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How To Choose A Medicare Drug Plan

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To choose the best Medicare Part D plan for you, consider taking the following steps, each of which are described below. Also keep in mind that an alternative way to get drug coverage through Medicare is with a Medicare Advantage Plan:

Step 1. Put together a list of medications you use and may need in the coming year.

Step 2. Determine the cost of medications you may need in the coming year.

Step 3. Decide what is important to you. 

Step 4. Compare Plan D plans in your area.

Step 5. When you find a plan in which you are interested, call the company to confirm your understanding..

Step 6. Take some time to review the available Medicare Advantage Plans. They provide drug coverage as part of health insurance coverage.

Step 7. Review all you've learned before making a final decision.

KEEP IN MIND that if you do not like your choice or your circumstances change, you can change plans at the end of every year during the open enrollment period..

If you want help, contact your state health insurance counseling program. Find the contact information at www.shiptalk.org offsite link (tel.: 800.677.1116) or go to www.eldercare.gov offsite link or call Eldercare Locator at 800.677.1116

STEPS TO CONSIDER WHEN CHOOSING A MEDICARE D DRUG PLAN

Step 1. Put together a list of medications you use and may need in the coming year.

While it is impossible to predict precisely, try to get an idea of what drugs you will need during the coming year and their cost. It will give you a benchmark against which to compare the effects of different plans for the coming year.

  • Pull out your List of Medications. If you do not have one, this is a good time to take a few minutes and create one. A List of Medications includes information about all the drugs you are taking. 
    • It will come in handy each time you see a doctor. 
    •  It is also advisable to carry a copy of your List of Medications in your wallet or purse in case of an emergency.
  • Ask your specialist or his or her head nurse what medications you may need next year.
    • Are there additional drugs you may need? If so, which ones and in what doses?
    • Are there drugs on your list that you are not likely to continue to need?
  • Check with your general practitioner (primary care physician) and any other doctors you may be seeing. Ask the same questions about drugs you're taking that do not relate to your life changing health condition.

Step 2. Determine the cost of medications you may need in the coming year.

  • The objective is to be able to make a reasoned estimate about how much you will spend on drugs each month.
  • Put together a list of what your current drugs cost per month, including drugs you only need occasionally. If you don' t know what you are paying, ask your pharmacist.
  • Likewise, for drugs which you may need in the coming year, ask your pharmacist for the price of the least expensive version.
  • Multiply the total times 12 to get the yearly cost.

Step 3. Decide what is important to you.

For instance:

  • Does it matter how you receive your medical care in the sense of whether you have free choice or your care is managed? If you're willing to have your care managed, consider drug coverage which is part of a Medicare Advantage plan. (Such plans show up in the Medicare site described in the next step.)
  • Do you have a preferred pharmacist? Not all pharmacies work with all plans. (To learn more, see Choosing A Pharmacy,How To Purchase Drugs)
  • Do you live in more than one area or travel out-of-state for lengthy periods of time? If you do, consider a plan that provides national coverage. If not, at least look for a plan that offers mail order services.
  • If money is a concern, consider coverage for the "donut hole." As you are likely aware, Part D coverage generally has a gap during which you pay 100% of the cost of your drugs. -- the gap during which you otherwise pay 100% of the cost of drugs. Your premiums may be higher to get the hole covered, but your overall costs are likely to be lower.
  • Do you qualify for "Extra Help" to help pay costs? (See: Extra Help)

Step 4. Compare Plan D plans in your area. Medicare makes it easy.

Go to www.medicare.gov offsite link, click on "Prescription Drug Plans" "Compare" or call Medicare's 24 hour hotline at 800.633.4227 and ask the representative to help you compare Part D plans. If you go to www.medicare.gov/find-a-plan offsite link, you can type in your drugs and dosages. The tool estimates your total costs over the yaer. It is advisable to repeat this process every year during open enrollment because coverage, costs and your drugs can change. (The tool also give you an idea of when you are likely to hit the doughnut hole.

