Part D Q&A Response Plus a New Part D Search Service!
By Terry Savage on November 12, 2024
My recent columns and newsletter about the changes in Medicare Part D generated so many terrific questions – most of which I couldn’t answer myself! – that I posed them to Thomas Dillon of JT Medicare Solutions (JT Medicare Solutions | Home). And, like you, the more I know, the more incredulous I become that seniors are put in this situation of difficult choices.
As a reminder, EVERYTHING about Part D changed this year, with the $2,000 out of pocket cap. You can be sure the insurers are figuring out how to make money despite the cap. So here are Thom’s answers to your intriguing questions – your real questions – and in no particular order.
I’ve also uncovered a great new help resource — www.heyMOE.com — (MOE stands for Medicare Open Enrollment). They do what the Medicare.gov website does — and much more! A real person reviews your situation, and since they search at least 15 pharmacies, they say 90% of those who use Hey MOE save money over their current plan. They’ll even help you find he best deal on uncovered drugs. It costs just $30 for this advice– and they do NOT SELL any policies, only help you choose! Plus, next year, they’ll automatically update your recommendations. Scroll down to the end of this page to read more about HeyMOE.com.
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Do all plans have roughly the same drugs, and the same NUMBER of drugs in their formularies?? Is that a competitive thing??
Thom’s Answer: Drug plans have VERY different formularies! Obviously having more drugs on their list gives you more depth but it’s meaningless unless you are prescribed those specific meds.
Strangely as drug plans age they get less competitive. The insurance companies remove drugs from their formulary over time. The newest plans tend to be the most competitive.
People think this is healthcare and it’s all the same. THIS IS A BUSINESS and the companies are trying to get your $$. They count on people’s inertia . They know discussing Medicare is right up there with root canals! People avoid it.
People, particularly older people HATE change. They keep what they have… because it’s easy.. but what they have changes — even if they keep the plan they had the year before, what it covers changes.
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What if your drug is not on any Part B formulary? Then, no cap? Where do you get it? Or if the generic doesn’t work for you?
Thom’s Answer: Not every plan covers every Drug. And yes, if you are taking a drug that no drug plan covers you will be paying more than the $2000 cap. It doesn’t sound right but that is the reality.
Medicare.gov is a great tool. At JT Medicare Solutions, we use a similar tool that gives us the ability to see all the drug plans available in your zip code and rank them by costs.
When we see a large amount over the $2000 cap we review the costs inside the plan. Did we list a Brand Name drug that has a generic equivalent?
This year we had some interesting drug plan evaluations for the drug Myrbetriq. Because Myrbetriq does have a generic equivalent but the plans that cover Myrbetriq DON’T cover the generic equivalent. It’s significantly cheaper to get the Brand name than the Generic. That’s never happened before.
Sometimes the drugs are covered at lower prices NOT using your drug plan at all but by using GoodRx or one of the other alternatives. We have found that about 20% of the time, with the more expensive drugs, that it is less expensive NOT using your plan.
Sometimes it’s something that seems insignificant like you choose capsules instead of tablets.
I’ve said this many times but Medicare Drug plans are only slightly less complicated than TIME TRAVEL machines– and this is the slimmed down version of Medicare Drug plans! In 2024, Medicare Drug plans had 4 phases and 6 tier levels. In 2025 they only have 3 phases and 6 tier levels. But it’s still not much easier for the average consumer!
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What drugs does Medicare cover – and what falls under Part D?
Thom’s Answer: Medicare makes 2 different categories for Drugs:
1) Drugs you get at a pharmacy and take home and put in your medicine cabinet and
2) Drugs received in a professional setting, such as an injection or an infusion, chemo therapy and dialysis. These drugs are all covered under Medicare Part B and NOT Medicare Part D (The D stands for Drug plans). In the case of drugs received in a professional setting, if you only have Medicare Parts A & B, you will be responsible for 20% of the drug costs with no cap or limit. If you have a Medicare Supplement, the Supplement might cover the 20% drug after the Part B deductible is paid ($285 in 2025) .
Now, if the drug is not covered at all in your plan formulary – even a generic version — then you must find a way to pay the entire cost – out of pocket. That could involve pleading with the drug company for a special deal, or using a card such as Good RX.
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Are all drug formularies equally broad, have roughly the same number of drugs – or does the zero cost Wellcare plan have a particularly limited drug formulary – thus creating a problem if you are later prescribed another drug? Should you try to “count” the number of drugs in the formulary for the plan you choose?
Thom’s Answer: Drug plans have specific drugs that they cover. Counting the # of drugs will give you broader possible coverage — but we still can’t know what drug we might or might not be prescribed. We are at risk of getting a new non-covered prescription each time we visit the Dr. Most Dr’s are very aware of the high cost of drugs and will usually work with their patients to find a 2nd or a 3rd drug that might be covered until we can change plans next year.
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If you’re taking an expensive drug under a Part D and reach the cap, what happens? Do you just get your prescription filled at no cost? Can they switch you to a generic??
Thom’s Answer: Once you hit the $2000 your copay goes to $0.00. Drug plans can’t change your prescriptions. Only your doctor can do that. BUT, generic drugs are usually significantly less expensive (But not always).
Note: The $2000 cap only applies to the money you spend on drugs and NOT the drug plan’s monthly premium. And the $2000 cap only applies to covered Medicare Drugs. Not all drugs are covered.
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Someone asked about star ratings for Part D plans. What could possibly be the difference if it’s just a matter of getting your drugs? Do star ratings matter in part D?
