Looking for a Medicare Part D drug plan that will cost you the least in 2010 and cover all or most of your prescription drugs? This guide provides a direct route to that information by taking you step by step through Medicare’s Prescription Drug Plan Finder, a useful online tool that allows you to compare many drug plans head to head to find your best deal. The plan finder does the math for you, so that you can see your likely out-of-pocket costs—premium, deductible and copays for the specific drugs you use—throughout the year.
Use this guide if:
• You’re currently enrolled in a Part D plan and want to compare it with other plan options available in 2010. (Open enrollment runs from Nov. 15 through Dec. 31, 2009 and special enrollment periods are available in some circumstances at other times of the year.) Plans will change their costs and benefits and offer new choices for 2010, so comparing plans is essential to making the right decision for next year.
• You’re new to Medicare, so you’re considering a Part D plan for the first time and want to find the plan that’s best for you out of a large number of choices.
• You’re helping a family member or friend who is now in a Part D plan or looking to join one.
The following process for comparing drug coverage is the same for “stand-alone” plans (the kind that cover only prescription drugs and are mainly used by people enrolled in traditional Medicare), for Medicare Advantage plans (which usually cover both medical and drug benefits in one package) and for Special Needs plans (which cover only certain groups of people—those who receive Medicaid, live in nursing homes or have certain chronic illnesses). However, if you’re considering a Medicare Advantage or Special Needs plan, you need to compare those plans’ costs and benefits for medical services as well as for drug coverage. (To do that, go to “Compare Health Plans” on the homepage of the Medicare website.)
Important: Before you start, make a list of the exact names of all the prescription drugs you use, plus their dosages and how often you take them. This is an essential step for finding out how much you’ll pay out of pocket under each plan in 2010.
Print this guide so that you can use it as you go. Each step refers to each successive page you see onscreen.
1. Go to www.medicare.gov, click on the "Resource Locator" tab at the top of the page, and select "Drug Plans."
2. Click on Find & Compare Plans.
3. IGNORE “Begin Personalized Search.” Click on Begin General Search.
4. Enter ZIP Code. IGNORE age and health status boxes. Answer the next three questions on this page. Click on Continue. (However, if you qualify for Extra Help in paying for your drugs, click Yes and go now to the “Other Kinds of Searches” section below in this guide for special steps on how to proceed from here.)
5. On the next page (“Review Current Coverage and Consider Options”), click on Continue.
6. Click on Enter My Drugs.
7. Enter your first drug name in the box and click on Search for Drug (or click on the alphabetical drug list to locate it). If another box appears with several drug names, click to highlight the one that’s yours. Click on Add Selected to Your Drug List. The drug will appear in a list box. Repeat for each drug you use. When all your drugs are on the list, click on the little box below the list to remove the check mark. (You can find out how to lower your drug costs at a later stage.) Click on Continue.
8. You will now see your list of drugs with dosages and quantities, which you can change to match your own. This is the most important step in the whole process. Plug in your exact dosage on the pull-down list alongside each drug name. Put in the exact quantities you take per month—for example, if you take two pills a day, change the default from 30 to 60. If you take a drug less frequently—say once a week or once every two months—use the pull-down lists to make that change. (If you’re not sure which dosage or frequency to enter, click the link provided to seek help, just above your drug list.) Click on Continue.
9. You can now save this drug list to avoid having to enter it all over again if you lose it or want to use it for a later search. Enter a password date that’s easy to remember (such as your birthday) and then click on Continue. You will then be given an ID number to use when retrieving the list on a future occasion. Make a note of the number and click Continue. If you don’t want to save the list, click on Skip This Step.
10. Click on No when invited to “select favorite pharmacies, and then click on Continue. (Selecting a specific pharmacy at this stage is unnecessary and may prevent you from finding the plans that are the least expensive for your needs.)
