In this post, we’ll give you some snapshots of consumer frustration, pulled from www.MedicareDrugPlans.com (a website operated by PharmacyChecker.com), about the problem of medications getting dropped from Part D Plans and tell you what is and is not actually permissible. I believe this practice is well characterized by the phrase “bait and switch.” Just listen to Riley from California talk about Blue Shield Medicare Enhanced Plan:
“Keep changing the drugs in the formulary. Just get stabilized on a drug and they drop it from the formulary or charge high tier prices. Then you start on a different drug fine one that works then it is no long covered in next formulary. There is no concern for the patient doesn’t matter to them if you wind in the emergency room at a cost of many thousands of dollars and patient’s pain and discomfort. It is not their problem the medical coverage has to pay for it and the drug coverage have saved themselves some money at the cost of medical coverage, medicare and the patient.”
Before choosing a plan, most experts encourage people to research plan premium and deductible costs, pharmacy networks, gap coverage, and – most importantly – which drugs are covered in a plan’s formulary. The beauty of the government’s Medicare Plan Finder is that you get to actually type in your medications and find plans that cover those drugs. So imagine doing just that: you look on the government’s site and find a plan that covers the three medications you take. You’ve taken THE BAIT and enroll in that plan. Come January all is well, your costs are manageable and you pat yourself on the back for a research job well done. Then in March – THE SWITCH – you find out that the brand name drug prescribed by your doctor, which has worked well for you for years, will no longer be covered and you either have to take an alternative drug that is covered or pay for the drug as an out-of-pocket cost.
Is this type of bait and switch legal? Yes. After reviewing the regulation, 42 CFR 423.120, the law is clear that Part D plan sponsors can take a covered drug off its formulary. There are some caveats but I don’t believe they compensate for how unfair these formulary changes are. The plan must either give you 60 days notification before the formulary change goes into effect or if you go to the pharmacy for a refill the plan must cover the drug with a 60-day supply. In other words, they need to warn you about the bait and switch to give you time to figure out your next move.
Some enrollees seem to have had good experiences with a plan and then everything just tanks. We learn from one Michigan resident about an experience using the Cigna-HealthSpring Rx Secure plan
“After 5 years in plan they dropped coverage on 3 of my 5 scripts, no value now, cheaper to buy all on my own”
Some consumers gave greater details about the costs incurred due to these bait and switch practices. Here’s what one Floridian said about AARP MedicareRx Saver Plus:
“They dropped an important Blood Pressure medication (Micardis) for 2015 as well as others. Out of pocket cost went from 2013 -$60.00, then in 2014 $120.00 now in 2015 over $545.00 for 90 day supplies of Micardis through Optum RX their online med source. Too late for me, will look for a better Part D source come next year.”
Our friend from Florida could look for a new plan for 2016 but what guarantees to they have that the same bait and switch won’t occur?
Is there an upshot here? You do receive notification with 60 days to figure out what to do. The notification that you’ll receive about your drug being dropped must contain, to quote from the federal regulation, “alternative drugs in the same therapeutic category.” It might seem like small consolation if the medication you’ve been using works but do not rule out a pharmaceutical alternative, probably a lesser expensive generic, IF your prescriber believes it will work just as well.
If you and your healthcare provider decide you should take the drug that was dropped and not a pharmaceutical alternative, and the costs are too high domestically, then you might consider an international online pharmacy verified by PharmacyChecker.com. Brand name drugs are often 90% lower outside the U.S. when purchased from a verified online pharmacy.
Finally, there is an appeal process that you and your healthcare provider can use if you believe your plan isn’t covering the medications you need – including ones that they drop! I’ve read that this process can be a serious nightmare. But this is a blog post unto itself and I plan on covering this topic in the weeks to come.
