$aving Money with Medicare

Using an Independent Medicare Plan D Broker

Kris and I asked around to find how people selected their Medicare Part D provider. Medicare Part D is also called the Medicare Prescription Drug Plan. We thought we found someone who was recommended by a friend. The person was initially very interested. But over time it became apparent they might not be that interested in helping us find the best deal. Kris is on several medications which takes some serious looking for the best, most cost effective plan for her.

We finally found an independent broker. This is someone who is not associated with a specific Medicare drug plan. Instead she buys into quite a number of different, independent plans. We gave her our lists. A few days later she came back with our options and pricing. Took a lot of work for her to do that.

Kris ended up with one Medicare Part D plan that best met her prescription and cost needs, I ended up with a separate one called SilverScript that best met mine.

I am NOT saying SilverScript is “the plan” for you. It depends on the medications you take and the Medicare Part D Formulary (drug list) covered by the Medicare Part D plan you choose. Please speak with your Medicare representative or Medicare broker, or use the Medicare Part D plan books yourself to determine the best drug coverage plan and pricing.

Per SilverScript,

“SilverScript Medicare Part D Formulary. A Medicare Part D drug list (Formulary) is a list of drugs covered by a plan. Formularies are developed to meet the needs of most members based on the most commonly prescribed drugs, including certain prescription drugs that Medicare requires that we cover.”
…

Federal law prohibits your Medicare Part D prescription drug plan from covering certain types of drugs, including:

• Non-prescription drugs (also called over-the-counter drugs).
• Drugs when used for treatment of anorexia, weight loss or weight gain.
• Drugs when used to promote fertility.
• Drugs when used for cosmetic or hair growth purposes.
• Drugs when used for the relief of cough or cold symptoms.
• Prescription vitamins and minerals (except for prenatal vitamins and fluoride preparations).
• Drugs when used for the treatment of sexual or erectile dysfunction (ED).
• Covered outpatient drugs which the manufacturers seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.”

There’s lots more “legalese” to wade through. This is why Kris and I decided to find an Independent Medicare Plan D Broker, someone not tied to a specific company’s drug plans. She was invaluable. We gave our Broker lists Kris and I made of all the prescription medications we are on. The Broker then price shopped and compared many different Medicare prescription drug plans for us. She also made the effort to see what pricing might look like next year. The Broker recommended one plan for Kris and a totally different plan and company for me. Each plan the best for our unique medication lists. Then when the next year rolls around we simply call our Broker, update any medications changes, and ask if we’re still in the best plans. The Broker recommends changes, or like last year no changes at all.

Now on to the Money $aving Part!

When I was on an employer’s medical and drug plan one of my medications cost me somewhere around $55.00 for 3 months. Once I got on Medicare the price jumped to $433.00 for 3 months. Somebody’s making a lot of money on this.

That was the best our Broker could find for me. GoodRx was $2-$3 more expensive.

Looking through the Medicare papers I noticed a footnote on one page that said if you can prove necessity for a different medication than the one Medicare recommends, Medicare might provide a Tier Reduction. Even our Broker said she didn’t know this. I appreciate her honesty. I work with people I trust.

Per SilverScript:

“Medicare Part D Formulary Tiers. Cost-Sharing Tier 1: Preferred Generic. Tier 1 is the lowest tier. Cost-Sharing Tier 2: Generic. Tier 2 includes preferred generic drugs. Cost-Sharing Tier 3: Preferred Brand. Cost-Sharing Tier 4: Non-Preferred Drug. Cost-Sharing Tier 5: Specialty Tier.”

The higher the Tier number generally the more expensive the drug. Mine was a Tier 4 drug. Very pricey.

I called SilverScript and asked for a Tier reduction. I was told the medication I was on was much more costly than the medication they wanted me to use. One minor problem – my Urologist and I had already gone through a full 3-months of testing the cheaper drug at progressively increasing doses. The final dosage required me to use so much of the cheaper medication to get the same effect as the more expensive medication, that the total cost of the cheaper medication was higher than the cost of the more expensive medication.

Different people respond to medications differently. In my case my system would not absorb the cheaper medication as well as it absorbed the more expensive medication. My Doctor thinks it may be because the more expensive medication that works for me is manufactured by a cosmetics company. Their skin care products are designed for best absorption.

