Ask the Medicare Specialist

QUESTION:

I just found out that I need to get the updated Shingles (Shingrix) shot, and in an online chat with the provider to inquire if it’s covered, I found out that my deductible for Tier 3 - 5 drugs is $435. The Shingrix shot is considered a Tier 3 drug and therefore subject to the deductible at a cost to me of $175.

That deductible seems a little high and isn’t something I anticipated. The monthly payment for my drug coverage is only $15/month, but I’m wondering if there’s a better plan that I should have been enrolled in. Without knowing what other Tier 3, 4, or 5 drugs I might be prescribed later in the year, is there some other plan you would recommend?

In addition, I was told the flu shot is covered under the B portion of my coverage, not D. Yet the Shingles shot is covered under Part D prescription coverage, which doesn’t make sense to me. Perhaps you know why.

ANSWER:

This is a great topic and we have lots to cover. Please be advised that only those on Stand Alone Part D plans have prescription drug deductibles. Those on Advantage Plans in Western Pennsylvania do not. To answer your question if there’s another Part D plan or company that would be a better fit? It’s no. The least expensive Part D plan that eliminates the deductible is more than $70/month. You would be paying $660 more in premium to eliminate a $435 deductible you most likely won’t meet, even after getting the Shingles vaccination. I have a question for you. Did you receive the other Shingles vaccination, Zostavax? Most everyone in their 60’s or older was prescribed it prior to the introduction of Shingrex in 2018. Like Shingrex, Zostovax is also a recommended vaccine by the CDC and offers protection from Shingles for up to five years according to the Mayo Clinic. I spoke with my own PCP prior to writing this column. Although he stated other doctors may not share his view, he told me he wasn’t going to be blanketly recommending Shingrex to every one of his patients over 60. He was going to do that on a case by case basis, taking into account several factors. Remember, the two vaccines are manufactured by competing pharmaceutical companies, both of which are for-profit.

You brought up a very common concern. What if I get prescribed new drugs during the year that aren’t covered? Most people think spending more money on a Part D plan is the solution. It isn’t. 95% of our clients are best on plans with premiums between $13-$22 for 2020. The reason there isn’t a need to spend more is Part D, including those provided by Advantage Plans, is regulated very well and provide consumers with several protections. In this case, the event a drug is prescribed that isn’t on the formulary, you must be given an “Emergency 30-day supply” which allows you time to get with your doctor and take one of two actions; get a new prescription for another covered drug that treats the same condition, or file for an “Exception to the Formulary.” If your doctor feels there is a viable medical reason you can’t take any of the medications that are covered, he or she can call the company or fill out a form making the case for the necessity of the originally prescribed drug. This process is more often than not, successful.

Another protection consumers have include requesting a “Tier Exception.” Often, generic drugs can be treated as if they are brand name and designated Tier 3 or Tier 4, which can result in a much higher co-pay than a Tier 1 or 2 generic. If the other Tier 1 or 2 drug(s) the company cover in place of the Tier 3, 4, or 5 can’t be taken due to either it being prescribed in the past without success or another medical reason, the doctor can make an appeal similar to an Exception to the Formulary.

I’d like to mention that clients of The Health Insurance Store do not have to deal with these processes on their own. An agent or member of our dedicated service staff takes our folks through them step by step, including calling the Part D company and contacting the prescribing physician to make sure the exceptions are filed for correctly and ruled upon in a timely manner. This is one of the many benefits of becoming a client. This service, among others, are provided at no cost.

As far as the size of the deductible, I agree with Sylvia. It’s high. Medicare sets that and it generally increases every year. This is yet another consequence of the ridiculously high cost of brand name medications. Unfortunately, no real actions are being taken to solve the problem by our legislators. I encourage everyone to make it clear to their Congressmen and women what a burden the deductible and Doughnut Hole are on seniors. Ask them to explain why the same brand name medications cost 50%-80% less in Canada than in the US. In the meantime, I suggest trying to be as diligent as possible in making sure you only take brand name drugs that are absolutely necessary. Question your doctor on why brand over a generic and get a second opinion from your local pharmacist. Buy from Canada when it’s less expensive as well. Unless Big Pharma is hit in their pockets, something Congress has shown they aren’t willing to do with common sense regulations, price gouging will continue in my opinion.

As far as why the Flu and Pneumonia vaccinations are covered in full by Medicare Part B, while Shingles vaccinations fall under Part D, it appears from my research that Medicare is not considering it a “Preventative Service.” My guess is over time it may, but there’s always the issue of Medicare’s solvency, which could be the reason why it’s not covered now.

I would like to add, it’s vital people have their Part D plan reviewed each year during the Annual Election Period (AEP), even if the drugs you’re taking haven’t changed. Part D plans follow a pattern that I’ve noticed in my 13 years in the Medicare field. A couple companies cycle in and dominate the market for two to three years, then hope their customers fall asleep at the wheel, so to speak, while they raise co-pays, shorten their list of covered drugs, or move medications up a tier or two from one year to the next. I can’t tell you how many times I’ve seen clients throw away as much as $1,000 by staying with the same plan. As a courtesy, we review every one of our Part D clients’ plans each AEP. If you would like to be added to our database so you can receive our annual letter and form to have your plan reviewed this October, call one of our office locations.

If you have any questions regarding this column or any other Medicare related topic, give us a call or visit our website. You can also submit a question for future columns or contact me directly at aaron@getyourbestplan.com. And if you’re turning 65 or retiring soon, call to set up an appointment for a no cost consultation. If you aren’t within a convenient drive to one of our three Western PA office locations, we can go over options over the phone or online in a “virtual appointment,” which is almost like sitting across the desk with one of our licensed agents.