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Medicare Prescription Drug Plan Pitfalls

  • Published: 2009-03-16 (Revised/Updated 2013-06-14) : Author: Jeremy Cockerill
  • Synopsis: Coverage for the New Medicare Prescription Drug Plan began on January 1 2006.

Quote: "Average monthly premiums, the annual deductible and the Out-Of-Pocket expenditure limits are expected to increase substantially every year."

Main Document

Coverage for the New Medicare Prescription Drug Plan began on January 1, 2006. Many seniors are feeling confused and concerned about this plan. Here are some of the pitfalls associated with this plan that Medicare eligible individuals will want to be aware of.

1. To join the Medicare Prescription Drug Plan (Medicare Part D) you must choose one Prescription Drug Plan from dozens of plans that are available (there are up to 50 plans in some states). Once you have chosen a plan you are "locked-in" until the enrollment period the following year.

2. Prescription Drug Plan (PDP) providers can change the particulars of their plans at any time with a short warning period for plan enrollees. These changes can include changes to which drugs are covered under the plan, which pharmacies are in the plans network, the charges associated with being a part of the plan and any other detail of the plan. These changes are at the discretion of the plan administrator and can be implemented at any time.

3. Once you have used $2250 worth of medications, you are 100% responsible for paying for the full amount of the drug until you reach the $5100 Catastrophic coverage limit. This range between $2250 and $5100 where you have to pay for 100% of your drug expenditures is known as the "donut hole".

4. At its greatest level of savings Medicare provides a 49% savings. This is only 7% better than the average savings experienced with a licensed Canadian pharmacy. This greatest savings occurs when people spend exactly $2250 on medication in one year (if you spend more or less than that the savings go down). That means that the greatest savings anyone on Medicare can experience above a Canadian pharmacy's average savings is $157.50 annually (7% of $2250) or $13.13 a month. Is $13 a month worth the risk of being "locked-in" to paying monthly premiums for a plan that can be switched on you at any time. (Note: Some people can save more than 49% if they spend well over $7100 per year. This is in the catastrophic coverage range).

5. If you do not sign up with at Medicare Prescription Drug Plan before May 15th, 2006 then you will be penalized with a cumulative 1% increase to your premiums for every month that you do not enroll in a plan after that date. This penalty is the governments way of forcing people, who do not really need a drug plan, into joining a plan and thus "subsidizing" the Medicare program. 1% of the average plan is 32 cents. So for every month after March 15th, 2006 that people are not in a plan, 32 cents will be added to your monthly premium or basically $1 for every 3 months you do not join. This penalty is however applied to your premium for all future monthly premiums. What many seniors groups are advocating is for people to wait until the deadline and then join the cheapest possible plan (approx. $10 monthly premium) and still order medicines from a licensed Canadian pharmacy like Universal Drugstore.

6. Average monthly premiums, the annual deductible and the Out-Of-Pocket expenditure limits are expected to increase substantially every year. This means you will be required to spend more and more money every year that you are part of the Medicare prescription plan.

7. Unless you are spending more than $800 on medications in 2006 there is no real savings with the Medicare Prescription Drug Plan. This required minimum amount of expenditure to experience savings will increase every year as the annual deductible, the monthly premiums and the Out-Of-Pocket expenditure limits are also increased every year.

8. It will be extremely time consuming and difficult to decipher myriad plans available in each state (all providing different coverage) and to try and figure out which plan is best for you personally. This will be twice as hard for a couple as the prescription drugs used by each person in the couple will be different and therefore they may require different plans. Even once a plan is chosen, there is still the risk of having the plan changed once you have made your decision and you are "locked-in".

9. Drug companies stand to make a ton of money off of the Medicare program. That is why they spent millions of dollars lobbying to get the legislation passed to make Medicare Part D a reality. It is also why Senator Bill Tauzin, a major advocate and motivating force behind getting the Medicare Prescription Drug Plan passed, is now a $2 million a year executive in Big Pharma's trade organization. Sen. John R. McCain (R-Ariz.) told the New York Times, "There's no doubt in my mind that the drug industry got everything it wanted and more," he said. "It perhaps should be called the 'Leave-No-Lobbyist-Behind Bill.' "

10. Plan providers have the ability to negotiate better drug pricing with the drug companies but they do not have to pass the savings on to the consumer or the government.

