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Medicare Part D Enrollment Considerations

Calculating Which Plan Is Best For You

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Updated June 09, 2014

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Medicare Part D Enrollment Considerations

Medicare and You - 2010

Health and Human Services.

People on Medicare may want to avoid considering changing their plans during the Medicare Part D enrollment period (from November 15 to December 31 annually). Reviewing plans may sound as daunting as doing your taxes. However, it is definitely worth your while to examine your options, because the total cost of plans and the drugs covered vary substantially from plan to plan.

Consumers Union warns that taking the path of least resistance -- doing nothing when you have a chance to review plan options -- can cost you. After looking at the costs of five prescription drugs commonly used by Medicare beneficiaries, a Consumers Union survey revealed that consumers in five states could shave off $2200 in drug costs by switching to another plan.

Tips on Getting the Most Out of Medicare Part D Enrollment

Patients with chronic urology conditions that require multiple medications and those treated with chemotherapy for urology cancers need to be attentive to cost differences between plans. Here are some tips to help you through the process:

  • Plan Out Your Needs. Make a list of all the drugs you take, including chemotherapy drugs and medications for all conditions, not just those related to urology problems. For drugs that you purchase in a pharmacy or by mail-order, check which plans cover them in your area and what the costs are.

    Medicare has developed a handy online tool to check what is on the formulary of plans in your zip code. This is the most important legwork that you can do to assess your drug needs and how health plans match them. Formularies are the list of approved drugs that your plan will cover. Simply input all your drugs and will see annual comparisons. When researching drug coverage, take time to be sure you understand what a formulary and formulary tiers are since a drug’s position is in the tier pricing system will impact how much you pay.

  • Remember that there is an appeals process throughout the year. Generic drugs are a great way to save money, but sometimes, they don't work as well in some individuals. If you’ve tried a drug that the insurer prefers, but had an adverse reaction to it, or it did not work, you can make a formal appeal to try an alternative that is not covered. You can learn more about appeals from advocacy organizations, such as the Medicare Rights Center, State Health Insurance Assistance Programs, and California Health Advocates. You also should be able to get information on the appeals process from your insurer.

  • Get the Facts About Chemotherapy Coverage. If you have a urologic or other cancer that requires chemotherapy, know that payments for chemotherapy have gotten blurred in some instances, in a large part due to the increase in the use of oral chemotherapy drugs. Chemotherapy used to be strictly covered under Medicare Part B, which reimburses you for chemotherapy via infusion. Under standard Medicare Part B, the government picks up 80% and you pay 20% for chemotherapy and related anti-nausea drugs for the entire duration of chemotherapy. However, if you are taking new oral chemotherapy drugs that have no infusion equivalent (such as those for advanced kidney cancer), they are paid for through Medicare Part D -- not Part B. If you are paying for oral chemotherapy on Part D, you will quickly reach what is known as the “doughnut hole,” which is the threshold at which you will start to pay 100% of your drug costs.

  • Look Beyond the Doughnut Hole. In 2010, you will reach the doughnut hole once you and your insurer have reached a combined payout of $2830 for your medications. Fortunately, the "doughnut hole" is just that: a hole in coverage. After you have spent an additional $4550, you are out of the doughnut hole, and your insurance policy resumes coverage.

Where to Get Help Choosing a Plan

It is understandable that you may feel overwhelmed by so many steps. Fortunately, there are many resources to help you through the process.

Don’t be afraid to ask for help from a family member, a Medicare rights advocacy group or your Congressperson, who may have information about Medicare Part D or offer resources that can help you make a decision.

Consumers also rate the quality of care in their plans. Medicare makes that information available to you as part of the decision-making process.

In addition, advocacy groups are available around the country that you can consult with:

  • California Health Advocates. -- Direct services are only available to California residents, but there is excellent information on Medicare on this site.
  • A toll free Medicare Help Line: 1-800-Medicare.
  • The State Health Insurance Assistance Program or SHIP, is a national program that offers one-on-one counseling and assistance to people with Medicare and their families. Through federal grants directed to states, SHIPs provide free counseling and assistance via telephone and face-to-face interactive sessions, public education presentations and programs, and media activities.

Sources

Medicare and You 2010. Dept. of Health and Human Services. 2009

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