Saturday, October 19, 2013

IBM Extend Health Choosing the Best part D Plan

OK, my title for this post is misleading as there is no such thing as the "best" part D plan.  There are a just a number of variables to consider when selecting a part D plan.  Choose the plan that best fits the variables that are the most important to you. Everything I am about to write applied when you were using IBM's prescription drug plan.  However, most people just used the IBM plan without considering these variables.

  • The Formulary - is the criteria that relates to the plan's drug list.  It is a complex term meaning what drugs will this insurance plan cover.  Part D insurance plans are allowed to decide which drugs they cover.  The only regulation applied by Medicare is for drugs that the plan cannot cover - by Medicare law.  (They are drugs that treat conditions like anorexia, hair loss, infertility and erectile dysfunction.)
    The best way to pick the right formulary is to  base it on the drugs you CURRENTLY take.  On plan finder will show whether or not a particular plan covers your drugs. There is no way to predict what drugs you will need to take and it doesn't make sense to pay a big premium for a part D plan because it has a big formulary. And, even if it does cover lots drugs  - the new drug you need might not be on the list!
     IF you are prescribed a drug during 2014 that is not on your plan's formulary, your plan will decline coverage.  You must appeal the denial!  Get a letter from you doctor stating why you need the drug and appeal the plan decision using Medicare's appeal process.  It may take a couple of iterations of appeal to get a third party review, but the plan will usually cover your drug - just for the rest of the year.  During fall open enrollment in 2014 you will need to select a new part D plan for 2015 that includes your drug in its formulary.
  •  Drug restrictions - is the criteria the part D plan imposes for the particular drug you use.  There are several ways restrictions come into play.  The plan may require you to go through "step therapy" to try another, less expensive drugs to treat your condition before they will allow you to fill a prescription for your drug (even though you currently use the drug).  The plan might limit the amount of your drug that can be purchased during a given period of time.  All drug restrictions are described on for each plan. You have to look at the details of the plan to find them. It may also be worthwhile to call the plan and make an agent tell you the restrictions or find the restrictions on the plan's website.  Make sure you take notes and names when you gather information about restrictions or lack thereof.  It is important evidence if you need to file an appeal because you feel you were misled about drug restrictions.
  • Pharmacy Network - is the criteria for where you get prescriptions filled.  When you first enter plan finder on you pick pharmacies you'd like to use.  The results for each plan will tell you whether those pharmacies are in that plan's network.  Pay attention to the results because they will use words like "in network" and "preferred network".  The pharmacies that are "preferred" provide the lowest cost coverage and is the basis for the annual cost computation.  There is also information about mail order services.  Not all plans provide mail order services or it may cost more to use such services.
  • Total Annual Cost - is the criteria for how much your out of pocket cost will be in 2014.  The estimate shown by plan finder includes the monthly premiums for the plan, any deductible, and the copays based on the drug tier assigned to your drugs.  The higher the drug tier the more your copay.  My recommendation - pick the plan that fulfills your criteria for the first 3 variables that provides the lowest total annual cost.

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