If you’re on Medicare, one thing that you might not know is this: The drug plan that might be appropriate to your needs might not work for your spouse.
Maybe that sounds like common sense, but Medicare isn’t always easy to navigate, if for no other reason than that there are so many moving parts—literally, Parts A, B, C and D—covering a range of services from hospital care to tests to doctor visits to prescription medications and more. The potential for a bad choice when choosing a drug plan is one example of many.
There’s a lot to sort out and keep straight, and most people aren’t experts when it comes to these issues. And think about it: If you’ve just turned 65, is that when you want to start making costly mistakes with your health insurance?
Thankfully, help is near at hand in the form of APPRISE, a free state health insurance counseling service for Medicare beneficiaries, and you can find it at Einstein.
Joanne Burke is manager of Einstein APPRISE, a program that is grant-funded by the state.
There has never been a greater need for APPRISE’s services, says Burke. “There are thousands of Baby Boomers aging into Medicare,” she says. We are saturated in this particular area.”
Einstein APPRISE counselors are there to answer any and all questions recipients or prospective beneficiaries might have about Medicare. Their goal is to make Medicare easier to understand, and to make sure recipients get the right coverage. Additionally, APPRISE counselors help explain financial assistance programs that might be available for such concerns as paying for premiums or prescription drug benefits.
Many of the program’s counselors are specially trained volunteers—people who have asked many of the same questions and puzzled through many of the same problems, and now they’re paying it forward.
With so much riding on making the right call, getting that kind of expert advice is essential.
Let’s go back to the drug plan example and see how easy it is to for, let’s say, a husband to make a costly mistake by signing up for coverage through the same plan his wife uses.
Drug benefits (Medicare Part D) are offered through a number of private plans, contracted under Medicare, and the drugs covered by the private plans are listed in what is called a formulary. The formulary has five tiers, ranging from drugs that have the lowest co-pays to those with the highest. You could pay a few dollars out of pocket at one end … and more than $100 at the other.
Generic drugs generally have the lowest co-pays. Co-pays get higher for drugs that are branded (not generic), and higher still for many medications that are more specialized. Depending on the plan, some of a beneficiary’s drugs might not be available, or only available for a limited period. Drugs can be removed from the formulary, or they can be moved to a higher tier—requiring a higher co-pay. And you might not be able to purchase your prescription medications at your favorite pharmacy if the pharmacy is not part of the prescription drug plan’s network. None of this might be a problem for the wife in our scenario, but it could be for the husband if he’s taking different medications.
That’s a lot to think about, but people often don’t. “If you’ve made a mistake and didn’t check with your doctor or look at the formulary before picking your plan, then you don’t have a way to get out of that for the remainder of the calendar year unless you are receiving some form of assistance," says Burke.
Einstein APPRISE devotes a lot of effort to making sure that health care consumers 65 and older know that the free service is available, with information offered at health and wellness fairs, senior expos and other events. Often, they wind up saving Medicare beneficiaries money.
“And we’re always trying to reach more,” says Burke. “We’re here to serve, and there are so many people struggling to understand Medicare.”
For information about Einstein APPRISE, call: 215-456-7600.