11. You will now see a list of five of the Medicare stand-alone drug plans available in your area. (To see drug coverage under Medicare Advantage plans or Special Needs plans, click on those links at the top of the page. To see plan details for 2009, instead of 2010, click on “Click here to display 2009 plan data” just above the list.) In each case, to see more or all of the plans in the category you choose, click on the plans per page links below the list. The first plan shown is the least expensive overall, reflecting an estimate of your likely out-of-pocket costs for all of 2010. The plans that follow are in ascending order of expense. The columns to the right of each plan’s name provide the following information:
• Estimated annual cost using retail pharmacy: This dollar amount shows your likely total out-of-pocket expenses for the whole year if you buy your drugs from the preferred retail pharmacies in this plan’s network. The dollar amount includes the plan’s fixed costs (monthly premium, annual deductible) and what you’ll pay for the drugs you’ve entered, including your expenses in the “doughnut hole” and the catastrophic coverage period if your drug costs go that high.
• Estimated annual cost using mail order pharmacy: This dollar amount shows your total out-of-pocket expenses for the whole year (including all the costs explained above) if you use this plan’s mail order option, which requires ordering 90-day supplies at a time and is often less expensive. (No information in this column means that the plan doesn’t offer a mail order service.)
• Monthly drug premium: What you pay each month for drug coverage from this plan.
• Annual deductible: What you pay for your drugs out of pocket at the beginning of the year (or whenever you join a Medicare drug plan) before coverage kicks in. $0.00 means the plan has no deductible.
• Coverage in the gap: This shows whether the plan covers any drugs in the doughnut hole, the gap in coverage in the middle of the Medicare drug benefit. If your drug costs are high enough to put you in the gap, you’d then normally pay 100 percent of your costs until you reach an out-of-pocket spending limit ($4,550 in 2010). No “stand-alone” drug plan in 2010 offers full coverage in the gap (meaning all the brand-name and generic drugs it normally covers), and only a few Medicare Advantage plans in some counties do so. But many plans offer coverage for “all” or “many” or “some” or “few” drugs in the gap, usually only generics. Here’s what these terms mean:
• all = 100 percent of generics on the plan’s formulary
• many = 65 percent to 99 percent
• some = 10 percent to 64 percent
• few = under 10 percent (but at least 15 drug products)
• Drug Restriction: If there is a “Yes” in this column, it means you must probably ask the plan’s permission before it will cover one or more of your drugs. Clicking on the Yes will open a page that tells you which of your drugs has a restriction—such as prior authorization, quantity limits or step therapy. These restrictions are explained under “Things to Keep in Mind” farther on in this guide.
• Number of network pharmacies: Clicking on the number in this column brings up a list of the pharmacies in your immediate area that are within this plan’s pharmacy network—meaning that they will accept your plan’s coverage when filling your prescriptions. You can alter the radius of miles to see more pharmacies a farther distance away.
12. The list of plans described in step 11 gives only a general idea of costs. To compare plans properly and make an informed choice between them, you need to look at the details of each plan—or at least those of the four or five plans that head the list. To start, click on the name of the first plan at the top of the left column. You will now see a page headed “Plan Drug Details,” which gives a lot of information about your drugs under the plan you have selected, including the following:
• Plan ratings: This rates the plan’s performance on certain questions—such as how good the plan’s customer service is, how easy it is to get prescriptions filled, how well it handles complaints, etc.—based on Medicare reviews and consumer feedback. The plan is rated on a scale of one to five stars: one (poor), two (fair), three (good), four (very good), five (excellent).
• Your fixed costs: Monthly premiums and annual deductible (if any).
• Total annual out-of-pocket costs (including premium) in two amounts: One for drugs bought from preferred network pharmacies (30-day supplies) and the other for drugs ordered by mail (90-day supplies). The column farthest to the right shows your out-of-pocket costs for the rest of the year if you’re comparing plans partway through the year.
• Drug coverage information: This gives a list of the drugs you have selected and the “tier” (level of charges) that applies to each drug. Tiers often range from 1 (least-expensive copay) to 4 or 5 (most-expensive copays). Some plans charge a straight percentage of the cost of all their covered drugs, instead of tiers. (To see the plan’s actual copays, click on View Important Notes and Benefit Summary at the left-hand top of the page.) The columns farther to the right show whether there are any restrictions on each drug. (For what these restrictions mean, see the “Things to Keep in Mind” section below in this guide.) If any of your drugs are not covered under this plan, it will be shown as “NOT ON FORMULARY” in the “Tier (Formulary Status)” column.
