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In This Chapter

^ Deciding how to fill your prescriptions ^ Picking the right pharmacies

^ Being a card-carrying member of a drug plan — and what your card says about you ^ Filling your prescriptions the first time out

M Bet you’ve never compared your pharmacist to a pilot in the cockpit of a fighter jet! Yet both pros have something in common: They rely on warp-speed electronic calculations to do their jobs. The pilot, facing enemy action, uses those calculations to fend off a missile attack. The pharmacist, facing Part D, uses them to tell you how much to pay for your Lipitor this month. Top Gun In a white coat!

This comparison may seem far-fetched, but it really isn’t. Just think how many calculations are necessary to arrive at that single payment. What you pay for each prescription depends on which Part D plan you’re in, where you’re at in the coverage cycle, whether you’re receiving Extra Help or additional coverage from outside of Part D, and even the pharmacy you go to. That’s complex math!

But all of these factors are chewed up somewhere in the ether and instantly spat out onto your pharmacist’s computer screen. If all goes smoothly, the result is the correct amount you should pay. If not, your pharmacist often can help you sort matters out. So the pharmacy is the front line in Part D, because your pharmacist is the go-between in your dealings with a drug plan. He’s the channel for your drug coverage and a useful person to answer questions.

This chapter has answers to issues that can arise when filling your prescriptions. I explain the various ways you can get your meds through Part D, the importance of going to pharmacies in your plan’s network whenever possible, and how your plan’s card is the key to coordinating all your benefits. I also cover what may happen the first time you have your prescriptions filled under a new Part D plan — because that’s when you’re most likely to hit any bumps in the road.

Choosing How to Fill Your Prescriptions

As ever in Part D, there are choices, rules, and pitfalls you need to know about when it comes to filling your prescriptions. The following sections explain the choices you have — between getting your drugs at a retail pharmacy or by mail order, if your plan offers that option — and the times when you may need to have a prescription filled at a specialty pharmacy that stocks and handles certain kinds of drugs. (Another option, long-term care pharmacies for people living in nursing homes, is covered in Chapter 18.)

Of course, you don’t have to choose just one pharmacy and stick with it. You can obtain your drugs from any pharmacy that accepts your plan’s card (and any others in an emergency; see the later section "Going to the Right Pharmacies and Avoiding the Wrong Ones"). And if you want to use mail order for some prescriptions and a retail pharmacy for others, that’s your call.

Retail pharmacies

By Retail pharmacy I mean the bricks-and-mortar kind on Main Street that you walk into (as opposed to the mail-order pharmacies that you visit only on the end of a phone or online). Part D plans use a variety of retail pharmacies — large chains, supermarket pharmacies, and small independent locations.

You may choose to fill your prescriptions at a retail pharmacy (instead of going through mail order) for very personal reasons. You know the pharmacist, you like the staff, and it’s a good place to stop by for a chat with neighbors. Retail pharmacies have more general advantages, too, if you have one in your immediate area. When you need a medication for some acute condition that comes on fast, you can get it quickly. And your pharmacist is an expert source of help if you have questions about your health condition or the drugs you’re taking. If you’re housebound, a local pharmacy can often deliver meds to your home. However, if you live in a very rural area, with a retail pharmacy a long distance away, it may make more sense to choose mail order. (I go into the pros and cons of mail order later in this chapter.)

Every Part D plan has its own Network Of retail pharmacies — those pharmacies that accept the plan’s card. And every plan must ensure that at least one in-network pharmacy is within a reasonable distance of enrollees’ homes. What’s a reasonable distance? That depends on where you live:

In an urban area, you’re likely to have dozens of in-network retail pharmacies to choose from — many within half a mile or so, and some even within walking distance.

In a very rural area, getting to the nearest in-network retail pharmacy may mean driving ten miles or more. If only one such pharmacy is within that sort of distance, all the Part D plans in the area are likely to include it in their networks. (Head to Chapter 10 for suggestions on how to check up on convenient pharmacies when choosing a plan.)

Part D plans label some retail pharmacies in their networks as Preferred. Generally, this means that the plan has a business relationship with these pharmacies, having negotiated lower dispensing fees or other special arrangements with them. Going to one of your plan’s preferred pharmacies

I Costs you somewhat less for your prescriptions than if you were to visit a nonpreferred pharmacy (as explained in Chapter 16).

