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Where do you shop for your $4 generic medications? Do you shop at the same pharmacy and run the charges through your Medicare Part D plan? Or do you shop at a different pharmacy and just pay cash for them?

Why would I ask you these questions?  A few years ago we ran all of our prescriptions through one pharmacy using our Medicare Part D plan.  Then one day we realized that in many instances $4 is not what is being charged against the Total Drug Cost. Instead, it’s a retail price on the generic drug being charged against the Total Drug Costs.

You take a prescription drug and it is in the pharmacy’s list of $4 generic drugs and your co-payment is $4.  When you get your Medicare Part D Explanation of Benefits you might see a charge of $15-$20 or more for that medication. That $15-$20 is applied to your Total Drug Cost and can put you into the Coverage Gap perhaps a few months sooner.

What Can You Do?

As much as it is an inconvenience, shop at two different pharmacies.  Don’t use your Part D plan for the $4 generic drugs.

The reason I recommend two different pharmacies is because once the pharmacy has your insurance information, it’s almost impossible to get them to stop running the $4 generic charges through your plan.

Just go to another pharmacy offering $4 generics and pay cash and these charges are never applied against your Total Drug Cost in your Medicare Part D plan.

It’s really worth the inconvenience of shopping at two pharmacies. One for $4 generics and one for brand name medications.  It won’t be until 2020 that the coverage gap is closed.  In the meantime, we need to look at ways to stay out of the Coverage Gap.

Check around and find out what some of the pharmacies in your area are offering.  One pharmacy in our area has a “no cost” antibiotic prescription program and they offer certain diabetes medications at no cost.

Let us know if you have any strategies for staying out of the Coverage Gap and let us know if pharmacies in your area have any prescription programs.  We would love to hear about them and share with our readers.

During 2011 2.8 million baby boomers will turn 65 and become eligible for Medicare and with the different plans available this can become overwhelming when trying to make a decision.

Do you just enroll in Original Medicare Part A, Part B and the Prescription Drug Plan (Part D)? Or do you enroll in a Medicare Advantage Plan (Part C)?

The Medicare Rights Center, http://medicarerights.org, suggests you consider a few key points when enrolling in a Medicare Advantage plan:

Key Points

• Choice of doctor
• Ease of access to specialists without unexpected bills
• Coverage away from home
• Prescription drug coverage
• Does the plan works with Medicaid if enrolling in a Medicare Advantage Plan

You are also encouraged to speak with your healthcare provider, their staff, friends, family or others to help you with your decision.  Here are some other important questions the Medicare Rights Center suggest you receive answers to before enrolling:

Get Answers to These Questions

• Can you use your current doctors?
• Are your doctors in the plan’s network and are they taking new patients?
• Do your doctors recommend joining this plan?
• What will happen if your doctors leave the plan?
• Which specialists, hospitals, home health agencies and skilled nursing facilities are in the plan’s network?
• If you have or develop a complex illness, what disease-related services are covered?
• What extra benefits does the plan offer? (Physical exams, dental services, vision care) and what rules do you have to follow to get them?
• Are your prescription drugs on the plan’s formulary (list of covered drugs)?
• Are there limits or caps on prescription drug coverage?
• Do you have to pay a monthly premium? If so, how much is it?
• How much is your co-payment for a visit with your Primary Care Physician or a visit with a specialist?
• How much will you pay for brand-name drugs? How much for generic drugs?
• How much will you pay for a hospital stay?
• How much will you pay if you use a non-network doctor or hospital?
• Are there higher co-pays for certain types of care, such as hospital stays or cancer treatment?
• What service area does the plan cover?
• What kind of coverage do you have if you travel outside of the service area?
• What type of disenrollment from the plan and how many members leave?
• How do members rate the health care they get from the Plan?

The questions are really good questions to consider.  If you decide to enroll in a Medicare Advantage Plan, the questions can be used to compare one plan against another plan.  Remember the Medicare Advantage Plans are run by private insurance companies.

The Medicare Rights Center has been helping people with Medicare since 1989 and is the largest independent, non-profit source of Medicare information and assistance.  You can contact them at 1-800-333-4114.

