In this issue . . .

Unwrapping the mystery of Medicare Part D - How much will my prescription drugs cost?

More Wellcare shenanigans

Will Medicare Advantage be Your Only Option?

How Is Medicare Part D Priced?

Without a doubt, Medicare Part D, AKA the Medicare Drug Plan, is the most confusing part of Original Medicare. With more moving parts than a Rube Goldberg contraption it’s no wonder folks don’t understand it.

Before I can price a drug plan and run a report I need your zip code and county.

You will also need to provide specific details about your prescription drugs.

The exact name & dosage for each medication

How often is each filled and the quantity?

Is it a pill (tablet), capsule, lotion, cream, ointment, patch, self injection, etc.

Are any of your medications extended release?

Are some of your meds a combination, such as losartan/HCTZ? 

Combination medications will have 2 numbers for the dosage, such as 100/25. I need both numbers to price it out.

Which pharmacy do you use?

Do you fill some or all of your med’s by mail?

Do you use a discount card, GoodRx or SingleCare, instead of your drug plan?

Once again, your cost will vary, depending on how your medicine is packaged (such as pill or capsule), the dosage and pharmacy.

In 2024 the Losartan/HCTZ 100/25 dosage will have an annual total cost (copay + premium) of anywhere from $6 to $1570!

In the 14 years I have worked the Medicare market, I have learned a lot, helped a number of folks discover the difference in OM + Medigap vs the Medicare Advantage plans, and have even had a few surprises.

Prior Authorization (PA) is fairly common with Advantage plans. When it comes up, normally it is for a test or procedure that is costly, $400 or so. Essentially the Advantage plans have a right to ask your provider for additional documentation that supports their view that what they want is “medically necessary”.

Original Medicare only applies PA on rare occasions. Most claims sail through the process and are stamped approved.

Last year Rachel had medically necessary blepharoplasty on both eyes because her “droopy” eyelids interfered with her vision. This type of surgery is also used when women or men want to look more youthful.

Because the claim could be necessary or cosmetic, Medicare asked for the diagnostic and treatment codes before approving her surgery. 

The prior approval was given the OK and the surgery was successful.

Prior approval may come up from time to time under Part D.Usually it is requested when the doctor issues a prescription for a medication that is expensive and the Part D carrier wants to be assured a less expensive drug will work just as well.

A few days ago Wellcare denied a drug that, under their guidelines, requires prior approval. The odd thing is, this is not a new drug nor is it expensive. My client has been taking the medication for years and their is no change in dosage.

Still, they denied the refill and suggested my client obtain prior approval from her doctor.

The medication is temazepam. Wellcare lists it as tier 4 and a 90 day supply is $41.

Rather than having the lady get the PA form completed by her doctor, then waiting on WC to make up their mind if they want to approve the drug, I suggested using GoodRx.

GoodRx discount pricing is $13.50 for a 90 day supply and she doesn’t have to go through prior approval.

I should add that this is the first time in 13 years of working with Part D where I was told by a client they needed prior approval.

Even if you are not involved in a PA tango, it never hurts to check pricing for GENERIC drugs against discount plans like GoodRx and SingleCare.

Will Medicare Advantage be Your ONLY Choice?

MedPage Today recently interviewed Chernew by phone and email about growing concerns -- throughout the country and among commission members -- that private Medicare Advantage plans in some ways may be failing their mission to improve access to quality care and lower costs.

Patients can't get a consultation at the Mayo Clinic in Arizona and Florida, and they can't get cancer care at Sloan Kettering. I have friends who have had symptoms that doctors in their MA networks couldn't diagnose, but the expert was at UC San Diego. They had to fork over $900 for an out-of-network visit. What do we say to these centers when 70% or 80% of the Medicare population can't benefit from their expertise? I don't think many realize that when they enroll.

Medicare Advantage involves a trade-off. Individuals choose to have a narrow network. The challenge is for CMS to make sure people have good quality care outside of academic medical centers. There's a penalty if you try to switch out of a Medicare Advantage plan because you could be underwritten in the Medigap market and it may be more expensive to get a Medigap plan.

It's not a penalty. It's often a rejection, right? There are 46 states that allow underwriting for supplemental plans and that usually means getting rejected for common health issues like uncontrolled diabetes or a recent hospitalization.

If everybody chooses the cheaper MA plan when they're healthy, and the supplement plans when they're sick, then the whole market collapses. In the states that prohibit underwriting, supplemental plan premiums are more expensive.

https://www.medpagetoday.com/special-reports/exclusives/108423

Roundup

Hard to believe we are already into February . . . Groundhog Day is behind us . . . Valentine's Day is coming up fast. Plan accordingly.

Georgia Medicare Plans on YouTube recently passed 70,000 views. This is amazing considering it is all organic traffic without paid advertising.

https://www.youtube.com/@GeorgiaMedicarePlans

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bob