When it comes to Medicare, one plan doesn’t fit all. When comparing Medicare plans for their patients, it’s essential for pharmacists to carefully evaluate different plans to make sure they’re choosing the best fit for their patient’s individual needs. While there are numerous factors to consider, some plans will never be in the patient’s best interests.
Here are 3 kinds of plans pharmacists should help their patients avoid:
#1 — Plans That Don’t Cover a Patient’s Medications
One of the most critical aspects of a Medicare plan is its drug coverage. Patients should be aware of a plan’s formulary, which is a list of medications covered by the plan. If a patient’s necessary medications are not included in the formulary, they may face higher out-of-pocket costs or be required to obtain prior authorization for coverage.
Making things tougher, these formularies can change every year. That’s why it’s necessary for Medicare patients to review their plan options during every Open Enrollment period; if they don’t, they might be stuck with a plan that no longer covers the medication they need.
To help their patients avoid plans that don’t cover their medications, pharmacists can:
- Review Patient Medication Lists: Carefully review patients’ medication lists to ensure that their current prescriptions are covered by the plans they are researching.
- Explore Alternatives: If a medication is not covered by the drug plan, discuss potential alternatives that may be included in the formulary or find plans that do cover it.
- Assist with the Prior Authorization Process: Explain the prior authorization process to patients and assist them in obtaining the necessary approvals to continue filling their medication.
#2 — Plans That Raise a Patient’s Out-of-Pocket Costs
Thanks to the Inflation Reduction Act, out-of-pocket costs will be capped at $2,000 for Medicare Part D beneficiaries starting in 2025. However, because more of the financial burden shifts to health plan providers once a patient enters catastrophic coverage, many industry experts predict that premiums and co-pays for those plans could increase.
(For more on this topic, download EnlivenHealth’s latest e-book, The Great Medicare Migration: A Community Pharmacy’s Guide to the 2025 Annual Enrollment Period.)
While it may make sense to find the health plan with the lowest premium when comparing Medicare plans, it’s also important to consider other costs, such as deductibles, co-pays, and out-of-pocket maximums (for Medicare Advantage plans, which don’t have the same thresholds as Part D prescription plans). Some plans may have higher out-of-pocket costs that can significantly impact a patient’s overall healthcare expenses.
To help their patients avoid plans that increase out-of-pocket costs, pharmacists can:
- Compare Total Plan Costs: Compare the total cost of a plan, including premiums, deductibles, co-pays, and out-of-pocket maximums (if the patient is looking at Medicare Advantage plans).
- Evaluate the Patient’s Financial Situation: Discuss the patient’s housing, food, and other costs with them and determine the plan that best aligns with their budget.
- Explore Low-Income Subsidies: If eligible, help patients apply for low-income subsidies (LIS) that can reduce out-of-pocket costs.
#3 — Plans That Put a Patient’s Care Team Out of Network
A patient’s choice of physician, pharmacy, and other care providers is crucial for their healthcare. Because of plan changes, some of a Medicare beneficiary’s providers may have opted out of participating in the plans they are considering. Plus, other Medicare plans may have limited provider networks, which can restrict a patient’s access to their preferred healthcare providers.
A patient shouldn’t have to change up the members of their care team to accommodate their health plan. It makes far more sense to change up the health plan to better fit the care team the patient wants.
To help their patients avoid plans that put their care team out of network, pharmacists can:
- Gather Provider Information: Work with the patient to put together a comprehensive list of their healthcare providers.
- Verify Network Status: Check if a patient’s preferred physician, pharmacy, and other care providers are in-network with the plans being reviewed.
- Discuss the Potential Costs: If any of the patient’s providers will be out of network on the plans being compared, discuss what those out-of-network costs could be and if they will fit within the patient’s budget.
Need Help Navigating Medicare with Your Patients?
At EnlivenHealth, we’re committed to helping pharmacists and their patients navigate the often complex task of comparing Medicare plans. Our comprehensive Medicare plan comparison tool, Medicare Match, empowers pharmacists to help their patients compares the costs and benefits of different plans available and make the best selection for their needs.
For more information about Medicare Match and how it can help your pharmacy have a successful Annual Enrollment Period, click the button below.