Q: I know that I can select a Part D plan once I am retired. I have looked at plans, and think I know what I want to do. I just don't know what to do if my medications change during the year? How do I know the plan I choose will be the best for me then?
A: As we select health insurance, we make that decision based on what we know. How is my health right now? How has my health been historically? How much can I afford to pay? Where am I going to live and travel? What medications do I currently take?
During the coming months and years the answers to all those questions will change. Most of us make our insurance decisions year to year. For most of us it is determined by the plans we have available at our place of employment.
Once you are eligible for Medicare, you have many more choices available to you. In our county there are 45 prescription drug plans to choose from. There are seven Medicare Advantage plans that provide health insurance but don't provide drug coverage. There are 17 Medicare Advantage plans that provide drug coverage as part of their product. There are 28 Stand Alone Prescription Drug Plans (PDPs) that would cover just your prescriptions medications. Of those 28 PDPs there are five that have been sanctioned by Centers for Medicare & Medicaid Services (CMS), so individuals are not allowed to enroll in them. So essentially you have 40 plans to choose from that may cover your prescription medications. I say "may" because no plan covers every medication.
All 40 plans have a formulary. The formulary is the medications they cover and how they cover them. You use that formulary list to make your insurance decision. I recommend using the www.medicare.gov website or the 1-800-medicare customer service to help with this process. Both these tools are set up to help you eliminate the plans that won't help you.
So when looking at plans, you choose the plan that works the best for you now. None of us can predict what will happen in the future. We can't predict when we will get ill, what will happen and how it will be treated. So we choose a product that works now, knowing that in the future we can switch to an alternative plan if we need to. That switching time with Medicare products is usually Oct. 15 to Dec. 7. This is when everyone on Medicare can switch their insurance to any other product.
There are also Special Enrollment Periods (SEPs) that are available to us throughout the year. There are 16 SEPs available, which is another article all together. But realize you can switch mid-year if you need to.
You can also request a review or appeal of a denied medication. If your plan doesn't cover a new medication you are prescribed, you and your doctor can appeal to have them change their mind. It never hurts to ask, right?
A way to prevent this type of problem is to take the formulary book with you to your medical appointments. If the doctor says "I want to put you on ..." you can pull out the book and have him review the medications that your plan covers. This will prevent you from going to the pharmacy and having your pharmacist tell you, "Your plan doesn't cover your medication, so it will be full price."
So, my advice is to choose a plan that works for you now, with the understanding that you can change every year as you need to. You also have SEPs available to you during the year to make changes for a serious change of situation.