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Question: I have a Medicare Part D prescription drug plan, and get notices from them each month. Do I need to keep them?
Answer: Centers for Medicare & Medicaid Services (CMS) sets a standard of practice within 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 ID 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 phases of coverage.
You want to look over these mailings. I also recommend saving these notices for at least a year. I regularly have clients come to me to talk about their medication co-pays, but they don't understand why they pay what they pay. This monthly mailing is the company's monthly coverage explanation and how it works for you.
First, look to see if the medications filled were medications you actually filled. There may be billing errors. Someone could be filling medications under your claim number and thereby getting you into that coverage gap sooner than you should be. 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 and you may find that your pharmacy receipts do not match the amount the insurance company indicates. If this happens, 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.
You may have EPIC, and with EPIC (New York State Pharmacy Assistance Program) there are times when EPIC maybe paying part of your costs for your medications. In this case, 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 phase of coverage for your medications. Remember that the Medicare Part D plans have phases of coverage. The first phase is the deductible (at most $505). The deductible, if you have one, is where you usually pay full price for your medication. Some plans give you Tier 1 and Tier 2 medications at a lower price even during the deductible. Once you have met your deductible, you begin to save money on all your medications, called Initial Coverage. This savings lasts until your total cost of Medications reaches $4660. The total cost includes both what you and the insurance carrier have paid for your medications. Many people don't reach this phase of coverage. If you are taking expensive medication, you reach the coverage gap (donut hole). At this phase your Medication cost is 25% of the retail price as negotiated by your insurance company. The Coverage Gap lasts until your Total Drug costs reach $11,206. (Less than 5% of those on Medicare reach this phase of coverage.) To reach this phase your Total Out of Pocket would be more than $7,400 this year. During the Catastrophic Coverage phase your costs are reduced significantly, 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 provide 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.
Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, email editorial@post-journal.com.