When I started writing this blog it was to remind you about some of the new things that were happening in 2011 for Medicare Part D, like the 50% co-payment by the pharmaceutical manufacturers for brand name drugs when you hit the coverage gap.

But as I started writing, I stumbled upon something interesting that could ultimately cost you more while in the coverage gap if you use generic drugs.

We know Part D providers encourage you to use a generic drug whenever possible.  And, where I live in the State of Florida, a pharmacy dispenses a generic drug unless it is written on your prescription that the “brand” is medically necessary.

Until you hit the coverage gap and you are using the generic drug, your monthly co-payment is generally less expensive than it would be if you were receiving a brand name drug.

What’s New

In 2011 when you hit the coverage gap (donut hole) you will receive a 50% discount on the total cost of your “brand” name drug(s) as long as the pharmaceutical manufacturer has an agreement with Medicare.

You will have a 93% cost share on your generic drugs during the coverage gap in 2011. This is the beginning of reducing the beneficiary co-insurance rate in the gap from 100% to 25% by 2020 for generic drugs.

Generics Could be More Expensive – A Catch 22

But, in some instances your costs for generics during the coverage gap in 2011 could be more expensive than a “brand” name drug.  This is somewhat of a “Catch 22.” You are sort of “damned if you do, and damned if you don’t.”

The Example:

You are prescribed “Brand X” which is a brand name drug and has a retail price of $170 and there is “Generic D” available.  Your Part D provider offers you a co-payment of $10 per month for using the generic versus $50 per month for using “Brand X.”  The generic has a retail price of $130 for a 30 day supply.  Along with your other drugs you hit the coverage gap. (As a note, these costs are based on an actual brand versus generic.)

The Catch

During the coverage gap, “Brand X” will cost you $85 per month, but “Generic D” will cost you $120 per month.  In this instance you are actually paying more for the generic than the brand during the coverage gap.

The Solution

There is no correct solution to this dilemma. You can ask your physician to write a prescription that is “medically necessary” for the brand name drug. What happens here is that you reach the coverage gap quicker because of the higher retail price.

But on the other hand, if you reach the coverage gap and use the generic drug, your out-of-pocket costs are much higher.

Let us know if you have a solution for this situation as I’m sure there will be many beneficiaries who will fall victim to this issue.

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by Mary Jane Stern

The 2011 Medicare plan data is now available at http://www.medicare.gov.  Even if you don’t want to change your plan(s), take a few minutes and review what changes your plan may have for 2011.  This might be your Medicare Advantage Plan (Part C) or Medicare Part D (Prescription Drug Plan – PDP).

This year we need to enroll in a new Part D Prescription Drug Plan.  I have been using Medicare’s new website and found the searches to be very helpful in terms of overall drug costs and which plan’s formulary have our prescription drugs.

But it still comes down to cost and although there is some relief with Part D, depending upon your condition, prescription drugs can be very, very expensive.  Although Medicare stated that there was a minimum jump in premiums for 2011, I didn’t find that to be the case in my area.  What I did find:

• Premiums increased
• Providers declined
• Less plans offer $0 deductible
• Increased cost sharing

One Way to Save – Spit the Pills

There are many insurance companies that have actually advocated pill splitting.  Some of your prescriptions come with a “score” and they are easy to cut or split.  There are others that have a hard coating and don’t split correctly.

But wouldn’t it be great to split those pills and stay out of the “donut hole,” which doesn’t close until 2021?

I want to share with you a site I stumbled across that has a different type of pill cutter that is unlike the “standard” pill cutter with a razor blade.  It’s a Swiss Pill Cutter machined from quality steel with blades that never dull and Made in the USA.  Here’s the website: http://www.pillcutter.com.

Here’s the concept of the cutter:

If the pill or tablet is hard, the razor blade has a difficult time cutting through it. In addition, the blades dull rapidly and need to be replaced because a dull razor blade tends to crush and crumble the pill.

The Swiss Pill Cutter is machined from tool quality steel and the “blades” never dull. The blades on the top and bottom never actually cut through the pill; they just cut through the hard outer coating and the pill then splits evenly. This method could be compared to cutting wallboard. You cut through the outer sheath and then the wallboard breaks evenly down the line of the cut.

