Leah Kari, retired pharmaceutical representative and licensed insurance agent
Licensed insurance agents are part analyst, sleuth, and detail man. As a former pharmaceutical representative of 16 years, people would joke about representatives being called “detail men” in days past. Diligence in details was a professional requirement. It is equally important for licensed insurance agents reviewing Medicare insurance plan options.
Here’s an overview of what occurs with researching your Medicare stand alone drug plan, Medicare Advantage HMO or PPO, or Medicare Supplement plan:
Medicare Prescription Drug Plans (aka stand alone prescription drug plans): Your detailed list of drugs is the foundation on which your drug plan is selected. An agent checks that your medicines are on the plan formulary and advises if your provider needs to address any exceptions or prior authorizations with your plan. Some plans may require you to have a quantity limit on certain drugs, or to try a lower cost drug before the plan will authorize you to use a more costly medicine. The rules change yearly and take time to explain carefully so that your responsibilities as a member are clearly understood. As an important example, if a drug is not on your plan’s formulary, your agent will tell you how the process works for you or your provider to ask for the drug to be made available to you.
Medicare Advantage HMO and PPO plans: Here the cornerstone of your plan hinges on your list of providers and your list of prescription drugs. While reviewing benefits can be appealing, researching to ensure that your providers are in network with the plan, as well as your list of prescription drugs being on formulary, is detailed, time consuming and crucial if your plan is to work as you hope it will. Knowing the line-by-line benefits of how your plan will work, once your providers and prescription drug lists are addressed through research, means that you enter into your new plan with confidence in how your plan works, what you will pay, and where and how you’ll access care.
Medicare Supplement Insurance Plans: This type of coverage is designed differently than a Medicare Advantage HMO or PPO plan, and understanding the differences is crucial.
Medicare Advantage plans differ in that generally a monthly premium may be a zero cost, and the member does not usually pay for care until he uses the plan. Contrast that with a Medicare Supplement Insurance plan which requires paying a monthly premium to keep the coverage in place.
Medicare Supplement policies do not include prescription drug coverage. You’ll want to have stand-alone drug coverage in place or risk a penalty. Medicare Supplements and Medicare Advantage plans differ in design, requirements for members and in how you access care.
Your agent will research options based on the information you provide. The goal is to have the plan that best meets your healthcare needs. As always: get the facts before the facts get you.
Contact Leah at 520-827-2460 (TTY users dial 711) or email leah@leahkarisolutions.com.