• Monthly drug cost details at network pharmacies: This chart shows what each of your drugs, if purchased from a retail pharmacy in the plan’s network, will cost on a monthly basis at four different levels of drug coverage:
• during the period before your deductible (if any) is met;
• during the initial coverage period (before the amounts spent by you and the plan for your drugs during the year reach the 2010 limit of $2,830);
• during the coverage gap, also known as the doughnut hole, when you pay 100 percent for your drugs, (unless this plan offers coverage in the gap or your costs are not high enough to reach it) until your out-of-pocket costs (not including premiums) reach the 2010 limit of $4,550 since the beginning of the year;
• during the catastrophic coverage period when you pay low copays, or no more than five percent of the cost of your drugs, after getting out of the gap until the end of the year.
The left column shows the full price of your drugs under this plan. This is what you pay until your annual deductible is met (if your plan has one) and during the coverage gap (unless the plan covers some of your drugs in the gap). If the full price also appears in the “initial coverage level” column, it usually means the plan doesn’t cover this drug at all. But this can also happen if the drug’s full price is less than the copay would be—in this case the plan is charging you the lesser of the two prices. If you see a copay instead of the full price in the “coverage gap” column, it means the plan covers this drug in the gap.
• Monthly drug cost details at mail order pharmacy: To see a similar chart showing the monthly cost of your drugs if purchased by mail order, click on the Show Information button on the right side. If the plan does not offer mail order, this option is missing from the page.
• My pharmacies—no pharmacies selected: Prices for your drugs may vary at different pharmacies in your plan’s network. See below in this guide under “Other Searches” for ways to see these different prices.
• Total monthly cost estimator for network pharmacies: The bar chart at the end of this page is a useful way to see at a glance how your out-of-pocket expenses are likely to change from month to month under this plan and whether you’ll fall into the doughnut hole. In essence, it’s a personalized profile of what you can expect to pay (premiums plus copays for the specific drugs you take) each month through the year. If the plan has no deductible and your drug costs are too low to put you into the doughnut hole, the cost for each month of the year will be the same. Otherwise, you’ll see different monthly amounts according to coverage level. For a detailed breakdown month by month, click on Show explanation of these costs.
• Total monthly cost estimator for mail order pharmacy: Click on the Show Information button to see a bar chart showing your likely out-of-pocket expenses month by month if you use the plan’s mail order option. This works in the same way as the cost chart for drugs purchased at retail pharmacies explained above. If the plan doesn’t offer mail order, this chart is omitted from the page.
• Whether this plan allows you to fill prescriptions anywhere in the United States: Click on View Important Notes and Benefit Summary at the top of the page. This information is useful for people who spend part of the year away from home in another state.
• How this plan’s costs in 2010 compare with its costs for 2009: To see last year’s costs, select Click here to display 2009 plan data at the top of the “Plan Drug Details” page. This comparison is shown only until Dec. 31, 2009.
13. Once you’ve viewed one plan’s details, click on your browser’s back button to return to the main list of plans and repeat the process above for each plan you want to consider. The main goal is to find one that covers all of your drugs for the least expense and with the fewest restrictions. In the rare case of a drug not being covered by any plan, you’ll have to make a decision based on the rest of your drugs. Once you’ve joined a plan, you can ask your doctor to support you in an appeal for coverage of a drug not on the plan’s formulary, if your doctor thinks it necessary for your medical condition. Or, with your doctor’s advice, you may be able to switch to a similar drug that is on the plan’s formulary.
14. If you wish to compare plans side by side, you can do this for three plans at a time. Check three boxes in the left column of the main plan list and click on the Compare up to 3 Plans button at the top of the list. Be aware, however, that these versions do not give as complete a picture as the full plan detail pages do. For example, restrictions on certain drugs (such as requirements for prior authorization, step therapy or quantity limits, as explained below under “Things to Keep in Mind”) are missing from these side-by-side lists.
