Gray Power: Factors to consider when renewing Medicare or choosing a new plan
Published 12:00 am Monday, November 13, 2006
Factors to Consider when Renewing Medicare Part D or Choosing a New Plan (Part 1):
-The amount of the monthly premium whether enrollees in the plan who are eligible for the low-income subsidy (extra help) will have to pay a portion of their premium. If the plan was a low-income subsidy plan in 2006, will it remain a low-income subsidy plan in 2007? If not, will the amount of premium people eligible for the full extra help will have to pay.
If the beneficiary will have a premium penalty for not enrolling in 2006, the amount of the penalty for those who enroll late is $1.91 per month in addition to the plan&8217;s premium.
-Whether the plan formulary includes or continues to include the particular drugs needed by the Medicare beneficiary or the strengths, packaging, and dosages of the drugs needed by the beneficiary or the number of days covered in each prescription (Example: 30, 60, 90 days) or coverage for off-label drug usage
-If the beneficiary received an exception from the plan in 2006 to cover a drug that is not on the formulary, by-pass utilization management requirements, or to reduce the beneficiary&8217;s cost-sharing.
Does the plan honor the exception in 2007 and continue to cover the drug, and what the beneficiary has to do to make sure coverage will continue? If the beneficiary has to file a new exception request for 2007, when can the new exception request be filed, and what is the process for doing so? If another plan includes the drug on its formulary so the beneficiary does not need to request an exception
-Identify if the plan&8217;s utilization management tools have been added to drugs that were on the formulary in 2006.
The prior authorization requires that the plan approve prescriptions for a formulary drug before it will cover or pay for the medication. If the plan requires step therapy required by certain medication(s) be tried before that prescribed by the beneficiary&8217;s physician.
Determine if the plan uses tiered cost sharing with different co-pays for generics, brands, or for specific drugs. Determine whether the plan offers therapeutic substitutions or if there are quantity limitations on number of prescriptions in a month, on number of pills in a prescription, and/or on dosage strength.
-Also determine whether the pharmacies in the plan&8217;s network include the pharmacies used by the beneficiary and the pharmacy used by the long-term care facility in which the beneficiary resides.
Continued next week