We’re two weeks into the open enrollment period of Part D Medicare Drug Plans and it is my deepest hope that if you are a Medicare enrollee then you are taking time to find the best plan. It’s not easy. Finding the right plan, however, could mean getting the medications you need to stay healthy, saving money, and avoiding lots of headaches throughout the year. Our website, MedicareDrugPlans.com, gives you basic information, such as premiums, deductibles and coverage levels, but also ratings and reviews about Part D plans that can inform you about the experiences of your peers in using the different plans. Your final search should be with the government’s website – Medicare Plan Finder – where you can find the plans that cover the medications you are already taking now and specific costs related to those plans. Below are key points about costs and coverage.
Part D Plan Costs
Plan costs have gone up this year. The deductible cap increased by 12.5%, from $320 to $360. Fifty-three percent of the plans are charging the full deductible, while the other 47% charge less. Average premiums have increased from $36.68 in 2015 to $41.46 in 2016. The lowest monthly premium is $6.80, that’s if you live in Puerto Rico and choose the Humana Preferred Rx Plan. The highest premium is $174.70, that’s if you live in Florida and choose Blue MedicareRx Option 2.
Part D Plan Choices
The overall trend of having fewer Part D plans to choose from continues this enrollment season, down to 886 this year compared to 1001 last year. Looked at historically, the declines are even more striking, as there were 1,875 plans in 2007. These numbers are the totals available in all states and U.S. territories but options are really state-based. Alaskans had only 19 plans to choose from, compared to a high of 29 in West Virginia and Pennsylvania.
Part D Plan Coverages Phases
There are four coverage phases for Part D plans: deductible, initial coverage period, the coverage gap, often referred to as the “donut hole,” and catastrophic coverage. The deductible is pretty straightforward–you pay the full cost of your medications up until that dollar amount, which can be as high as $360. During the initial coverage period, you usually pay about 25% of drug costs and the plan picks up 75% until total costs have reached $3,310. At that point you’re in the coverage gap, but you’re paying discounted prices, 45% and 58% of brand and generic drug costs, respectively. Once total costs have exceeded $7,515, you are in catastrophic coverage territory, and only have to pay 5% of your total drug costs until the next year begins.
Understanding these generalities about Part D plans is important, but the devil is in the details, which can only be understood through research. It’s not enough to just stick with the plan you have. Nine out of 10 Medicare enrollees do not change plans, and many end up with higher drug costs because they don’t. The landscape of plans changes every year; so do your research, shop around, and get the best plan for your health and wallet!
For a thorough plan analysis see Kaiser Family Foundation.
For ratings and reviews, check out www.medicaredrugplans.com.
To finalize your decision go to Medicare Plan Finder.
To hear it from the pharmaceutical industry, Medicare Part D, the federal program that helps American seniors and the disabled cover medication costs, is a highly popular, successful, low-cost program. That’s bunk. According to a new paper, written by authors Marc-Andrew Gagon, PhD. and Sidney Wolfe, MD (Carleton University’s School of Public Policy and Administration and Public Citizen, respectively), drug prices covered under Medicare Part D are wildly inflated compared to drug prices in all other countries. Ok. We knew that already. That’s why seniors continue to import medication from other countries! But seriously, this report includes fresh data and critical analysis to reminds us, and hopefully convince Congress, that not only are we paying too much as taxpayers and consumers but Americans often cannot afford to take prescribed medication at all, and that leads to more hospitalizations and higher healthcare costs.
We’ve noted on many occasions the government’s survey data showing that about five million Americans import prescription drugs for personal use due to cost. About 750,000 are seniors, most who are subject to the coverage gap known as the “doughnut hole” of Part D, which, despite improvements under Obamacare, still leads to millions of seniors struggling to afford medication. Their decision to buy more affordable medication internationally makes sense. According to the new report, even the rebated brand name drugs under Part D are almost twice (198%) the cost paid in countries that make up the Organization of Economic Cooperation and Development (OECD) – the most advanced economies.