OTHER KINDS OF SEARCHES
Here’s how to use the Medicare Prescription Drug Plan Finder to drill down for more specific information—ways to lower your out-of-pocket costs, find convenient pharmacies in plan networks, compare prices between network pharmacies, and see what you’re likely to pay over the year if you qualify for Extra Help:
Lowering your out-of-pocket costs
You may be able to lower the costs you’ve seen in your search so far, depending on the drugs you’ve selected. This is another very important step in the process.
• On the main plan list, click on Lower this cost in the second column of the plan that most interests you. (Or click on a similar link that appears at the top of the plan’s details page.)
• You now see a page headed “Ways to Further Lower My Cost Share.” If any of your drugs have a generic or a lower-priced brand-name drug that might be equally effective for your medical condition, it is shown in the third column. The monthly costs for these alternative drugs are shown in the fourth column. Such savings are sometimes substantial. For example, choosing the generic version of a brand-name drug could drop your copay to the Tier 1 level. Some plans charge nothing for drugs in this tier.
• To find the name of a generic or lower-cost drug indicated in the third column, click on the link. You now see another table showing the name of the drug, its copay under this plan and (where appropriate) the dosage and quantities you need to take for this drug to be as effective as your prescribed drug.
• To see how these alternative drugs would change your overall costs, enter their names on the list of your drugs now showing on the main drug list page—and don’t forget to remove the existing ones. Also alter the dosage and quantity if they’re different from the previous drugs you entered. Click Continue. Once again, the main drug plan list will appear—but this time, it will probably show different plans as the least expensive for your drugs. (Some plans may cover the generic version of your drug but not the brand-name original.) So it’s worth comparing several plans again based on these lower-cost drugs.
• If you find worthwhile savings by doing this search, discuss the results with your doctor. He or she can tell you if these lower-cost drugs would work as well for your health condition as the ones originally prescribed.
• What if there are no lower-cost alternatives for any of your prescribed brand-name drugs? In that case, you may find it useful to look at the fifth column of the chart that appears when you click on Lower My Cost Share. This column, headed “Pharmaceutical Assistance Program” shows either a “Yes” or “No” for each of your drugs. “Yes” means that the manufacturer of the drug provides it free or at low cost for people who qualify. Clicking on Yes takes you directly to the manufacturer’s patient assistance program website, where you can see at a glance the eligibility criteria (for example, income limits) and information on how to apply. These programs are a useful way to obtain costly drugs during the Part D coverage gap for people whose incomes are limited but too high to qualify for Extra Help.
• Another source of assistance is featured on the “Lower My Cost Share” page. Look above the chart and click on the here link to see if a state pharmacy assistance program (SPAP) is available in your state. If there is, the link takes you directly to details and contact information for that program. In some states, the income limits for SPAPs are higher than those for Part D’s Extra Help program, and some have no asset tests.
Note: If you click on the links above and nothing happens, you may have to disable your pop-up blocker to access the linked pages.
Finding convenient retail pharmacies
Each Part D plan has its own network of retail pharmacies, all of which accept the plan’s card. Choosing a plan that has at least one in-network pharmacy within easy reach of your home is not just a question of convenience. Unless you fill your prescriptions at pharmacies that accept your plan’s card, you’ll pay more than you should for them—perhaps even full price—except in certain unavoidable circumstances.
Most plans have a wide selection of pharmacies in their networks, including small independent ones as well as large chains. Individual pharmacies may be in the networks of many Part D plans.
To find which pharmacies in your area are in any plan’s network, go to the details page for that plan. Click on View Pharmacy Network on the menu at the top of the page. (If nothing happens, turn off your pop-up blocker.) The pharmacy names that appear onscreen are those in this plan’s network within a certain distance of your ZIP Code. To see more network pharmacies farther away, alter the distance shown in the box and click on Find Pharmacies.
The column headed “Pharmacy Type” may give more precise information about some of these pharmacies—for example, if they supply home infusion drugs (those that can be injected at home) or specialist drugs (those that require special handling, such as some anticancer drugs). The phrase “long-term care” indicates a pharmacy that supplies specially packaged drugs to nursing homes and other long-term care facilities.