Here’s the SilverScript information on a Tier reduction:

Re: Request for a lower Copay (Tiering Exception):

Information about this Request for a Lower Copay (Tiering Exception) Use this form to request coverage of a brand or generic in a higher cost sharing tier at a lower cost sharing tier. Certain restrictions apply. To process this request, documentation that all of drugs to treat the same medical condition on the lower cost sharing tier would not be as effective or would have adverse effects must be provided. Please provide clinical information or other evidence to support the medical necessity of the drug on the higher cost sharing tier, including previous drugs attempted for this patient’s condition. Please note: Tiering exceptions cannot be requested for non-formulary drugs approved under the formulary exception process, drugs in the specialty tier, or brand-name drugs at the price of a generic drug.

…

Where: *Copay, copayment or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

So my Doctor sent them all our test results. Medicare reduced my medication from a Tier 4 to a Tier 3 for the remainder of 2018. I went from paying $433.00 for 3-months to $85.00 for 3-months. All by dropping 1 Tier level.

The Story Gets Even Better (Not)

After all this work I contacted the mail-order pharmacy to make sure the Tier reduction would follow into 2019. I was told I’d have to “re-up” my Tier reduction but couldn’t do it until the last few days of the year. Don’t ask. I have no idea why.

So I waited obediently until just after Christmas. The person at the mail-order pharmacy said he found all my papers but my medication was no long Formulary. Meaning the pharmacy no longer covered this particular medication, so of course the Tier reduction was gone, too. After trying to find out what happened, he said it’d cost me over $200.00 every 3-months. I have no idea where that dollar figure came from. He was patient with my questions.

I finally asked to speak with his supervisor. He said he had to get permission for me to speak with the supervisor, so he’d get back to me. I waited, not wanting to get lost by calling back and forth. Finally he came back with his supervisor on the line. She had gone over the files and found the first person was wrong, the medication was still covered in their drug list, i.e. it is Formulary. I did have to get my Urologist to re-up the papers the pharmacy already had. While I waited, they contacted my Urologist who I called earlier to tell them what was going on and to please respond as soon as possible to the on-line pharmacy.

The supervisor, who was being very nice, got back on. My Urologist responded immediately. (Yeah! Love that guy!) So the supervisor then passed me to an on-line pharmacy person to review the files and determine if I could get the Tier reduction.

The on-line pharmacy person, also very nice, reviewed the files. We spoke briefly about why I couldn’t use the cheaper product as proved by 3 months of testing. She approved the Tier reduction.

All this took a full hour on the phone to accomplish. But I’m saving a ton of money.

The Moral of the Story

Check into possible Tier reductions on your prescriptions. Could save you a bundle of money.

If you must use a particular medication like I do, file for a Tier reduction to see if you can save some serious money. Be patient and polite when dealing with the on-line pharmacy. They have strange and wondrous rules they are required to follow. And they make mistakes like everyone else.

But wait – You’d think it couldn’t get any better … (deep sigh) it did

The mail-order pharmacy I had selected to fill my Medicare prescriptions normally sends me texts, asking if I want to put an order through, I respond with “Yes,” and the order appears within a week or so. My auto-orders were also on auto-pay. Super simple. Worked great. Everyone was happy.

I hadn’t been contacted for the past few months on my auto-order medications. Thought I better check. What I found was surprising and disappointing. I had been taken off auto-pay. When I asked why, no reason was given. They didn’t know. As a result I was overdue in my payments. However they never notified me my payments were overdue. And because I wasn’t paying for my medications, the pharmacy took me off auto-order. Sigh.

I paid the overdue bills, got back on auto-order and auto-pay. All is right with the world once again!?

The Moral of the Story – Part II

If something seems wrong with your prescription communications, delivery or pricing, it’s a very good idea to check it out.

Getting angry about something I have no control over is a complete waste of my time and energy. Anger makes others upset, sometimes even people not remotely involved in the situation, and complicates and delays most everything.

I’ve learned rather than be angry, use that time and energy to resolve the problem(s). Things get done more quickly with far fewer antacid tablets. And the next time you call them about an issue they won’t be heard saying in the background “It’s him/her again.”

This is Not to Say Ignore a Problem

Of course how far you take a problem depends on its severity. If life threatening I will go to the very top if necessary. If a problem is basically a “who cares” I’d most likely drop the entire thing and get on with Life. Why waste my time and energy over something that really doesn’t matter in the end.

If you think something is important enough that it needs fixing:

• find out who to contact with your issues, get a name and their contact information
• share your concerns directly with that person, staying calm, refusing to get angry
• ask them to share the steps they propose to prevent this problem from happening again

Best if done in person or by phone. If done by email ask them to respond to your email to let you know they received it. And thank them for a quick response.

I’m careful to not come across as rude or angry. And by asking to see their proposed resolution I am demonstrating my interest in truly fixing the problem.