Possibly allows you to get your meds in 90-day supplies in one of the following ways:

• By paying the same amount or co-pay for 90-day supplies as you’d pay for three separate 30-day prescriptions.

• By paying the same discounted price or co-pay for a 90-day supply as you’d pay if you got the drugs from your plan’s mail-order service.

• By paying the discounted mail-order price or co-pay for a 90-day supply, plus an extra amount for dispensing fees.

• By paying the same co-pay for a 90-day supply as for a 30-day supply. (This option applies Only If you’re receiving Extra Help.)

To find out which retail pharmacies are preferred, look at your plan’s pharmacy network list in your information packet (see Chapter 13), call the plan, or go to its Web site.

Mail-order pharmacies

Most plans offer a mail-order service for filling prescriptions, though not all do. Using this option can be convenient and save you money. But when deciding about mail order, consider the following:

I You can only purchase 90-day supplies, so mail order is best used for medicines you take regularly over a long period of time.

I Most plans (though not all) offer discounts for mail order — sometimes substantial ones. You may have lower co-pays and pay less in the deductible period and in the doughnut hole (formally known as the coverage gap; see Chapter 15) than at a retail pharmacy. (I explain more about possible savings and give examples in Chapter 16.)

I Because you pay for a three-month supply in advance, you pay more upfront than if you buy a 30-day supply each month. And in certain circumstances, you may fall into the doughnut hole earlier as a result.

Your drugs are mailed directly to your home, which may be convenient, especially if you’re homebound or live miles from the nearest retail pharmacy in your plan’s network. Shipping is free.

I You have to remember to phone in your next prescription or reorder online and allow time for delivery (usually seven to ten days) to ensure you don’t run out of your meds before the new ones arrive.

To find out how to use your plan’s mail-order service, check out the plan’s info packet, go to its Web site, or call its customer service number. Regardless, you’ll probably need to fill out a form to request this service.

Specialty pharmacies

Certain drugs must be handled extra carefully when they’re being dispensed — such as some drugs used for cancer, transplant rejection, multiple sclerosis, and other treatments. If you take one of these types of drugs, you need to purchase it at a specialty pharmacy that’s equipped to handle it. (The Food and Drug Administration allows some of these drugs to be distributed Only To specialty pharmacies.)

The Specialty Label may be applied to a regular pharmacy that meets the conditions for dispensing these drugs, to a hospital pharmacy department, or to a doctor’s office. Your plan’s pharmacy list should indicate which specialty pharmacies are in-network.

If no in-network specialty pharmacy is in your area, you can go out of network, but call your plan first for guidance. Due to the circumstances, some Part D plans don’t offer mail-order service for these kinds of drugs.

Going to the Right Pharmacies and Avoiding the Wrong Ones

A pharmacy is a pharmacy is a pharmacy, isn’t it? How can there be right ones and wrong ones? This classification has nothing to do with quality. It’s just that going to a pharmacy outside your plan’s network, except in special circumstances, has consequences — consequences that cost you money. By staying in your plan’s network, you get your meds at the plan’s regular charges and ensure the costs count toward your out-of-pocket limit. I explain what you need to know in the following sections.

Using in-network pharmacies

Your Part D plan gives you access to a large number of retail pharmacies, either within its service area or all across the country. All of these pharmacies accept your plan’s card. That means you pay whatever the plan requires for your drugs and no more. Preferred pharmacies within the network may charge you less, as I touch on in the earlier section "Retail pharmacies."

You can identify the retail pharmacies (including specialty ones) in your plan’s network by looking at the list in the plan’s information packet, going to its Web site, or using the Medicare Prescription Drug Plan Finder at www. Medicare. gov (as explained in Chapter 10). If your plan allows you to fill prescriptions anywhere in the U. S. and you need to do so while traveling, you can call its customer service number (shown on your card) to check on network pharmacies where you are. Or you can show your card at any pharmacy and ask whether it’s in your plan’s network.

If you move away from where you live now and need to switch to a different Part D plan in your new area, the new plan sends you details about its in-network pharmacies there as part of its enrollment package. If you remain in the same plan — for example, if you’re in a statewide stand-alone drug plan and you move to a new home within the same state — you can find a list of local in-network pharmacies by calling the plan, visiting its Web site, or going to the Medicare Prescription Drug Plan Finder at Www. medicare. gov.

