Is your medicine covered? Can you keep your pharmacy? And other FAQs from Sanford Health Plan

Transcript

Mick Garry (host): Welcome to “Medicare Simplified,” a podcast by Sanford Health Plan that will help you make the most of your Medicare Advantage benefits. I'm your host, Mick Garry.

Today we're going to help you decipher prescription coverage under Medicare. It can be a daunting project because there are so many ways to get prescription coverage. There are lots of questions that come with the process itself, but also with the kinds of issues you should be talking about with your agent when you are comparing options.

To help us learn more about Medicare prescription coverage and the kinds of questions we should be considering, we're joined today by Jack Arnett, an inside sales manager for Sanford Health Plan.

Jack, let's start with the basics.

What drugs are covered by Medicare Part D for seniors?

Jack Arnett (guest): Good to see you again. Always glad to participate with these podcasts.

So what drugs are covered by Part D plans? Each plan has a formulary. Medicare will set the parameters for Part D drug companies. Medicare establishes the required list of drugs private insurance companies must cover. Drug companies are allowed to expand on that to create a formulary. A formulary is a list of covered drugs that include a wide range of prescription medications that are then put into tiers, or categorized into tiers.

Mick Garry: Can you explain what drug tiers are?

Jack Arnett: Formularies have different tiers. What you will see on most prescription drug plans across the country are Tiers 1 through 5. Some will have 6 different tiers. The lower the tier, the lower the cost of the drug.

Tiers 1 and 2 are normally your preferred generic drugs or just basic generic drugs. Most of those will come with either a $0 copay or a very low copay. And then you get into your preferred brand name drugs and your specialty drugs. The higher you go with the tiers, the more expensive those drugs are going to be.

So when a Medicare beneficiary is shopping for a Part D coverage, it is very important to have a list of the prescriptions that they're on. Having a list of the prescriptions they’re taking will give the agents they’re working with the information they need to give the beneficiary an accurate account of how much they will pay for their prescriptions.

Mick Garry: It does seem like when you're reviewing this and when you're making those decisions, that having a chart available to you would make this maybe a little bit clearer for some people.

Jack Arnett: It does. In my career, and I've been involved in Part D since it began, I've literally helped thousands of individuals with their Part D coverage. The ones that come prepared with a full list of their drugs and the pharmacies that they want to use is very important.

There's an outstanding tool that Medicare provides all beneficiaries and all individuals that are helping individuals enroll in Part D. It can be found on medicare.gov. We simply enter the ZIP code of that individual and it'll pull up all the network pharmacies and we can enter the drugs they’re taking. We don't even need the spelling because if you type in the first couple letters, it will pop up automatically. Beneficiaries can enter the cadence that they take that drug and the dosage and then hit the enter button.

Medicare will list every Part D plan available to that individual based on costs and what those costs will include, like the tiers and the copays that they would pay. There's generally a deductible associated with most Part D plans. So yes, the more you're prepared, the better it will go.

Mick Garry: We hear the term “pharmacy network.” What does that entail in this context?

Jack Arnett: For most Medicare beneficiaries, they've been with the same pharmacy for quite some time, maybe even for their lifetime. When they're considering Part D coverage and making choices for a health care provider – a doctor, a specialist, or a hospital, for instance – Part D plans have network pharmacies that participate with that individual plan. I can tell you that some of the national pharmacies participate with just about every Part D plan. It’s rare that you would find a pharmacy that doesn't participate in the vast majority of plans. But that being said, you should be absolutely sure that your Part D plan participates with the pharmacy that you want to go to.

Mick Garry: How about when you're traveling?

Jack Arnett: Great segue, especially with some of the national ones. You know, here in South Dakota, we have a lot of Medicare beneficiaries who may head south for the winter. And so if you get your drugs at a local pharmacy – what I would call kind of a “mom and pop” type shop versus any of the national pharmacies like CVS, Walgreens, or Walmart – you're going to want to make sure that you get your prescriptions filled before you leave and make sure you have enough to last until you return.

But for most Medicare beneficiaries, if you're getting your prescriptions filled at a national brand pharmacy, you are absolutely going to be able to get your prescription filled whether you're here in South Dakota, North Dakota, Minnesota, or Florida or Arizona for the wintertime.

