Medicare Tips: 7 Ways To Manage Drug Costs
For Americans on Medicare who need expensive drugs, drug costs can get high. Unlike many private health insurance plans, Medicare Part D, which is Medicare’s prescription drug coverage, has no limit on personal spending each year.
In fact, in 2019, nearly 1.5 million people enrolled in Medicare Part D spent more than the catastrophic coverage threshold (which is $ 6,550 in 2021) on their drugs, according to a Health Policy study. non-profit Kaiser Family Foundation.
Once you reach the catastrophic coverage threshold for prescription drug expenses, you remain responsible for the coinsurance or co-pay of your drugs, regardless of how much you have to spend. If your medications are expensive, it can cost you a lot of money by the end of the year.
For example, for drugs used to treat cancer, hepatitis C, multiple sclerosis and rheumatoid arthritis, the median annual out-of-pocket expenditure in 2019 ranged from $ 2,622 for a hepatitis C drug to $ 16,551 for a leukemia drug, according to another KFF analysis.
Medicines administered by a doctor are covered by Part B, which has no payment limit under the original health insurance. Biogen’s new Alzheimer’s drug, Aduhelm, would fall under Plan B if approved for Medicare; it has a list price of $ 56,000 per year and could cost Medicare beneficiaries $ 11,500 per year in coinsurance.
If you are facing high prescription costs on Medicare, there are strategies that can help you lower the bill. Here are a few things to try:
1. Know your medications
Understanding how your medications are covered can help lower your costs. Here’s what to consider:
- Use the plan finder: When purchasing Medicare or Medicare Advantage plans, be sure to enter your prescription drugs in Medicare Plan Finder to see how the plans cover them. (Medicare Advantage is an all-in-one alternative to Original Medicare, offered by private insurers, which typically includes Part D drug coverage.)
- Get a Medigap plan: If you take medications that you do not administer to yourself (those that you get from a doctor’s office or infusion center), they will be covered by Medicare Part B. If you have Medicare Original, you can purchase Medicare supplemental insurance (Medigap ) which will contribute to the co-insurance and co-payments of Part B.
- Compare with Medicare Advantage plans: Although Part B of the original Medicare does not have a cap, Medicare Advantage plans are required by law to limit the amount you can spend per year. Ask yourself if Medicare Advantage would reduce the cost of your medications.
Some insurers also differ on where they cover certain drugs – under Medicare Part B or Part D – so it’s worth noting where yours lands.
“Under Part B, most people have some form of supplemental coverage that helps cover cost sharing, so they’re not completely exposed to the cost sharing that can be under Part D. , which does not have a hard cap. out of pocket costs, ”says Gretchen Jacobson, vice president of Medicare for the Commonwealth Fund, a private foundation focused on promoting a strong health care system.
2. Compare pharmacies
Drugs can cost different amounts depending on the pharmacy. Use a site like GoodRx to compare the prices of a drug at local pharmacies, or call a few pharmacies to ask how much your prescription will cost.
Likewise, research your health insurance plan’s favorite pharmacies to make sure you are buying from one. Or you may be able to get a lower price through your insurer’s mail order pharmacy.
“Insurers develop pharmacy networks just as they develop physician networks,” explains Jacobson. “They benefit from a preferential rate. “
3. Appeal your plan’s coverage
In some cases, health insurance companies may require people to try an alternative drug or change coverage of the drug from Medicare Part B to Part D by asking people to give themselves the drug at residence. You can appeal this decision and ask your plan to continue to cover your brand-name drug (rather than an alternative) or to continue to cover it under Part B.
(Why would you prefer Part B coverage? Part B has a payment cap under Medicare Advantage, or you can purchase a Medigap plan to help cover coinsurance and co-pay under Original Medicare.)
If a newly prescribed drug is not covered by your plan, you can request a formulary exception, which may result in your drug being covered or covered at a lower price. This may take some time – your medical team will need to provide documentation that the medicine is medically necessary.
“What is striking and concerning is that relatively few denials are appealed,” says Jacobson. “A lot of people may not realize that they can appeal coverage determinations, and most coverage determinations that are appealed are in fact overturned.”
4. Talk to your infusion site
If you receive an infused drug at a medical facility or health center, talk to your provider about the success they have had with health insurance companies. Their billing support staff and social work department may have good information on which insurance plans are best suited to cover their services and medications.
“They’re used to it,” says Katy Votava, president and founder of Goodcare, a consulting firm specializing in the health insurance economy. “Rely on your suppliers. “
5. Try the generic
This is old advice, but it’s always good to try: If there is a cheaper version of the medicine that treats your condition, ask your doctor if this might be a suitable alternative.
If you are starting a new medicine, you may be able to try samples at your doctor’s office first before getting a full prescription. This way you can see if the medicine is working for you.
6. Check drug assistance programs
“Almost all of the big pharmaceutical companies have a drug assistance program,” Jacobson explains. These programs can provide financial assistance to eligible individuals. You can search for your medications on the Medicare Programs Finder to see if there is an assistance program.
Your state may also offer a drug assistance program. Medicare also has a search tool for these.
People with limited resources and income may be eligible for Medicare’s Supplemental Assistance Program, which covers costs such as monthly premiums, deductibles, and prescription copayments as part of a health care plan. Medicare prescription drugs.
7. Store plans
If you are considering switching to a Medicare Advantage plan, don’t let Part D be a secondary consideration.
“Often when people are trying to decide whether to opt for Medicare Advantage over traditional Medicare, they weigh other trade-offs like the provider network and the spending cap for parts A and B,” says Votava. “But drug coverage can be a very important part of people’s decisions. “
For example, some Part D plans provide additional coverage during the “donut hole” or gap in coverage that exists after you reach a certain threshold for out-of-pocket expenses but have not yet reached coverage. catastrophic.
When comparing plans, be sure to check each drug plan’s formulary to see if your current medications are covered. Also, keep an eye out for limits on how much of a particular drug a plan will pay for in a year, or requirements that you try a cheaper drug before you get approved for a more expensive drug.
“You have to hunt and peck,” Votava says. “But being a shrewd, intelligent shopper and spending the time is well worth it.”
More from NerdWallet
Kate Ashford writes for NerdWallet. Email: [email protected] Twitter: @kateashford.
The article 7 Ways to Manage Medicare Drug Costs originally appeared on NerdWallet.