Sylvia was upset. Her out of pocket costs for her diabetes medication just went through the roof. Her doctor prescribed one additional insulin injection and her cost more than doubled. She planned on cutting back one or the other taking them on alternate days to stretch her already strained budget. Would it be groceries or medicine?
Sylvia called me with her dilemma. I requested she bring me a list of her current medications, and I began the research process. She was in a Medicare Advantage HMO plan that was specifically designed for people with diabetes or certain heart problems. Her Insulin, normally costing $429.21 without insurance, had a co-pay of $37 on her current plan. As it turned out, so did the newly prescribed insulin injections. Her insulin alone was $74 per month on top of all the other medicine she needed to take to remain healthy.
After putting all her medications into my computer, I learned there was a better plan. Her co-pay for the two insulin injections would be $0 each. As it turned out, many of her “pills” would also have a $0 copay. Still other medications were reasonably priced, and I informed her that if she were to request a 3-month supply of her other medications, she only pays for 2 months, the third month is free!
Pharmacy costs are just one consideration when picking a Medicare Advantage plan. The other major consideration is your medical providers. Luck for Sylvia, her Primary Care Provider (PCP) was on this recommended plan as well, and all but one of her specialists in Bakersfield were a match. As she didn’t anticipate needing the non-covered surgeon, she was a good match for the cost saving plan.
“What about the other benefits?” she asked. I went to www.Medicare.gov to use their “Compare Tool” to learn that both plans had a $0 copay for hospitalization, $0 copay for Primary office visits and specialists were also $0 copay. Emergency room visits were $120 for each plan and the new plan was $0 for radiology such as MRIs and CT scans versus the current plan charges a $60 copay.
Her current plan had a lower copay of just $25 per day in a skilled nursing facility after 31 days, while the recommended plan covered only 20 days for $0 then jumped to $170.50 per day. Sylvia had no plans to need a skilled nursing facility. Her budget could use the prescription relief.
I reviewed many of the benefits of both plans. It was a no brainer to change, but Sylvia had another question. She, like many people on Medicare, thought she would have to wait until October for the Medicare “Annual Enrollment Period” [AEP] (October 15 – December 7; new coverage beginning January 1.) I informed her that she was entitled to a Special Enrollment Period [SEP] due to her diabetes or chronic heart problem for a “Special Needs Plan” which can be enrolled in year-round. There was no need to wait, and her lower prescription savings would begin the first of the month following the simple application which we completed for her right here in the office.
To research the writing of this article, I reviewed 56 insulin medications. I was surprised to learn that only eight medications were not covered by either plan. Further comparison found that some of the $0 copay plans for the favored plan for Sylvia were off formulary on her current plan. The reverse was also true. The new plan didn’t cover some medications that were favored on the current plan.
The bottom line is what I have been preaching for many years; everybody needs to review their medication annually. People with diabetes, even though they may not be insulin dependent, and controlling their condition with diet, can get a review year-round.
Speaking of year-round, people on Medi-Cal, along with their Medicare Advantage, are entitled to get a review year-round as well. They can change their plans up to three times a year, keeping their changing health conditions under check.
Not all doctors are on all plans, so it is important to get reviewed as your circumstances change throughout the year. The only way to get an honest comparison is to seek out a health insurance agent who represents all the available companies. If you go into a Ford dealership for a new car, chances are you will drive off with a new Ford. What if a Honda was better for you? The Ford dealership doesn’t know much about the competitors.
Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 27 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail email@example.com or visit him on the web at www.harrythal.com.