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From October 15th to December 7th, customers aged 65 and older will be reviewing their medical coverage and health care needs, including Medicare Part D plans. The detailed information needed for 2021 (premiums, copays, formulary tiers, gap coverage, etc.) will not be officially available until October 15th, by CMS regulations. Still, you can get yourself familiar with the procedure to get ready by using 2020 information. 

In addition to familiarizing yourself with plan options, it is also important to remember to be helpful and knowledgeable in navigating Medicare Part D enrollment. Not only will you be providing a valuable service to your patients – who will remember the time and effort you put into helping them, but you will be boosting your standing as a trusted medical voice in the community. 

Here are some essential tips and guidance to consider: 

Drug Regimens & Insurance Brokers

Use a drug regimen from a few of your present Medicare D plan members and run each through multiple plans available in your region.  

  • Don’t forget to consider the premium fees and copays & deductibles (many plans hide behind a $425 deductible, which increases the monthly premium by $35.42 a month).  
  • The drug regimens of each patient can influence the actual yearly cost to your patient (brand name drugs, specialty, etc.) These are shown by which Tier a drug is shown to be in by each Medicare D plan; differences in plans are expected even with generic medications.

Also, insurance brokers are available that can be a big help in working with your patients during the enrollment period. Still, please interview them to ensure they do not have an alliance with one plan over another. The Chains use brokers in their stores that push specific plans where the Chain is preferred, which is considered a gray area.

CMS Regulations Prohibit Steering

Be careful. The copays and estimated out-of-pocket amounts reflect what a patient will pay at YOUR pharmacy, which is essential to remember.

    • Plans will often show tags as “Preferred,” “Chain,” “Mail-order,” or “Gap Coverage.”
    • Know which plans YOU are Preferred with and, more importantly, which you are NOT preferred. Check with your PSAO.
    • The “Chain” tag indicates lower copays for drugs filled at a big box chain pharmacy.
    • “Mail-order” – know which plans push patients to use mail-order.
    • “Gap Coverage” – the plan offers lower copays on specific drugs, usually generics, during the donut hole. These plans generally have higher premiums.
    • Watch out for plans with multiple drug restrictions in their formulary and view those restrictions (day’s supply, PA, DAW 9, & other limits.)
    • DIR’s affect your bottom line – know each plan’s DIR formula.
    • Use the following programs or websites: 
      • Medicare.Gov – you will have to supply a drug regimen and manually make comparisons.
      • Amplicare – will populate the drug regimen from your computer system and automatically compare plans active in your region.  
      • Prescribe Medicare – will populate your computer system’s drug regimen and automatically compare plans active in your region. 

Notify Your Patients

Also, be prepared for your pharmacy to offer advice, answer questions, and assist your patients in plan comparisons in as many ways as possible. Some suggestions include:

  • Contact your customers who qualify and ask them if they have questions – they may feel embarrassed about not understanding the process. Reaching out to them first can help put them at ease and enroll them quicker and less anxiety.
  • Print up flyers and bag stuffers, letting customers know the enrollment period is coming up, and you’re there to answer any questions they may have.
  • Update social media graphics to include reminders about the enrollment period and your pharmacy’s ability to help.
  • Schedule some time every day to be available to speak to customers and address any concerns they may have regarding their Medicare Part D coverage.

Closing Thoughts

Understanding Medicare Part D can be a challenge for customers and pharmacists alike. Make it less of a challenge by keeping up to date on CMS plan changes, educating yourself and your customer, and keeping confusion and stress to a minimum. As 2021 is offering new plans to the mix, please learn as much as you can about all plans and how they will affect your patients, as well as your pharmacy. Get involved and educate as many employees as possible to be able to answer questions.

Not sure where to start? Through our partnership with Aspire Health, PPSC can help navigate the challenges associated with open enrollment and provide your pharmacy with some tools to assist and educate your patients. To learn more about our solutions, please connect with us.