Make Sure You Know The Correct Co-pay Before You Fill That Prescription!
When Leslie R., of Arizona recently called her drug plan to refill a 90 day supply of her insulin drug Lantus, the customer service representatives insisted the co-pay was $1,800 because she had hit the Part D doughnut hole. But a check of the drug price information found on Medicare’s Drug Plan Finder indicated the actual co-insurance amount was significantly lower — $855. When Leslie called her mail order pharmacy back to question the first quote, she was told that the correct amount for her 90-day supply of Lantus was actually $855.88. Because Leslie did not immediately fill her prescription when first given the $1,800 quote avoided an overcharge of $944.
How can you protect yourself from overcharges? Get cost information for your drug first from the Medicare website. You can get free one-on-one counseling (see link at end of this article) or you can try looking up info yourself. Here’s what to do:
Check the Medicare Drug Plan Finder. The Medicare drug plan finder lists all the drug and Medicare Advantage plans serving your area. You may search for drug costs using a “General Search,” or by entering your Medicare number. (The General Search often works as well or better than the personalized search with a Medicare number, and the following is for using the General Search.)
You will be prompted to enter your zip code, county, and asked about your Medicare coverage, and whether you get Extra Help, which is the low-income program that helps with prescription drug costs. You will be asked to enter your prescription drugs. You may enter them all, or just check a specific drug that you want information about. TIP: Write down your drug ID list number when finished entering the drugs, in case you need to check again later. You will be prompted to choose two retail pharmacies, even if you tend to use your drug plan’s mail order pharmacies to fill most of your prescriptions. After selecting your pharmacies, you will be taken to a list of all drug plans in your area. This may be about 20 to 30 Part D plans. The number of Medicare Advantage plans will be fewer. If you don’t see your plan on the page click “show all plans”.
If you are using a General Search, you may need to scroll through the list to find your drug plan. Make sure you check the plan that has the same plan name as the one on your drug or health plan card. Once you have found your plan, click on the name of the plan for plan details. Click on the link marked “Drug Costs During Coverage Levels.”
Clicking that link will show links to each of the retail pharmacies that you selected, as well as the Mail Order pharmacy. Click on all of the tabs to learn your drug’s price at each of the pharmacies. The price of your drug can vary dramatically, depending on whether you get your prescription by mail order or at a walk-in pharmacy, and whether you are using a preferred network pharmacy.
The chart of drug prices shows the selected drug(s), the full retail cost of each drug, refill frequency, what you pay for the during the deductible stage of coverage if any, the co-pay at the initial coverage level, what you pay in the coverage gap and catastrophic level of coverage. If you require an expensive specialty drug, note that drug plans are allowed to charge a co-insurance rather than a fixed co-pay. In Leslie R’s case, for example, her Part D plan charged a top 40% co-insurance during the initial coverage phase. However, the Part D doughnut hole is filling, and by law, drug plans are not allowed to charge more than 35% co-insurance in the coverage gap. The cost information shown for what Leslie would pay for Lantus in the coverage gap reflected the 35% co-insurance in the coverage gap.
Law changes passed earlier this year will lower that amount even further to 25% in 2019. But Medicare Part D beneficiaries still have to spend $5,000 out of pocket before reaching the level of catastrophic coverage when the co-insurance drops to 5%.
Part D costs can break a retiree’s budget quickly. To learn what options you have we urge you to get free one-on-one counseling through your State Health Insurance Assistance Program (SHIP). Get contact information for the SHIP program here.