Case Studies Part D Prescription Drug

A Medicare Advantage case study.

If you, a loved one, friend or neighbor has experienced “sticker shock” with your Medicare Part D prescription drug co-payment, the following case study may interest you.

Earlier this week, I received this message from an Albany New York County couple: “We were talking with our neighbor Kathy about the sudden and unaffordable cost of our medications. She said you helped her and you might be able to help us change our Medicare plan.

I called back and confirmed a time to get together for a complimentary review of their current plan, the doctors they see and medications they are currently taking.

Why ask about the medications?
In Medicare Part D terminology, generic medications are typically categorized as Tier 1 or 2 medications and brand name medications as Tiers 3, 4 or 5. The higher the tier, the higher the cost to the consumer.
Both the husband and wife are taking generic but also a few brand name medications.

But there’s more.
Similar to the deductible we pay for our auto or home insurance, many Medicare Part D plans include a deductible; that is, we pay the full cost of the medication up to a certain level. Most Part D plans don’t apply any deductible to the lower cost Tier 1 and 2 medications and limit the deductible to Tiers 3, 4 and 5 medications. So, for many, if your medication list is all Tier 1 or 2 generics, the deductible amount may not apply to you.

So what happened here?
The couple showed me their current Medicare Advantage HMO cards and, sure enough, I confirmed there is a $295 deductible applicable to the brand name tiers 3, 4 and 5 medications. But, the couple insisted, they never paid this before. That seemed odd so I did a little research and discovered their plan did not include any drug deductible in 2018. Something had changed.

Annual Notice of Change (ANOC) letter.
Their Medicare Advantage plan, sometime in September 2018, sent the ANOC letter advising members of the plan changes effective January 1, 2019. This notice is required by federal rules. The couple didn’t recall this notice and when asked if their agent had reached out to alert them, the reply was “we don’t have an agent.” I explained how I host early October conference calls to go through with my clients any plan changes announced in those ANOC letters.

And when the couple went to the pharmacy for a 90 day supply refill, that’s when they each faced the $295 deductible; which they did not plan for.

“We can’t afford this and don’t think we can change our plan after January 1. Kathy said you know how to do that.”

Yes, most Medicare beneficiaries know about the October 15 through December 7 Annual Enrollment Period yet few are aware of other enrollment periods available throughout the year. This couple was pleasantly surprised their neighbor Kathy mentioned and I confirmed how they could change their Medicare Advantage plan after January 1.

The solution?
It took some research time but we found a replacement Medicare Advantage plan i) with a monthly premium at or less than their current plan, ii) that their primary and specialist doctors participate with and iii) with a drug tier structure that does not impose a deductible on their current brand name medications.

And more good news. Because the husband and wife are income eligible to be enrolled in the New York State Pharmaceutical Assistance Program (EPIC), their monthly plan premium will be 100% subsidized and their brand name copay amounts no greater than $20.

“Dan, can we make this plan change effective for tomorrow, March 1?” Yes, both husband and wife applications were processed electronically for the requested March 1 (next day) effective date.

Some reminders from this case:

1) Many Medicare Part D beneficiaries are not aware of which tiers their medications are assigned to.
2) Medicare Advantage plans are required to send a notice 90 days before the effective date of any change.
3) Plan formularies are not alike. For example, a medication listed as in one tier plan A can be categorized in a different tier level with Plan B. .
4) Part D plan deductibles are not alike. Some plans have $0 drug deductible, others apply a deductible to Tier 3, 4 and 5.
5) There are several enrollment periods available throughout the calendar year.
6) New York State residents enrolled in a Part D plan should consider NY EPIC.
7) Having a local agent versed in plans available in your area can help.
8) I love these cases. A referral from a satisfied client results in two new satisfied clients.

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