The site sorts by cost or by participating pharmacy. It allows you to compare three plans at a time side-by-side. (For safety's sake, so you don't have to unnecessarily repeat the process, when you create a comparison, immediately print.) Depending on your priorities, look at:

  • How much does the Plan cost annually? Include premiums, deductible, copayments and coinsurance for the drugs you believe you will need.
  • Whether the Plan covers the drugs you take - especially the expensive ones. 
    • Covered drugs are listed on each Plan's formulary (a list of drugs which are covered.)  If a drug is not on the Plan's formulary, the cost is generally not covered. In addition, purchases from an unauthorized source do not count as expenses while you are in the so-called Doughnut Hole. Plans are allowed to change their formulary during the year so there is no guarantee that the drugs you need will continue to be covered. However, if this happens, you can ask the Plan for an exception in your case.
    • Check the following potentially expensive details that are frequently overlooked with respect to prescription drugs:
      • Is the pharmacy you use on the "preferred" list? 
      • Do you have to try a less expensive alternative before paying for your current prescription? 
      • Are there limits on the quantity of a prescription you can get?
    • It may be worthwhile to look at www.yourpharmacybenefit.org offsite link, a site created by a collaboration of non-profit organizations to help consumers figure out which drugs are covered under different plans.
  • Are there any restrictions on a drug you take or are considering taking -- such as a limited amount of the drug the Plan will pay for each month? 
  • Where you can buy drugs. Does it include your regular pharmacy? (If you do not purchase drugs from the appropriate source, the cost may not be covered. Purchased from an unauthorized source do not count as expenses while you are in the so-called Doughnut Hole.)
  • Will it cover drugs when traveling? (Some plans coordinate with national chains.)
  • If you have other health benefits, how does the Plan coordinate with them? For example, if you have drug coverage from your employer:
    • Will the Plan pay? 
    • Will it wrap around the employer plan?
  • If you will use financial assistance to purchase Part D coverage, it is better to speak with a Medicare representative instead of using the comparison tool.
  • If you can't find a plan that covers all of your drugs, find the plan that covers most of them.

Ask your doctor (and possibly your pharmacist) whether there are other drugs which are plans' formularies which would work as well as the drugs you're on.

If the doctor says there is no substitute, before switching:

  • See if your condition qualifies you for an exception for the drugs.
  • If not, ask each company if you can get an exception to use the particular drug(s). You may not be able to find this out until you actually join the plan, but it's worth a call (and the time on hold) to at least learn what the company's practice has been in the past. You'll likely need a supervisor at a call center to be able to give you the information you need.

Step 5. When you find a plan in which you're interested, call the company to confirm your understanding..

  • Double check the formulary to be sure that not only a drug, but also the dosage and form you take are there.
  • Ask whether the plan requires "step therapy" -- that you try a cheaper drug which is supposed to be equivalent to a medication you take or which is prescribed.
  • Ask whether the plan requires that your doctor explain why you need a certain drug before it will be covered. Some plans don't ask questions.
  • Make notes about what you're told. Include the name of the person with whom you spoke, contact information, the date and time, and what was said. Keep the notes with your Medicare file. You never know if you'll need them in the future.

Step 6. Take some time to review the available Medicare Advantage Plans. They provide drug coverage as part of health insurance coverage.

Medicare Advantage Plans in your state are listed on www.medicare.gov offsite link.

If you obtain your health coverage through a Medicare Advantage plan, you must use the plan's drug coverage.

Look at the restrictions, such as whether your doctors and specialist(s) are covered, whether you need approval before you can see a Specialist, whether you can afford the costs. Some of these plans have become looser about doctor and hospital choices. Some also offer additional benefits such as complementary therapies and dental benefits. (To learn more, see Complementary Therapies.) If you are comparing Original Medicare plus Part D coverage to a Medicare Advantage Plan, consider using ourHealth Plan Evaluator

Step 7. Review all you've learned before making a final decision.

KEEP IN MIND that if you do not like your choice or your circumstances change, you can change plans at the end of every year.

NOTE: If you want help, contact your state health insurance counseling program. Find the contact information at www.shiptalk.org offsite link (tel.: 800.677.1116) or go towww.eldercare.gov offsite link or call Eldercare Locator at 800.677.1116


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