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Monthly Claim Report Is A Standard Of Practice

Question: I have a Medicare Part D prescription drug plan. I keep getting notices from them and don’t know why. I get a print out from my pharmacy when I pick up my medications. Why am I getting this as well?

Answer: Centers for Medicare & Medicaid Services (CMS) sets a standards of practice as part of the policies that the Medicare Part D Insurance companies have to abide while providing Prescription Drug coverage to those enrolled in their plans. This monthly claim report is one of those standards of practice. Each insurance carrier must send each individual enrolled in their plan a monthly listing of the medications filed under their claim number. This information can be very useful to you. It includes the medications you filled, how much you should have paid, and where you are in the different categories of coverage.

You want to look over these mailings. I also recommend saving this notices for at least a year. I regularly have clients come to me to talk about their medications co-pays, but they understand why they pay what they pay. This monthly mailing is the companies attempt at illustrating your coverage and how it works for you.

First, look to see if the medications filled were medications you actually got. There may be billing errors. Someone could be filling medications under your claim number and thereby getting you into that donut hole or coverage gap sooner than necessary. You also want to look to see that the amount you were supposed to pay was the amount the pharmacy charged you. There are sometimes errors here. If you find that your pharmacy receipts do not match the amount the insurance company indicates you need to take your print out to the pharmacy to see if they can resolve the problem. If not call your insurance carrier to talk about this discrepancy. You may be able to file a claim to receive any overpayment back from the pharmacy or the insurance carrier.

It is also important to remember that you may have Elderly Parmacuetical Insurance Coverage (EPIC). When an individual has EPIC (New York State Pharmacy Assistance Program) there are times when EPIC pays part of your costs for your medications. So the statement from your Part D plan, may not include that information, or may list it as ‘payment from another source”

This monthly notice also tells you where you are in the coverage of your medications. Remember that the Medicare Part D plans have categories of coverage. The first phase is the deductible (at most $415). The deductible, if you have one, is where you pay full price for your medication. Once you have met your deductible, you begin to save money on your medications, this phase is called your Initial Coverage. This savings lasts until your total cost of Medications reaches $3820. The total cost includes both what you and the insurance carrier have paid for your medications. If you are still getting medication at this point, you reach the coverage gap (donut hole). At this phase your Medication cost is 25% for Brand-Name Medication and 37% for Generic Medication. The Coverage Gap lasts until your Total Drug costs reach $8,139.54. Now I know this is a different dollar figure than you usually see. I know the math doesn’t seem to work, but the amount of $8,139.54 also includes your deductible previously paid and any co-pays paid during your Initial Coverage Limit. All this applies to your Total Out of Pocket of $5,100 per year. After you have paid $5,100, if you get that far and I hope you don’t, your costs reduce significantly because you have reached the Catastrophic Coverage Limit. This period means your co-pays go down to 5% of the total drug cost.

All this was said to remind you to review those monthly notices from your Prescription Drug Coverage Carrier. These monthly notices provides valuable information to you. Also save these notices, that way if there is an error you have proof to fight that error. If you switch insurance companies you can check to be sure your coverage has transferred properly. The money you spend under one carrier at the pharmacy carries over to your new plan during the same calendar year. You don’t start all over with your coverage if you switch plans in the middle of the year.

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

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