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7 Methods To Handle Medicare Remedy Prices

August
4, 2021

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This story originally appeared on NerdWallet

For Americans on Medicare in need of expensive drugs, drug costs can get steep. Unlike many private health insurances, Medicare Part D, Medicare's prescription drug insurance, has no annual cost limit.

In 2019, nearly 1.5 million people who participated in Medicare Part D spent more than the disaster coverage threshold (which is $ 6,550 in 2021) on their medications, according to a study by the health care nonprofit Kaiser Family Foundation.

As soon as you hit the catastrophic coverage threshold for spending on prescription drugs, you remain responsible for co-insurance or co-payment for your medication, regardless of how much money you have to spend. If your medication is expensive, it can lead to a huge expense by the end of the year.

For drugs used to treat cancer, hepatitis C, multiple sclerosis, and rheumatoid arthritis, for example, the median annual outlays 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 expense limit under Original Medicare. 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 co-insurance.

If you are faced with high prescribing costs with Medicare, there are strategies that can help you keep the costs down. Here are a few things you can try:

1. Know your medication

Knowing how your medications are covered can help reduce your costs. Please note the following:

Use the plan finder: When purchasing Medicare or Medicare Advantage plans, be sure to add your prescription medications to the Medicare Plan Finder so you can see how those plans cover you. (Medicare Advantage is an all-in-one alternative to Original Medicare offered by private insurers and typically includes Part D drug coverage.)
Get a Medigap Plan: If you are taking medication that you do not self-administer (given at a doctor's office or infusion center), Medicare Part B covers it. If you have Original Medicare, you can have Medicare Supplementary Insurance (Medigap) that will help with Part B Co-insurance and co-payments.
Compare with Medicare Advantage plans: While Part B has no cap under Original Medicare, Medicare Advantage plans are required by law to limit how much you can spend in a year. Think about whether Medicare Advantage would lower your drug costs.

Some insurers also differ in where they cover certain drugs – under Medicare Part B or Part D – so it's worth noting where yours ends up.

“Under Part B, most people have some sort of supplemental insurance that helps cover the co-payment so that they are not fully exposed to the co-payment that may be included under Part D. Pocket money, ”said Gretchen Jacobson, vice president of Medicare at the Commonwealth Fund, a private foundation that focuses on promoting a high-performing health system.

2. Compare pharmacies

Medication levels can vary depending on the pharmacy. Use a website like GoodRx to compare the prices of a drug at local pharmacies, or give some pharmacies a call to ask them what your prescription will cost.

Also, check out your Medicare plan's preferred pharmacies to make sure you are buying from one of them. Or you can get a cheaper price by going through your insurer's mail order pharmacy.

“Insurers build networks of pharmacies just as they build networks of doctors,” Jacobson says. "You get preferential rates."

3. Appeal the coverage of your plan

In some cases, Medicare companies may require people to try an alternative drug or change the coverage of the drug from Medicare Part B to Part D by self-administering the drug at home. You can appeal this decision and ask for your plan to continue to cover your original medicine (instead of an alternative) or to keep it covered under Part B.

(Why might you prefer Part B coverage? Part B has a Medicare Advantage deductible, or you can purchase a Medigap plan to cover co-insurance and co-payments under Original Medicare.)

If a newly prescribed medication is not covered by your plan, you can request a formal exemption which may result in your medication being covered or covered at a lower cost. This may take some time – your medical team will need to provide evidence that the drug is medically necessary.

"What is remarkable and worrying is that relatively few rejections are being challenged," says Jacobson. “A lot of people may not know they can appeal cover notes, and most of the cover notes that are being appealed are actually lifted.

4. Talk to your infusion site

If you are given an infused drug at a medical facility or care center, speak to your provider about their success with Medicare companies. Your payroll support and social work staff may have good information about which insurance plans best cover their services and medications.

"You're used to it," said Katy Votava, president and founder of Goodcare, a consultancy focused on the economics of Medicare. "Rely on your providers."

5. Try the generic

It's old advice, but it's still good to try: if there is a cheaper version of the drug that will treat your condition, ask your doctor if this might be a suitable alternative.

When starting a new medication, you may be able to try samples from your doctor's office first before getting a full prescription. This way you can see if the drug is working well for you.

6. Examine drug support programs

"Almost every large pharmaceutical company has a drug relief program," says Jacobson. These programs can provide financial assistance to individuals who qualify. You can look up your medication in the Medicare Program Finder to see if there is an aid program.

Your state may also offer a pharmaceutical assistance program. Medicare has a finder for this too.

Those with limited resources and income can qualify for Medicare's Complementary Assistance Program, which supports costs such as monthly premiums, deductibles, and prescription co-payments under a Medicare Prescription Drug Plan.

7. Shop plans

If you are thinking of switching to a Medicare Advantage plan, don't let Part D be secondary.

"When people decide whether to go for Medicare Advantage or Traditional Medicare, they often weigh other tradeoffs, such as the provider network and the self-service cap on Part A and Part B," says Votava. "But drug coverage can be a very important part of people's choices."

For example, some Part-D plans provide additional coverage during the donut hole, or the coverage gap that exists when you have reached a certain threshold on home expenses but have not yet hit catastrophic coverage.

When comparing plans, look at each medication plan's formulary to see if your current medications are covered. Also, watch out for limits on how much of a given drug can be paid in a year, or requirements that you try a cheaper drug before being approved for a more expensive drug.

“You have to hunt and peck,” says Votava. "But it's worth being a smart, intelligent shopper and taking the time."

Kate Ashford writes for NerdWallet. Email: kashford@nerdwallet.com. Twitter: @kateashford.

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