Always check with your physician to make sure the medication prescribed can be safely taken if you split the pill.  But if you can, consider the savings.  For us, splitting a few pills will keep us out of the donut hole in 2011.

Here’s an article from Consumer Reports on 10 Ways to Reduce Drug Costs.

Do you have any other ways to save on prescription drugs that you want to share with us?

October 1 starts the official Medicare marketing season.  There are numerous choices for health and prescription drug plans and it can become overwhelming.

November 15 – December 31, 2010 is Medicare Open Enrollment.  And Medicare Advantage members, this is your enrollment period too for 2011.

In my local newspaper there was an article about Extend Health who is now offering their services to Medicare beneficiaries through their website or customer service center.  Not a bad tool to use to help you with Medicare Open Enrollment.

Extend Health

Extend Health was at one time used by retirees from large corporations to assess their health care needs, for out of pocket expenses, prescription drugs, etc.

Now they are extending this same service to Medicare beneficiaries.

I went to their site http://extendhealth.com because I wanted to make sure this would be something people could use throughout the country.  I used various zip codes from Boston to Phoenix to San Francisco and different plans and options for the respective zip code were made available.

What was explained in the news article was that Extend Health represents about 100 companies.  What this means is that not all of your options are available through their site.

As an example, in my zip code for the Medigap plans they only had one company and that was Mutual of Omaha.  I was disappointed here because I know AARP and Banker’s Life offer the different Medigap plans in my area.

If we read on further about Extend Health, they do get a commission from the insurance provider if they enroll you. The commission is part of the plan cost, which means you pay no more or no less if you use Extend Health or sign up for the plan on your own.

Q1 Medicare

The other site that is great to use is http://Q1Medicare.com.  They originally started out with a great database on the Medicare Part D plans for your area.  Now they have expanded to include Medicare Advantage plans.  They offer all types of information including premiums.

They have included the rating on the plan using the 5 Star System.  You will also notice a column called MOOP – Maximum Out Of Pocket expense.  This is what you can expect to pay yourself during the year before a plan will pay 100 percent.

Medicare.Gov

If you like a particular plan or need more information, remember to check out the Plan’s website.  All this information can be found Medicare’s website http://www.medicare.gov.

How did we make choices years ago?  Information is at our finger tips today. Do you have any special Medicare Open Enrollment tools?  If so, please share with us.  Thanks.

Medicare has changed some of its wording and makes reading a little more confusing as to what will actually be applied to your out-of-pocket expenses while in the donut hole.

The Agreement

As we have been told the pharmaceutical companies have agreed to invest $18 billion towards Part D prescription drug costs for beneficiaries who fall into the Coverage Gap.  It has been agreed that they will contribute 50% of the agreed upon price and the beneficiary will pay 50% all starting in 2011.

The Concern

But a recent comment about how much would actually be applied to a beneficiary’s out-of-pocket expense had some good points.  The way things are written sounds like only the 50% copayment by the beneficiary would be applied to the out-of-pocket expense, and reaching catastrophic coverage could take much longer giving little value to the 50% discount.

The Good News

I have written before about Q1Medicare and what a great resource for Medicare Part D information.  So I asked Q1Medicare the question and they came back and told me that both contributions (1) 50% from the Pharmaceutical Company and (2) 50% from you, the beneficiary, would be applied towards the total out-of-pocket costs through the coverage gap.

What this means is if you have a prescription drug that costs $400 per month at the agreed upon price, 50% or $200 will be paid by the pharmaceutical company and 50% or $200 by the beneficiary, but $400 will count towards your total out-of-pocket expense.

Who is Eligible?

You are eligible if you have a Part D stand alone plan or a Part D plan through Medicare Advantage and you are NOT receiving any type of Low Income Subsidy (LIS). Sometimes you are referred to as a non-LIS Beneficiary.

A word of caution: In order for the “brand” name drug to be included, the pharmaceutical manufacturer must sign an agreement with Medicare.  If there is no agreement for a particular drug, then it is NOT entitled to the 50% discount.

I am sure Medicare will start posting those drugs that will be part of the Coverage Gap as the agreements are received.

Beginning October 1, 2010 Medicare Part D Prescription Drug plan Marketing Activities can begin.  This is the time you want to start getting your information together to compare other plans.