Making sense of Medicare options

Q: What are some of the key challenges beneficiaries face when it comes to Medicare enrollment?

A: There are a multitude of Medicare enrollment options, and many of them can be very complicated to understand. For example, each of the enrollment options offers different co-pays and deductibles. Some offer low premiums with higher cost shares, others offer high premiums with lower cost shares.

Each plan has a different medication formulary – which can impact whether a beneficiary’s medications will be covered. Each has a different approach to whether prior authorization or step therapy is required in order for a patient to be covered for a specific medication. All of these different variables can be intimidating, especially for senior citizens who are managing multiple conditions that require multiple medications, and for those who are living on a conservative fixed income.

Selecting the ‘wrong’ Medicare plan can be very costly, financially.Many Medicare beneficiaries also don’t know who to turn to for help understanding the various plan options. Medicare.gov is a great resource for helping beneficiaries understand the plan-by-plan costs based on each beneficiary’s unique needs. But some beneficiaries still don’t feel comfortable using the Internet – and even those who are Internet-savvy still feel more comfortable with talking with a knowledgeable healthcare professional about their options.

Q: What are some of the key issues beneficiaries need to consider when selecting Medicare enrollment options?

A: Beneficiaries first need to understand how each Medicare enrollment option will impact them financially – both in terms of up-front costs and on a per-drug basis.

Secondly, they need to understand how each plan addresses issues like prior authorization and step therapies, for each of the medications they are taking. One of the most troubling things that can happen to a Medicare beneficiary is to sign up for a plan and not realize until coverage kicks in that one or more of the medications they are taking are not on that plan’s formulary – or that they’re required to get prior authorization for that medication, or to take another medication before being approved for a medication they’ve already been taking. Having that knowledge up front is very important.

Third, beneficiaries need to understand whether the plan(s) they are considering will allow them to continue to use their pharmacy, or whether they have to use a ‘preferred pharmacy ’ in order to have access to the plan’s advertised co-pay. This is an important consideration, especially for senior citizens who have long-standing, strong, personal relationships with their local neighborhood pharmacist. In many cases, the community pharmacist is a beneficiary’s most accessible healthcare professional – and the provider with whom they have the most frequent contact. If that personal relationship is important to the patient, they should be sure to check whether the Medicare options they’re considering place restrictions on where they can fill their prescriptions.

Lastly, Medicare beneficiaries should go to Medicare.gov or ask their pharmacist to help them determine if they qualify for financial assistance. Some beneficiaries may also qualify for Medicaid or state, community or low-income assistance programs, which can provide additional subsidies to make their medications more affordable.

Q: What are some of the common ‘mistakes’ beneficiaries can make when selecting Medicare options?

A: Because each Medicare plan is multi-faceted, it can be easy for a beneficiary to select an option that doesn’t meet all of their needs or cover their costs. For example, some low-income beneficiaries aren’t aware that their co-pays are subsidized. So many select a “preferred plan” that offers the lowest copay – thinking that plan will save them the most money – when that’s not usually the case. In these instances, the enrollee may not realize until they fill their first prescription in January that their plan will not cover medications that are filled at the community pharmacy that they’ve been using for years, because it isn’t on the plan’s ‘preferred’ list. Low-income beneficiaries can find this particularly frustrating when they realize that their co-pay would’ve been the same if they had chosen another, less limiting plan.

Because each Medicare plan is multi-faceted, it can be easy for a beneficiary to select an option that doesn’t meet all of their needs or cover their costs.

For example, some low-income beneficiaries aren’t aware that their co-pays are subsidized. So many select a “preferred plan” that offers the lowest copay – thinking that plan will save them the most money – when that’s not usually the case. In these instances, the enrollee may not realize until they fill their first prescription in January that their plan will not cover medications that are filled at the community pharmacy that they’ve been using for years, because it isn’t on the plan’s ‘preferred’ list. Low-income beneficiaries can find this particularly frustrating when they realize that their co-pay would’ve been the same if they had chosen another, less limiting plan.

In reality, low-income beneficiaries should be less concerned with co-pays because they will usually be subsidized, and minimal, regardless of the plan they choose. To save the most money on prescriptions, low-income beneficiaries should instead generally search for the Medicare plan whose formulary covers as many of their medications as possible.

And that’s one of the other common enrollment ‘mistakes:’ enrolling in a plan whose formulary doesn’t cover the specific medications an enrollee is taking. This can be a costly error, particularly for patients who are taking multiple medications, or particularly high-cost medications.

Another common error is enrolling in a Medicare Advantage Plan, which requires a higher co-pay, when in reality they would likely have had lower overall costs if they had stayed in a Medicare Part A or B plan.

Q: What are the ‘new or different’ Medicare enrollment options that beneficiaries need to know about this year?

A: The Medicare enrollment options have mostly remained consistent from last year to this year. I think the single most significant ‘change’ in Medicare is that so many more senior citizens are participating, as more and more Baby Boomers reach retirement age. By 2030, 37 million more Americans will be using Medicare than in 2010, that’s about 10,000 new beneficiaries each day.

Q: How can community pharmacists help?

A: In many cases, the neighborhood pharmacist is a community’s single most accessible health care expert. Medicare beneficiaries usually spend more time, more frequently, in their community pharmacy than in any other healthcare setting. They often have long standing, personal relationships with their local pharmacist – and that pharmacist usually has a comprehensive understanding of his or her patient’s full medication regimen. The community pharmacist is an excellent resource to help Medicare beneficiaries select the coverage options that best meet their needs.

Community pharmacists can help enrollees – particularly those who are uncomfortable using the Internet – to navigate Medicare.gov and find out the option that is most likely to meet their unique needs.

Understanding how formularies work, and figuring out which medications are covered can be very confusing. Community pharmacists help enrollees understand how formularies work, and to determine whether their prescription medications are covered by the various plans. In cases when a medication isn’t covered by a specific plan, community pharmacists can work in partnership with a patient’s physician to suggest formulary-approved medications.

They can also help enrollees understand how each plan addresses issues like prior authorization, step therapy and tiered co-pays. This is important, so the beneficiary understands not just how each plan will impact them financially, but how each plan might impact their medication regimen or the time needed to get approved for a specific medication.

If a patient can’t afford a drug, the community pharmacist can also work with the patient and their doctor to find other drugs that cost less and are covered on the plan’s formulary.

Community pharmacists can leverage their deep knowledge of each patient and their individual needs, and their relationships with their patients’ local physicians, to help each beneficiary select the Medicare option that best meets their needs.


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