Most plans, though not all, offer a mail-order service. If you prefer to obtain your meds this way, you must use the in-network mail-order service specified by your plan. (The plan won’t cover your drugs if you use any other mailorder pharmacy, even if the plan doesn’t provide one of its own.) You can request mail-order service on a form your plan sends you if you check this option on your plan enrollment form or if you call the plan and ask for it.

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Avoiding out-of-network pharmacies

Except in certain circumstances that I describe in the next section, these are the consequences of filling prescriptions at an out-of-network pharmacy:

U You pay a lot more for your drugs. In most cases, you pay the full price. Sending the receipts to your plan doesn’t do a scrap of good. The plan isn’t going to pay for them, period.

U These payments don’t count toward your out-of-pocket limit. If you

Fall into the doughnut hole, your plan disregards these payments when calculating your True out-of-pocket costs (TrOOP) — your expenses that count toward the limit that ends the coverage gap and triggers the beginning of catastrophic coverage, as explained in Chapter 15.

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Knowing when going out of network may be okay

Obviously, situations may arise when you need to have a prescription filled outside of your plan’s pharmacy network. These times include

I When you’re traveling outside your plan’s service area within the U. S. (and maybe abroad, if your plan allows this exception for emergencies), and you run out of your meds, lose them, or become ill and need drugs for treatment.

I If you need to fill a prescription quickly outside business hours, but can’t find a 24/7 network pharmacy within a reasonable driving distance.

I If you need to start taking a specialty drug quickly and don’t have access to in-network pharmacies that stock this type of drug.

I When undergoing emergency or urgent treatment in a hospital, clinic, or outpatient facility and you receive Part D-covered drugs from the facility’s pharmacy, but it’s not in your plan’s network.

I If you have to leave your home area after a local calamity that’s been declared a state or federal disaster or a public health emergency.

Medicare expects all Part D plans to guarantee coverage at out-of-network pharmacies in any of the preceding circumstances — providing the plan covers the drugs in question and the request is reasonable. But if you regularly go to a 24/7 pharmacy that’s outside your plan’s network because you find it more convenient to shop late at night, expect the plan to quibble.

If you need to go out of network for any other reason than those I provide here, call your plan in advance and ask whether it’s okay to do so. A quick phone call may save you time, money and frustration in the long run.

When filling prescriptions out of network, you normally pay the full cost and later send the receipts to your plan, asking for the appropriate refund. If you can’t afford the full cost, call the plan and request assistance. (If you’re receiving Extra Help, which I describe in Chapter 5, ask the pharmacist for aid.) What if the plan rejects your claim for a refund? You can file a complaint and appeal against the decision, as explained in Chapter 19.

Your plan Is Allowed to charge you more for going out of network, even in these special circumstances. Whether it does depends on its policy. If you do have to pay more, though, the extra cost counts toward your out-of-pocket limit (as explained in Chapter 15). However, if you receive Extra Help, you can’t be charged any more than you would be at an in-network pharmacy. Also, you can’t be charged more if you’re enrolled in a Private Fee-for-Service plan that provides drug coverage (see Chapter 9), even if it has a pharmacy network.

Unlocking the Information in Your

Membership Card

It’s all in the cards! No, your Part D plan membership card doesn’t magically foretell the future — except maybe to show how close you are to the doughnut hole. Yet it has a lot of detail locked inside that you can’t see on the surface. This information is all about you. I tell you how to decipher these facts and make sure they’re right in the next couple of sections.

Understanding what your membership card says about you

So what deep secrets does your card reveal about you? Nothing sexy, that’s for sure — no exciting dark strangers in your past or future. But it does say a lot about your personal coverage for prescription drugs and what you should pay for them. Following is what your card reveals when the pharmacist scans it through the computer system, depending on your plan and individual circumstances:

U Which Part D plan you belong to: Zillions of Part D plans are out there, so your pharmacist needs to know whom to bill and where to send the purchase details.

U Which phase of coverage you’re in: You may be in one of four phases, and in order for your pharmacist to bill you properly, he has to know which one applies to you at which time. I cover the various coverage levels in detail in Chapter 15, but here’s a quick breakdown:

• The deductible (when you pay the full price, if your plan has one)

• The initial coverage phase (when the plan pays a share of the cost of your drugs)

• The doughnut hole (when you pay the full price, if your costs are high enough to land you in it)

• The catastrophic coverage phase (when you pay very little, if your overall costs run that high in a year)

U Whether you receive Extra Help: This program for eligible people with limited incomes, which I explain in Chapter 5, reduces your payments a great deal and provides continuous coverage throughout the year (meaning no doughnut hole).

