICL (initial coverage limit) reaches $4660 and ends when your total out of pocket reaches $7400.

Factors that impact YOUR cost for drugs include: preferred pharmacy, plan formulary, type of medication (tablet, capsule, cream, lotion, insert . . .)

The only way to know if you would be better off changing your plan for 2023 is to run a report comparing your CURRENT plan to a different 2023 plan. I now have the ability to offer the comparison as well as store your medication list, avoiding the need to input your drugs each time I run a report.

Many will find the $7 Aetna plan (for those who use GoodRx) or the $11 Wellcare plan (lower copay than GoodRx) will work fine.

Some folks have no problem ordering medication from Canada or other countries . . . others do have a concern.

Many drugs that are brand only here offer generic versions in other countries, often at significant savings.

I have a number of clients who use Eliquis. With some plans, Eliquis is a tier 3 drug with a retail price of $1700 for a 90 day supply (5mg BID).

Not only is your copay high with a Part D plan you will also reach the donut hole mid-year and the catastrophic level soon afterwards.

Progressive Rx currently has 54 pills (5mg) for $113. Low pricing on other med’s as well.

https://www.progressiverx.com/store/search.php?mode=search&page=1&keep_https=yes

Canadian Pharmacy Service offers 56 pills (5mg) for $75.

https://www.canadianpharmacyservice.com/drug/eliquis

This information is provided as an information resource only, and is not to be considered medical advice.

Before switching to a generic version, or ordering from a non-US pharmacy, ask your doctor for advice.

The annual open enrollment can be hectic, frustrating and tiring. Get started early, make a decision and move on.

I can’t tell you how many folks call after Thanksgiving and ask “Is it too late to change my drug plan?”. Don’t be one of those folks.

I will probably compose one more newsletter before the end of the year, but unless something earth shattering happens, this is the last one devoted to Part D.

If we don’t talk before the end of the year, enjoy your holidays.

Take care,

Bob