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Why you must look at your Medicare Advantage Plan, and Part D Prescription Drug Plan Today



Updated: December 08, 2014

You may also want to read:   I'm Falling into the Doughnut Hole

Robert Fassbach, editor, www.seniorark.com  

What you do right now can determine how well you do, for all of next year, in getting the medical care and prescriptions you need. YOU MUST CAREFULLY STUDY THE PLANS WE ARE ABOUT TO DISCUSS - EVERY YEAR.


MEDICARE ADVANTAGE - Around 25% of U.S. Seniors choose a private Medicare Advantage Insurance plan to cover their healthcare, or their healthcare plus prescriptions. Medicare makes a monthly payment to these insurance companies of around $800 - $1,000 for every senior they enroll. Details of these insurance companies vary widely, and must be studied very carefully. I turned 65 the day before Christmas 2007, and wanted to find a Medicare Advantage plan that covered both my healthcare and my prescriptions . Selecting a Medicare Advantage Plan was a traumatic experience. I have been studying and writing about the nuances of Medicare for nearly 10 years on SeniorArk, and in various other publications. But until I entered the scene myself, I had no idea of the extreme confusion surrounding the process. Even now, having made an "informed" decision for next year, I am not completely  sure I made the best choice for my needs, because I am not completely sure what my needs will be as the year unfolds . I have a plan that will work, and it includes Prescription Drug coverage, but Pennsylvania has dozens of plan possibilities out there, all being offered by private insurance companies interested more in my money than my health. During insurance company  plan presentations I heard misrepresentation, half-truths, and outright misinformation. But a choice was needed, so one was made.

MEDICARE PART D, AND MEDIGAP - Most Seniors stay with traditional Medicare that pays 80% of most healthcare expense, but does not cover most prescriptions. (Private Medigap insurance can help close the gap on the last 20%, but nothing for prescriptions. Shop for Medigap and the Part D prescription program at: Medicare.gov.)  Enter Part D. This is yet another private insurance scheme  that is paid for by Medicare, and is designed to cover some portion of most prescriptions. If you enroll in a Part D plan, you will pay a premium, perhaps an initial annual deduction, and a co-pay on each prescription.  Co-pays vary widely from company to company, and from one "tier" of medication to another. For example, a common generic may have a co-pay of $7, and a higher tier generic may be $15. A common branded drug may be $45, while a newer, higher tier branded drug could be considerably more. You MUST study these insurance plans carefully, taking into consideration your anticipated specific medications. 

DEALING WITH THE DONUT HOLE - Now let's assume that you have signed up for a Medicare Advantage plan  with prescription drug coverage. Or you are in traditional Medicare with a stand-alone part D drug plan. Then today you need to think about the doughnut hole. The best time to begin avoiding it is right now. I met with my doctor to go over the salad of drugs that seem necessary to keep me going each month. I told him I wanted to find a generic for every one of them. He was willing to do that.

Here are some examples of the savings when switching from Brand to Generic:

  • Celebrex 200mg, a medication used for arthritis, costs about $100 for a one-month supply. Replace with Meloxican 15 mg (generic for Mobic) costs about $8. Cost difference,$1100/yr.

  • Lipitor 20mg, used for cholesterol, costs about $111 for a month's supply (in 2011).  Simvastatin, (generic for Zocor) cost $11. Savings, $1200/yr.

  • Prevacid 30mg, a medication for heartburn, costs about $144 for a one-month supply. Omeprazole 20mg (generic for Prilosec) costs about $27, or a savings of $1400/yr.

  • Tricor 145mg, a medication for triglicerides, costs around $100/mo. Fenofibrate (generic for Tricor) costs $37, for a savings of about $750/yr.

(By the way, this is also a good time to go over your medications to determine if you still need every one of them. Over time, medications are prescribed that should be given for a limited time, but they are never stopped. Several doctors, including your specialists, may have written prescriptions that just keep refilling automatically long after their need ends. Doctors are so busy these days, that many overlook this. Make them look.)


Go online to see if you you qualify for Federal help with your Medicare expenses.

 Go online, (click your state on the map at this page) or call your state's agency on aging, or the equivalent department, to determine if you may actually qualify for additional state prescription help. There is a lot of it out there. My state, Pennsylvania, has 2 tremendous plans for couples earning less than $31,500, and individuals below $23,500. You may be passing up help that is staring at you. See our "Surviving the Doughnut Hole" page for 15 ideas on dealing with the doughnut hole.

Many retail pharmacies (ie. Walmart, Target, grocery chain-stores like Giant Eagle) have reduced rates for prescriptions that are commonly used (as low as $4). Some even offer free antibiotics and other drugs. My co-pay with my Medicare Advantage Plan is $8, so $4 is a better deal. But be sure that they are not charging additional amounts to your Part D or Medicare Advantage plans. To make sure this does not happen, thus pushing you toward the donut hole, I only get the free or reduced cost prescriptions from the grocery store, and other drugs at a different pharmacy. The grocery store pharmacy does not have my insurance information, so they cannot intentionally, or inadvertently charge my insurance company. They had my account number, and made so many charging errors, that I asked them to completely erase any reference to insurance.

We hope all of this adds to your options, and not to your confusion, If questions remain, you can always search at www.medicare.gov, or call 1-800-MEDICARE. There may also be a state representative available to give you some help.

So what is my choice with Medicare and/or Part "D"?

I went with HealthAmerica/Coventry/Advantra for 2014. 2015 will be another challenging decision, but it appears that Advantra has taken a hatchet to my benefits, and I will be leaving them (I went with UPMC for Life Deductible with RX). I am a government-created gambler; I gamble on what I will need during the next year. What a system!


A final comment. I think it is obscene that our government puts us through this traumatic, risky, confusing process. I totally support a "single-payer" system, run by the highly competent Medicare section of the Department of Health and Human Services. It needs to cover traditional Medicare, plus what is now Medigap, and Part D. It needs to be wrapped up in ONE SIMPLE, EASY TO UNDERSTAND package. They can administer the program more cheaply, and would have huge negotiating power with drug and other suppliers (this negotiating power was outlawed by the Republican Congress when the prescription drug plan was passed). The only thing standing in the way has been Congressional backbone, and Presidential consent. Insurance and drug lobbyists have wielded enough power to control these programs up to this point. Until it is changed, we must sift through this program as best we can. Profiteers benefit from our confusion, and our unwillingness to compare. Best wishes.

Click here for a link to the Medicare Part D/ Medicare Advantage/Medigap comparison site.