Mick Garry: When we're talking with someone for the first time about prescription drug coverage, what are some really important things that we should ask about?

Jack Arnett: When finding a Part D plan and working with that trusted advisor or that licensed insurance agent who is approved to market Part D plans, the first thing you want to review is the list of prescriptions you take. Then you put that up against the plan that you're considering.

Medicare allows a deductible for all Part D plans. Some plans choose not to put a deductible on it, some have a partial deductible and some have the full deductible. There are also the copays that an individual will sometimes have to pay. It does vary plan by plan. The drug may be the same, but one company may charge X and the other company charge Z.

You absolutely are going to want to pay attention to those cost shares because that will impact you financially.

Another important issue is finding out about the different plans you can choose. For a Medicare beneficiary, there's two ways of obtaining your prescription drug coverage: One is just from a standalone prescription drug plan. These are private insurance companies that just offer prescription drug coverage.

The other, the one that well over half the 63 million Americans on Medicare choose, is what's called a Medicare Advantage plan or Part C of Medicare. A lot of Part C plans or Medicare Advantage plans actually build the Part D component right into the plan so you don't have to shop for a standalone part D plan.

I think another thing that Medicare beneficiaries should want to consider when they're looking at Part D plans are the costs. It’s a big part of the decision-making process. Deductibles, copays and cost shares are all very important.

I think it's also important to review the track record of a particular company you are considering. Have they had nominal increases that most of us expect? Or have there been quantum leap increases, or kind of a rollercoaster effect that we have seen where the costs are high one year and down the next? It can be very hard to budget that way.

Another thing: Are there any rules or limits that individuals need to know about relative to switching plans? In our own personal lives, we change everything from the gas we buy to the milk we buy. Sometimes we just become dissatisfied with a particular brand and want to try something else.

People just can't switch drug plans anytime they want, however. Medicare has certain rules, certain enrollment periods that do allow for a plan change but then there's also a good chunk of the year that you're going to be locked in.

So when you're talking with that licensed insurance agent or that trusted advisor, make sure she or he educates you relative to those issues.

I want to reemphasize how important it is to make your decision based on the prescriptions you use. Are my drugs covered? That's the first thing you need to know. Let’s say you found what you think is a good plan – you've heard of this company, you've seen their advertising – but they don't cover your drugs. Then what good is it? There are a variety of nuances in choosing a prescription drug plan.

Of course, individuals are certainly allowed to navigate that process themselves. There are a great deal of resources available for that. One way is going to our Align website. We do stay on top of Part D. There are some changes coming for 2025, and we'll be posting some of that information on our website.

We'll be hosting a lot of informational sessions this fall throughout the region so people can stay up to speed on the upcoming changes.

Most importantly, talk with a trusted advisor. Get with somebody that you know personally that you've worked with in the past or comes highly recommended. Let that individual usher and guide you through that process.

We all feel best when we're well informed in making decisions. What is going to give you peace of mind is working with someone who has experience in this field and can help you navigate the many decisions you're going to have to make.

Mick Garry: Just listening to you talk on this, you’re saying you have to respect the challenge – it's a big one – but also have some faith that there are a lot of people who can help you and provide you with the information you need.

Jack Arnett: Prescription drug coverage is a good thing. I've helped a lot of people in the past who take very few or no drugs and wonder why they should enroll in a plan if they’re not going to use it.

No. 1, none of us have a crystal ball and knows what our health will be weeks, months, or years down the road. There's that old cliché: Would you rather have it and not need it, or need it and not have it? And so for most individuals, having that peace of mind that they have solid prescription drug coverage is important.

My earnest hope is that no one ever has to use it because they've stayed in good health. But we know better and we know that Medicare beneficiaries, throughout their life, may have some health challenges that are going to require prescription drugs as part of part of their regimen.

There are so many options out there, but there are good options, and this is a good thing. We’re here to help the folks at Sanford Health Plan, we are here to help navigate whether you're a Sanford Health Plan member or not. We just provide that solid education to help you make those informed decisions.

Mick Garry: Great, Jack, I appreciate that. Thank you for sharing your expert insights today on questions to ask when looking for Medicare prescription coverage.

If you'd like to learn more about Medicare Advantage plans options from Sanford Health, visit align.sanfordhealthplan.com or find more information in our episode show notes.

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