It’s Open Enrollment for Medicare: is Your Drug Plan Working For You?
Medicare plans change every year. That means that every year during Medicare open enrollment, you can explore the plans you’re enrolled in and see if there’s something better and less expensive for you. Open Enrollment gives you the opportunity to make changes to your Medicare supplemental gap insurance, Medicare advantage plans, and Medicare Drug plans from October 15 through December 7.
Not every plan is the same. Not every Plan offers the same benefits. Not every plan has the same monthly premium.
The best thing you can do for yourself is to Google the Senior Health Insurance Program (SHIP) in your state. SHIP volunteers are trained for such purpose and charge no fee. They will help you make selections that most benefit your needs and your pocketbook.
I’m not going to address Medicare advantage plans in this blog because I tell my clients to run from them. While they sound really great on paper and offer all kinds of perks and benefits, when you really need them for a serious or catastrophic illness, they don’t cover you adequately. Check out my November 24, 2024 blog on my website www.Klemonshealthcareconsulting.com in which I write about straight Medicare versus Medicare advantage plans.
Personally, I have been using an AETNA drug plan for the past several years. I am on no prescription drugs. My first year premium was around seven dollars. And then that same drug plan premium went up to $36 per month. Mind you, that $36 a month just gives me the privilege of being able to spend money with that drug company. It doesn’t cover any drug costs. And it doesn’t count toward my annual deductible or my annual maximum out-of-pocket cost.
My husband is on 8 prescription drugs and he was paying $76 a month for his Cigna plan D.
A few weeks ago, my husband got notification that his drug plan was going to no longer exist as it was being bought out by another company. And even though that new company said they service our county in Wisconsin, they claim they didn’t service the city that we lived in. So we needed to search for a new drug plan for him.
We reached out to a local Medicare specialist somebody had recommended. He was delightful and knowledgeable, licensed and contracted with 17 different insurance programs so he wasn’t trying to push us into any one plan that would benefit him rather than us.
We decided to buy the Humana Super Rx Plan D. The monthly premiums are zero dollars. They offer mail in service and 90 day supplies of medication. The annual deductible that we have to meet out of pocket is $601 a calendar year. Once we pay $601 out-of-pocket our tier 3, tier 4, and tier 5 medications, which are the more expensive ones, go down dramatically in price. From the very first day of our coverage, all tier 1 and tier 2 drugs are free. And thanks to the Biden administration, our maximum cap of out-of-pocket expenses is $2001. That means once we hit $2001 in out-of-pocket expenses paid, all drugs, regardless of their tier level are free. For my husband, that usually happens around July.
You need to be aware that monthly premiums paid to the drug company do not apply toward your annual deductible or your maximum out-of-pocket expense.
When selecting a new Drug Plan (Plan D), you need to know which pharmacies are their preferred and in- network pharmacies. This is critical in keeping your drug costs down and working towards paying off your annual deductible.
Generally, the amount you pay out of pocket for covered drugs at a non-preferred pharmacy can count toward your annual Part D deductible, as long as:
✅ The drug itself is covered by your Medicare Part D plan’s formulary, and
✅ The pharmacy is in your plan’s network (even if it’s “non-preferred” rather than “preferred”).
Here’s the distinction:
Preferred network pharmacy: You pay lower copays or coinsurance.
Non-preferred network pharmacy: You can still fill prescriptions there, but you’ll usually pay more. Out of pocket expenses apply to your annual deductible and maximum out of pocket costs.
Out-of-network pharmacy: Usually not covered at all, unless it’s an emergency or your plan approves an exception — and those costs typically don’t count toward your deductible or out-of-pocket maximum.
Be smart for yourself. Medicare plans change every year. Be sure you’re in the best plan for your health needs and budget.
Check out plans at medicare.gov or reach out to SHIP.
1-800-MEDICARE
QUESTIONS TO ASK WHEN BUYING A DRUG PLAN:
What are the monthly premiums? Do they apply toward my annual deductible and my out-of-pocket maximum expenses?
What is my annual deductible?
How much is my maximum out-of-pocket expense for the year?
What is the cost for tier 1-5 drugs?
Which are your preferred pharmacies? What happens if I buy a drug from a non-preferred pharmacy? What happens if I buy a drug from an out of Network pharmacy.
Do you have a mail order program?
Can I order 90 day supplies?
How does my health care provider communicate with you?