Thom’s Answer: The star rating is the evaluation the plan gets from its own members for the previous year. Soooo… most of us never interact with the Insurance company of our drug plan. We mostly interact with the pharmacy.. and they are a separate company.
BUT.. if you need to get a FORMULARY EXCEPTION you do have to go through the Insurance company. I’d say that 90% of the time, the ratings are moot. BUT the people that did rate the plan poorly probably had a reason. Insurance companies hate to grant exceptions, and they make you wait… so they get lower ratings.
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A Reader complains: We have no way to tell which plan has the widest formulary, one that would be more likely to cover a new drug. Do more expensive Part D plans have a larger formulary than less costly plans? I feel like I am buying a pig in a poke so to speak. What if we bought auto insurance this way, have the wreck and then find out if is of the type covered.It’s very frustrating.
Thom’s response: Great question! And unfortunately… they hit the nail right on the head.
We can’t know what drugs we “might” be prescribed next year. And because NO drug plan covers all the possible drugs that could or might be prescribed.. every Medicare beneficiary is taking a big risk beginning in January of the New Year.
Because we can only change drug plans during the Annual Enrollment Period (AEP) or when we move out of the service area (Moving is usually not a good option). The next time we go to the doctor we might get prescribed a drug NOT covered by our current plan and there is nothing we can do except wait till next year.
Fortunately most Dr’s are very aware of this and most Dr’s know that not every Drug plan is covered under every Medicare Drug Plan so usually Dr’s will give a 2nd drug that isn’t so expensive.. But sometimes there is only 1 drug for the condition — and if it isn’t covered we are going to pay a lot till the next year.
This is why I’m so busy this time of year. I stress the need for annual reviews for drug plans because rarely does a person’s drug list stay the same from 1 year to the next. And remember the drug companies and the insurance companies are trying to make $$ from you! They will try and charge you the most they can.
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Here’s a frightening story, which I will copy in full – and follow with Thom’s response:
“I read with interest your column on Medicare Part D drug coverage. This situation is even more complicated and unfair for residents of Long Term Care facilities and the family members who oversee their care.
My husband’s Long Term Care facility orders all prescriptions from its on-site pharmacy, and family has no choice about this. Further, the pharmacy is not a “preferred pharmacy” under any Part D plan. As I have done further research, I have discovered that a “Long Term Care Pharmacy” is a separate category of pharmacy, and it appears that no LTC Pharmacy is a preferred pharmacy.
And your suggestion to see if my husband’s drugs are included in our Part D plan is great – except that I do not know what drugs he will need in the coming year. This past year, he developed a pressure wound, and the ointments used to treat that were very expensive – and I knew nothing about it until one month when I received a pharmacy bill of $1,400.
Something should be done to shield nursing home patients from exorbitant drug costs when there are so many cheaper alternatives available. I am already paying $17,000/ month for his care, and adding a monthly drug cost of several hundred dollars doesn’t help.”
Thom’s response:
Long term care facilities exist in their own world with their own rules. I have gone through this more times than I want to remember.
I have contacted.. maybe 20 different facilities.. and I’ve never received a return call. They seem to create their own pharmacies and their own costs (I think they become profit sources). I’ve never been able get any information about what pharmacy they use and if it was a preferred or Standard pharmacy. Since I’m not a resident or a relative of a resident they were aggressive in their lack of information provided.
The $2000 cap is going to help.. but the plan premiums are going to rise.
TERRY’s NOTE: This report was posted on 11/12/24. As more questions of general interest come in to my blog I will get answers and post them here, updating this report.
Again, I urge EVERY SENIOR to review their Part D drug plan — whether a stand-alone plan or your coverage inside a Medicare Advantage plan.
Start at Medicare.gov using the plan finder tool where you can input your current meds.
If you need help, go to www.ShipHelp.org — the state-by-state website of trusted help and advice.
Don’t delay. You only have until December 7 to make changes — After that you’re STUCK for all of 1015!
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READ ABOUT www.HeyMOE.com — a personalized Part D drug search service — NOT a sales organization!
I’ve always assumed that the online Part D search engine at Medicare.gov was the best place to find the best Part D plan – one that covers your drugs at your pharmacies for the least cost.
Well, wait. I have another resource for you. It costs $30 – but it has demonstrated the ability to find lower cost plans and gives human advice on getting some of the most expensive drugs covered – even if your original Medicare search says otherwise!
Michael Caughill of www.HeyMOE.com (stands for Medicare Open Enrollment) says that almost every time a client does an online search, their individualized review process turns up savings. It can come because their search includes at least 15 pharmacies, while the Medicare.gov search is limited to five. Or because they know that if you list your drugs on a monthly basis vs a 90 day supply, an existing plan may offer coverage.
These little “quirks” in search language can result in huge savings. And for those who truly have prescriptions that are not covered at all by Medicare, they offer advice on pharmacy cards and manufacturers special programs.
Plus, once you’ve signed in, you’ll automatically get an email reminder review for next year’s inevitable drug changes.
HeyMoe.com does not SELL drug plans, does not get a commission. They don’t even ask for your phone number. Instead, you’ll get an emailed printout of the best plans for you – and phone numbers and websites to do your own signup.
HeyMoe.com figured out a better computer program combined with human oversight and advice to guide you through a money-savings Part D process. It’s worth the $30 if you have a complicated drug situation, uncovered prescriptions, or just need some intelligent hand-holding. And that’s The Savage Truth!
