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Choosing Your Medicare Prescription Drug Provider

By Winston Law Group in Medicare

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With the addition of prescription drug coverage under Medicare Part D in 2006, Medicare beneficiaries need to select an insurance company or other private company approved by Medicare to provide pharmaceuticals. How the provider is chosen will depend upon whether the beneficiary has original Medicare Part A and Part B coverage with independence in choosing its providers, or has joined a Medicare “Advantage Plan” under Part C, which is sometimes called a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO).

Individuals who have Medicare Part A and Part B coverage need to select a private insurer or company under Medicare Part D, sometimes called a “Prescription Drug Plan” or PDP, which offers a drug coverage that will meet its needs. Some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans are also part of this group. There are many private plans offering medications, and the marketing competition can be agressive in signing up beneficiaries.
If the person already has a Part D plan in place, the plan will probably attempt to keep the individual enrolled for the following year, and will otherwise announce the forthcoming annual premium in advance, no later than October of the current year. This will give the individual the opportunity to compare or switch if they’re not pleased with the service or cost. The federal Medicare agency, CMS, has announced that the average monthly premium for these plans this coming year is $31, even though drug coverage has increased and deductibles have been reduced under the Affordable Care Act.

There is an annual open enrollment period for the Medicare beneficiary to select the Part D provider for the coming year that begins October 15 and ends December 7. If a new plan is chosen, it will become effective on January 1. If an individual reaches age 65 or becomes eligible for Medicare this year or next year, or otherwise loses other drug coverage, other enrollment period rules apply. To join, you would go to the particular plan’s website or call, and eventually fill out an application to become enrolled.

The second option, a Medicare Advantage Plan under Part C, is the easier one for the member beneficiary to make a decision for, primarily because the decisions are limited to what the plan provides in its agreement with the member. The primary care physician or assistant at the HMO and PPO prescribes medications according to the plan terms, and the member only has to go to a pharmacy and pay the deductible as required under the plan.

If a Medicare beneficiary has independent coverage under Part A and Part B, and wants to join a HMO or PPO in order to obtain this type of drug coverage, then enrollment periods to join the HMO or PPO are limited under certain circumstances and there could be delays in obtaining coverage. An individual already in a Medicare Advantage Plan may wish to enroll under a Part D plan to obtain drug coverage under that plan rather than receiving the drug coverage under the HMO or PPO plan, but the individual will then be automatically disenrolled from the Advantage Plan and will receive services under standard Part A and Part B Medicare coverage.

The Medicare program has a website, http://www.medicare.gov/part-d, which provides comprehensive and reliable information. Be careful about so-called Medicare websites that do not have the URL “.gov” following the name because it might be a private company masquerading as an official Medicare website in a misleading way. The individual can also call 1-800-MEDICARE (1-800-633-4227).

Deciding whether to join a Part C or Part D plan for drug coverage, and what plan to join, can be confusing and time consuming, and individuals sometimes need assistance in making this selection. The Massachusetts Executive Office of Elder Affairs administers a program called “SHINE”, which trains counselors to assist current or potential Medicare beneficiaries in understanding options and choices under the Medicare pharmaceutical plans, as well as other medical care insurance choices, such as additional coverage under the so-called “Medigap” policies or some of the Commonwealth Care programs. A SHINE counselor can be found and scheduled by calling 1-800-AGE-INFO (1-800-243-4636).