The column headed “Preferred” indicates whether any of these pharmacies offer special terms to this plan, such as discounted dispensing fees. Your drugs may cost a little less at preferred pharmacies. But in most cases, you’ll see “Not Applicable” in this column. It just means that you would pay the same amount for your share of the cost of your prescription at all of the pharmacies in this plan’s network.
If the plan you’re considering seems to have “low” overall costs, but has no in-network pharmacies convenient to you, look at other plans with in-network pharmacies closer to where you live. In some cases, cost has to be weighed against convenience.
Comparing prices at different in-network pharmacies
Preferred pharmacies within a single plan’s network may charge different prices for your drugs. The plan finder allows you to compare them—though bear in mind that prices can change throughout the year. If a plan charges fixed copays for your drugs, you’ll pay the same amount at any network pharmacy, at least during the initial coverage period. But variations in pharmacy prices will affect you in the deductible and coverage gap (when you pay full price) or if the plan requires you to pay coinsurance (a percentage of the drug’s cost) instead of a flat copay. Here’s how to use the plan finder to compare prices at different pharmacies:
• Make a note of the names of any pharmacies you’re likely to use that are in the network of a particular plan, as explained in the previous section.
• Return to the main plan list. Scroll down to the “My Pharmacies” section and click on Change Pharmacy Selection.
• You now see a list of all the pharmacies in your area—not just those used by a particular plan. (You may have to click on the All one page link to see all the ones in your area, and expand the mileage radius as explained in the previous section.) Select one or two of the pharmacies that you’ve noted down, by clicking on the small box alongside. Click on Continue.
• Return to the details page of the plan you’re interested in. The out-of-pocket costs for your drugs at the selected pharmacy (or pharmacies) now appear in the “Annual Drug Costs” and “Monthly Drug Costs” fields, under the pharmacy name(s) you’ve chosen.
• If any pharmacy you select is not in your plan’s network, you’ll see a warning notice saying: “You’ll pay 100% of the cost for drugs at this pharmacy because it is not in the plan’s network.”
• Return to the mail plan list and repeat this process to see prices at other pharmacies in this or another plan’s network.
Finding out what you’ll pay for your drugs if you qualify for Extra Help
Extra Help is a special program within Part D that allows people with limited incomes under a certain level to pay far less for prescription drug coverage than people pay in the regular program. If you qualify for full Extra Help, you pay no premiums or deductibles and only small copays for your medicines. If you qualify for partial Extra Help, you pay reduced premiums and deductibles and 15 percent of the cost of your meds. Whichever you qualify for, you get continuous coverage all year—no doughnut hole. For more information on eligibility and benefits, click here.
If you qualify for Extra Help, you still need to pick a plan that covers your drugs. Using Medicare’s drug plan finder, you can see what your 2010 out-of-pocket expenses will be for your drugs under any Part D plan in your area. Here’s how:
• Go to www.medicare.gov and click on Compare Drug Plans.
• Click on Find & Compare Plans.
• Click on Begin General Search.
• Enter ZIP Code. Ignore age and health status boxes. Answer the next three questions by clicking on those that apply to you. It’s important to answer the third question—about whether you got a letter from Medicare or the Social Security Administration about Extra Help—accurately. Depending on your answer, you’ll see other questions appear. Answering these questions determines whether you qualify for full or partial Extra Help and enables you to see how much you’d pay out of pocket under any drug plan.
• Now follow steps 5 through 15 above in the general instructions for navigating the plan finder. The difference is that the cost information you see—premium, deductible and copays—will reflect the kind of Extra Help you’re entitled to. Note that only a certain number of plans offer zero premiums for people who qualify for full Extra Help. You will see which plans do and which plans, instead, charge reduced premiums.
THINGS TO KEEP IN MIND
• The Medicare drug plan finder is a sophisticated and useful computer tool, but not free of glitches and errors. When you’ve found the plan that looks best, check its details with the company that provides it.
