Question: I have used the same pharmacy for years, and I was reading the material my insurance carrier sent to me. It looks like I would save money by switching to a different pharmacy. What should I do? Do I have to change pharmacies?

Answer: This is a great question. There are over 45 different insurance options available in our region of the state and each of those plans have different rules for the pharmacy benefit. I will speak to this question generally, since I don’t know what insurance plan you actually are enrolled in.

The insurance company you chose, not Original Medicare, covers the Prescription Drug Benefit (Part D). Each of those insurance companies have different coverage rules regarding the pharmacies they include in their network.

There are some Prescription Drug Plans (PDP’s) & Medicare Advantage Plans (HMO’s & PPO’s) that have the same co-pay structure no matter what pharmacy you go to. There are other PDP’s, HMO’s & PPO’s that have two pricing structures; Standard and Preferred. The Preferred Pharmacy list includes the pharmacy where you will save the most possible money on the medications you take. The Standard Pharmacy list includes the pharmacies you can use, but that may cost you a more than the Preferred Pharmacy list. The information regarding the pharmacies would be included in the packet of information that is mailed to you each year about your chosen plan. I am thrilled to see you reviewed that packet of material that was sent to you.

There is also a mail order option on many of the plans available. The mail order option may or may not save you money on your medications, depending on the plan and the medications you take. There are also some medications that cannot be mailed easily or at all (Insulin & Hydrocodone for example)

As you consider your insurance plan choice during Open Enrollment each year, this pharmacy list is one of the factors to consider. Your insurance may have stayed the same name, because you didn’t change it, but that does not mean your coverage is the same as it was last year.

Each year Insurance Plans may switch the pharmacies that give you the lowest price. In some situations the pharmacies year to year change in their status (Standard vs Preferred).

You have read my articles enough to know that I always recommend evaluating your decision every year. Participating Pharmacy status is certainly part of this evaluation process. In some of the plans for 2017, if you went to a particular pharmacy you may have gotten your medication for a very low co-pay or even for free. In 2018 there are very few of those types of free co-pays anymore. Almost all insurance companies require some co-pay for even the inexpensive generics. If you chose a plan in 2017 because some of your medication copay structure, that may be changing for 2018. In some of the plans that only have Standard Contracts with all pharmacies, now have a Preferred list of pharmacies. Some plans have broadened their Preferred Pharmacy list. Some plans have narrowed their Preferred Pharmacy list.

Are you willing to switch pharmacies? That is up to you. It is not that hard to do, but many of us choose the pharmacy we have because it is convenient, you like the people who work there, or it is close to where you work or live. If you have to drive across town to save some money, will you be happy with that choice? How often do you have to drive there? Will you be saving money if it is out of your way?

The negotiated cost of your medications can also be very different from pharmacy to pharmacy with the same insurance product. Typically the Preferred Pharmacy list has an overall lower price for your medications. The Standard Pharmacy may have a higher overall price for your medications. When your negotiated cost is higher for your medication, you could hit the Coverage Gap (Donut Hole) sooner. Then your costs could increase significantly. Although this year the Coverage Gap has you paying less for your medications. The Brand Name cost will be 35 percent of the total cost of the medication. The Generic cost will be 44 percent of the total cost of the medication. This is down from the 2017 Coverage Gape pricing structure.

I know that many people don’t like change all that much. This system asks them to evaluate the insurance products available each year to help control costs. Sometimes that evaluation process then requires a decision to change or not to change to save that money. Only you can decide when and how much change makes the savings worthwhile.

I have heard on more than one occasion, I don’t care what it costs I won’t change (blank). You fill in the blank — doctor, pharmacy, hospital — whatever. Sometimes that is “the line in the sand.” But maybe for you switching to another pharmacy isn’t such a big deal and it could save you some money on your medications.

Talk to your pharmacist and see what he or she knows. Some pharmacists are good at talking about insurance; some feel they never want to hear the word again in their lives. The pharmacists may be able to explain some of the changes. Sometimes they don’t know the changes until it pops up on the computer screen as they fill your medications.

You can also contact your insurance product to ask these questions or for clarifications.

The www.medicare.gov website and tools there help you through this research. The information on the website is very useful. The 1-800-medicare staff can also help you evaluate this information. There are also many resources in your local area, Senior Life Matters, Insurance companies themselves, Office For the Aging or Southwestern Independent Living center, all have staff available to help with this process. Your current plan has sent you information on pharmacy changes and co-pay structures as well. So review that material and use the resources to research the options. This research could save you a money in 2018 or even just help you understand what you have and how it works.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.