The report is called “Mirror, Mirror, on the Wall: Medicare Part D pays needlessly high brand-name drug prices compared with other OECD countries and U.S. government programs.” You can find it here. (more…)
If you were to take a time machine and go back to 2006 and put a hundred bucks in a savings account with 5% annual interest, you’d have $147.50 in 2014. Not bad. But if your interest rate was tied to the annual price increases of brand name drugs you’d end up with…$202. And if for some crazy reason you just wanted to have the same purchasing power 8 years later, and tied your interest rate to inflation, you’d only end up with $125.
Clearly the increase of drug prices are out of line with the prices for everything else, and while the numbers figured above only take in to account brand name prices, generic prices are rising, too. On average, generics cost 5% more in 2014 than they did in 2013. That’s on average – some generic drug prices increased by 2,500 %!
But there’s good news on the way. Senators Sanders and Klobuchar are fighting for more affordable medication. Some more good news, at least for seniors, was released this past week. The Wall Street Journal reports that the Obama administration’s fiscal budget for 2016 calls for the government to negotiate prices for biologic and high-cost drugs for Medicare Part D. While, we’d like to see prices negotiated for all drugs, this can still represent huge savings for the government. Estimates suggest that 9.1% of national health spending could be on specialty drugs. That’s total health spending, not just drug spending.
We’re eager to see if the government will actually able to negotiate prices in 2016 – who knows how the budget will change or if Pharma will push to prevent negotiations. We’ll be keeping an eye on this and will certainly let you know.
A Bittersweet Prescription
OPEN enrollment for Medicare Part D drug plans ended this past Sunday, but my thoughts about them linger. Our website www.MedicareDrugpPlans.com received about 150 ratings of part D plans in 2014 – most of them highly critical, and some of them downright scathing! Whether it’s a plan’s horrible customer service, lack of coverage of many brand name drugs, or dropped coverage, we’re hearing from many irate seniors. At the same time, some studies have shown most seniors are happy with their plans. Why all the contradictions about Part D? To understand, please join me on a trip down Part D memory lane.
When PharmacyChecker.com was founded in 2002, American seniors did not have pharmacy benefit plans through Medicare. While most seniors had some drug coverage through private health insurance or Medicaid, 25% were without any drug coverage and, thus, vulnerable to a pharmacy’s highest retail price. Just eight months after our website launched in April 2003, Congress passed and the president signed the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), which created a pharmacy benefit opportunity for all Medicare enrollees known as Part D.
It’s amazing and sad to report that, today, the problem of high drug prices for Americans overall is worse than the problems existing before the MMA was born. In 2001, the Commonwealth Fund reported that 28 million Americans did not fill a prescription due to cost. That number shot up to 50 million Americans in 2012!
Since open enrollment began two days ago, Medicare beneficiaries all over the country have been looking for new Medicare Part D plans. In fact, based on our analysis of recent Part D Reviews on MedicareDrugPlans.com, you’d think most enrollees were looking for new plans! Of the past 50 reviews on the site, this is what we found:
- 44% had customer service issues, including unresponsive service, rude representatives, and billing and enrollment errors.
- 42% complained about mail order issues, such as shipments taking too long, poor packaging and instructions, and poor website experiences.
- 30% had problems prescribed drugs not being covered, inaccurate pricing, or coverage refusal after requesting authorization.
While we can’t say much about how to prevent dealing with mail order pharmacy or customer service issues, we know that you have the power to tackle formulary problems. Just so we’re clear, the way to find out which plans cover the drugs you need is at the government’s site, Medicare.gov – not on MedicareDrugPlans.com. MedicareDrugPlans.com serves as a listening board for what you need to look out for when you pick your plan, and is meant to be a supplement to the government’s site, so we recommend using both while selecting a plan. That way, you can make sure your drugs are covered and hopefully avoid any unforeseen issues.
Finally, it’s unfortunate that most of the reviews and ratings of Part D plans are negative ones. We want positive ones! We know that many Americans are benefiting from the plans. To whomever this applies: please help your peers by reviewing and rating the Part D plans that you like.
Good luck searching for the right plan!