• Additional help: If you still have difficulty locating the information you need from the online plan finder, you can call Medicare’s help line at 1-800-633-4227 and talk to a customer service representative who will do the same search and send you a printout of the results. If you need personal help finding a plan, especially if you qualify for Extra Help, call your state health insurance information program (SHIP) which provides free, expert help from a trained counselor. To find contact information for your SHIP, go to www.shiptalk.org. Whether you call Medicare or your SHIP, you can ask for the help of an interpreter if English is not your first language.
• Out-of-pocket costs: The premiums and deductibles shown on the plan finder are those offered for 2010 and cannot be changed until the end of the year. But plans are allowed by law to alter the prices they charge for drugs on a weekly basis throughout the year. They can also switch drugs from one tier of charges to another (if Medicare approves)—which could raise or lower copays. Plans must notify enrollees of such changes 60 days in advance. However, if you are already taking a drug that is switched to a higher tier, your original copay will stay the same for the remainder of the year.
• Drug coverage restrictions: Most plans set restrictions, which are intended to hold down costs, on certain drugs—as indicated under the “Drug Coverage Information” section of the plan details page. Here’s what each of those restrictions means:
• Prior Authorization: Before the plan will cover a drug, your doctor must inform the plan that it is necessary to your medical condition to take this drug instead of a similar one that is less expensive.
• Step Therapy: The plan requires you to first try a similar drug that has been shown effective in treating the same condition but is less expensive than the one prescribed. Again, your doctor can ask the plan to grant an exception to its policy by stating that you’ve already tried less-expensive drugs, which haven’t worked, or that the prescribed drug is necessary to your health.
• Quantity Limits: This does NOT mean that your supply of drugs will be cut off after a certain time. It means that the plan will not automatically cover a drug that is prescribed at a higher dosage or more frequently than the plan considers normal for your medical condition. For example, if a “normal” dose of Lipitor is considered to be 10 mg taken once a day, you must ask the plan’s permission to receive coverage for a higher dosage/frequency. Note that the plan finder shows a “Yes” for a quantity limit restriction on a particular drug, even if your own dosage/frequency is equal to or less than the plan’s limit—and in this case you will not have to seek the plan’s permission for coverage. If you’re prescribed a higher dosage/frequency than the limit, your doctor can request an exception by showing that the prescribed dosage is necessary for your health.
Bear in mind that different plans don’t impose the same restrictions on the same drugs. So by comparing plans, you may be able to find at least one that has no restrictions on any of your drugs.
If you enroll in a plan that restricts any of your drugs, it’s worth asking your doctor if an alternative drug that isn’t restricted (such as a generic version of your brand-name drug) would work as well for you. Otherwise, with your doctor’s help, you can ask the plan for an exception. Look at your plan’s information packet, or go to its website, for information on how to request an exception. If the plan denies an exception, you can appeal the decision—again, the process is explained in the plan’s information packet and on its website.
If you already received exceptions from a plan in 2009, the plan must notify you of its policy for 2010. Some plans will “grandfather” your 2009 exceptions and continue them into 2010, so that you don’t have to request them again. Some plans require you to apply again by a given date. However, if you switch to a different plan for 2010, you’ll likely have to go through the process of requesting exceptions, with your doctor’s support, once again—unless you choose a new plan that covers the drug without restrictions.
• Staying with the plan you’re in now: If you’re already in a Part D plan in 2009 and after comparing other options you decide to stay in this plan for 2010, you need do nothing. Your coverage in the same plan continues next year, with any changed premiums, deductibles or copays that the plan requires in 2010.
• Enrolling in a different plan: If you decide to use the annual open enrollment period (Nov. 15 to Dec. 31) to switch to another plan for 2010, you can enroll in it by clicking on the “Enroll Now” button that appears in the right-hand column of the main plan page alongside the plan of your choice and following the instructions.
• Enrolling early: If you decide to switch to another plan for next year, it’s best to enroll before the second week in December if possible. That will allow time for your plan enrollment details to be uploaded correctly into Medicare’s computer system, so that when you fill a prescription in early January the pharmacist will know which plan you’re in and what to charge you.
Patricia Barry is a senior editor at the AARP Bulletin and author of the Ask Ms. Medicare column, which answers readers’ questions about Medicare on the AARP Bulletin Today website.