Golden Opportunities

Medicare Part D never seems as easy as A,B,C! Thankfully, Alynn Anzevino “lettered” in tackling our Medicare drug benefits — and she’s here to spell out the specifics. Alynn is with Kaiser Permanente.

Question: I'm not going to ask you to spell all of the terms associated with Medicare Part D - but I would like you to give a definition and use them in a sentence! Let's start with "formulary drugs".

Answer: Formulary drugs are a list of drugs that are covered by a beneficiary’s co-pay, so you’ll only have to pay a portion and the insurance covers the rest. Each individual plan will have its own formulary.
Now there are certain categories of drugs that are required to be a part of all formulary lists. Medicare has identified six classes of clinical concern — and certain medications from these must be on every formulary, no matter what plan you have. These include things like chemotherapy drugs and vaccines.

Question: If there are certain drugs that have to be on every list, are there also drugs that ate excluded from every list?

Answer: Yes. These include certain categories such as many cough and cold medications along with narcotic anxiety medications. Medicare identifies these drugs and they cannot be included in any plan.

Question: What if a drug you're using isn't excluded from all plans. But, at the same time, isn't included on your plan's formulary list? What do you do then?

Answer: Approved drugs that are not on your formulary list are identified as non-formulary drugs. They are not excluded, but your policy won’t pay for them. For any drug not on your formulary plan, there will be a drug from the same class of drugs available to you.
For example, Nexium is a drug dealing with acid reflux. It is not on Kaiser’s plan. However, Prilosec, an equally effective drug to treat the same condition, is on Kaiser’s formulary list.

Question: What's the "penalty" for using a non-formulary drug?

Answer: You pay full cost.

Question: But, if we really like the drugs we already take, should we look for and pick a plan that covers those specifically?

Answer: Not necessarily, though it can be a consideration. Any plan you choose, by law, cannot compromise your health care; that is why there is an equivalent drug always offered and available.
You also have a course of action if there is a specific non-formulary drug you take that you do not want a substitution for: You can ask for the drug to be reviewed to see if it can be accepted. With Kaiser’s plan, this involved the physician completing a “request for coverage consideration.” The request is then reviewed by a team who determines whether the request should be granted. It’s best to check with your personal plan provider to see what steps you would need to take with your own plan.
And this same kind of review process is available if you wanted a name brand drug instead of a generic.

Question: Do plans generally prefer generic drugs?

Answer: In most cases, generic drugs are generally required if they are available. One thing to remember about generic drugs is that the FDA has determined that the generic alternative works in the same way as the brand name drug. They must have the same active ingredients, though inactive/filler ingredients may differ. They are equally effective.
And Medicare isn’t the only one to prefer generic drugs — patients do, too. This keeps their cost down. On average, a generic drug will cost $9 for a co-pay while a brand name drug co-pay would cost $35.every time you refill?
But, if there isn’t a generic alternative, you would receive the brand name drug and, most likely, need to pay the higher co-pay. .

Question: When people hit the dreaded "donut hole" in Medicare Part D coverage, what kind of costs can they expect for their prescriptions?

Answer: Most plans are like Kaiser’s in that, even in the “donut hole,” you never pay the cash price for a generic drug.
Even if the generic drug cost $1,000, you would still pay the $9 co-pay.

When it comes to Medicare Part D, it’s good to “D-fine” your coverage needs and then “D-termine” which plan is best for you. My thanks to Alynn for “D-livering” this important information.