11. If you joined a Medicare Prescription Drug Plan (PDP) at any time after Dec 31, 2005 your coverage is not available to you until the first day of the following month.

12. Action is required to enroll in Medicare Part D (the Prescription Drug Plan part) unlike Medicare parts A and B which are automatic. You are not simply enrolled in the best plan for you. You have to wade through piles of information to decide what is best for you.

13. It is very difficult for persons who qualify for Medicare Part D to be sure if their drugs will be covered under their plans formulary (which can change at any time anyways.) A formulary is a list of drugs covered under particular drug plan.

14. You may not qualify for Medicare Prescription Drug Benefits if your annual income is too high or if you own too many assets.

15. Different plans will have different monthly premiums. The plan you need may have a really high monthly premium. $32.20 is simply the "predicted" average monthly premium.

16. Will your plan cover temporary-use medications (such as antibiotics or heartburn medications) or only chronic medications (such as drugs used for diabetes or heart conditions)

17. Plans with lower monthly premiums may have higher deductibles and co-pays.

18. Payments for drugs which are not on your plans formulary are not counted towards your Out-Of-Pocket expenditure limit.

19. Payments made by insurance plans do not count towards your Out-Of-Pocket expenditure limit

20. Is your regular pharmacy included in your plans network of pharmacies? Like many people you have most likely come to rely on a pharmacist that knows you and your medical conditions well. However, you may be forced to go to another pharmacy if your pharmacy is not included in your plans network of pharmacies.

21. How many days of medicine can you get at one time? Do you need to keep going back to the pharmacy every month or can you get 90 days

22. Will your drug be covered by your plan the next time you go into your pharmacy

23. Does your plan require step-up therapy or prior authorization? Step-up therapy means using drugs in a series of stages or steps in order to treat your condition. For example if you have GERD your plan may not cover Nexium unless you have previously tried ranitidine (Zantac) and/or omeprazole (Prilosec) first. Prior Authorization means that for certain drugs, your plan will not cover the drug without first reviewing your medical and drug history to determine if your treatment steps have been appropriate.

24. The Prescription Drug Plan providers stand to make a ton of money from the Medicare program (drug companies stand to make the biggest windfall).

25. Net cost to the government for Medicare Prescription Drug Benefits is estimated to go from $37.4 Billion in 2006 to $109.2 Billion in 2015 (estimate by Health and Human Services department). However, much higher estimates of the costs of Medicare Part D can also be found from non-government resources. Two years ago Congress reluctantly approved for the plan at a cost of no more than $395 billion dollars over 10 years. A few months later the cost ballooned to $534 billion and earlier this year it shot to $795 billion. Big Pharma is the biggest recipients of the increased dollars added to the costs of this program.

26. Plan may force you to use generics when you are used brand name medications and may not be able to tolerate generic versions.

27. The appeals process for some plans is very confusing and convoluted. (You can appeal to your plan if your drug is not covered.)

28. Many of the big pharmaceutical companies are now making anyone eligible for Medicare Part D, ineligible for their assistance programs. These companies are effectively forcing seniors into a "voluntary" program that may not be right for them. The AstraZeneca Foundation was the first to take such steps.

29. Many people are finding it difficult to obtain accurate, updated lists of what medications each plan will cover.

30. Medicare's own hotline can only answer general questions. For more specific questions you must contact each individual insurance provider.

31. Many people have waited 30 minutes or more when calling the Medicare hotline to get information that they need.

32. Rep. Dan Burton (R-Ind.) in a 60 Minutes segment televised said, "Seniors, when they find out what's in that bill, are going to be very angry. The problem is, they're not going to find out about it until after this next election."

Reference: Jeremy Cockerill is a licensed Canadian pharmacist who owns and operates one of the top Canadian mail-order pharmacies. Mr. Cockerill graduated from the Faculty of Pharmacy at the University of Manitoba with Honors in 1998. Mr. Cockerill recently won the 2005 Manager of the Year award from the Manitoba Customer Contact Association. Mr. Cockerill has been studying the new Medicare Prescription Drug plan since early 2005.


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