U Whether you receive other drug coverage from elsewhere: Your pharmacist needs to know whether to bill your former employer or union plan, a State Pharmacy Assistance Program (SPAP), or another source, in addition to or in place of your Part D coverage. See Chapter 6 for more details.

U What you should pay for each prescription: All of these factors play into what you actually pay at the pharmacy:

• The phase of coverage you’re in

• Whether you have extra benefits

• What your plan charges as co-pays or coinsurance

• Whether your plan has negotiated any discounts from this particular pharmacy

Making sure your benefits are correct and coordinated

The electronic wizardry that records all of your information saves a lot of hassle. Otherwise — just imagine! — you’d have to file a refund claim for every single prescription. But like any other automated system that relies on human input, it isn’t free from error.

Here’s what you can do to help ensure you receive all the benefits you’re entitled to and pay the correct amounts:

U Tell your plan what other coverage you have. If you have any other coverage at all, letting your plan know these details is crucial. The best way to guarantee that your plan coordinates all of your benefits is to fill out the form it sends you upon enrollment asking for these details. Medicare also sends you a similar form when you first come into the program. See Chapter 13 for more about disclosing other coverage.

U Know how other coverage fits in with Part D. If you receive insurance coverage from outside of Medicare — such as an employer or union plan, federal health benefits, or a State Pharmacy Assistance Program (SPAP) — your plan can give you specific details about how its coverage coordinates with Medicare prescription drug coverage. Or you can flip to Chapter 6 for the details of how Part D coordinates with each type of alternative coverage.

U Show your Part D plan card at the pharmacy. Presenting your card every time you fill a prescription — even during the deductible phase or the doughnut hole when you’re paying the full costs — ensures that your pharmacist charges you the correct amount according to your level of coverage. It also guarantees that the payments will count toward your out-of-pocket limit (as explained in Chapter 15).

U Check your statements. The Explanation of Benefits (EOB) statement That you receive regularly from your Part D plan, and any type of health insurance coverage, shows which of your payments the plan has covered. Reviewing the EOB is your best way of checking the accuracy of your payments and tracking your expenses and progress through different coverage levels.

U Tell your plan if your benefits situation changes. If you get a new job

That affects your drug coverage — for example, your new employer pays your Part D premiums, whereas your previous one didn’t — or your current employer alters your benefits, write or fax your plan with this updated coverage information. (If new employment now gives you creditable coverage that you didn’t have before, you can disenroll from your Part D plan, as explained in Chapter 17.)

U Take action if you think something’s incorrect: Contact your Part D plan if you think you’re paying more than you should — the wrong amount for any of your drugs or for the coverage level you’re on, for example. (If this approach doesn’t resolve the issue, see Chapter 19 for how to file a complaint or an appeal.) If the issue involves another plan that provides additional drug coverage and coordinates with Part D, contact that plan for help.

Putting Your Plan to the Test: Filling Your Prescriptions on Day One

Day One is when you go to a retail pharmacy to fill a prescription for the first time under your new Part D plan. Whether you’re a newbie to Part D or you’ve switched to a new plan, I bet you’re wondering: How easily will I get my drugs under this new coverage? Will I hit any snags?

In the following sections, I suggest what you can do to make the process go as smoothly as possible. And, in case you do encounter problems, I explain what to do so you don’t leave the pharmacy without your medicine.

Dodging possible snags and delays by verifying your coverage

Normally, the procedure you follow to have your prescriptions filled under a Part D plan is simple; you just go to the pharmacy with your prescription (or have your doctor call it in), show your plan membership card, and pay whatever’s due. But when you go to a pharmacy for the first time under a new Part D plan, your pharmacist needs to verify your coverage, especially if you haven’t yet received your card or your enrollment information isn’t yet in the pharmacy’s computer system.

You can help speed up the process and avoid or minimize delays by following these tips:

U Pick the right pharmacy. Make sure the pharmacy you go to is in your plan’s network. (I explain why doing so is important earlier in this chapter.) You can find a list of in-network pharmacies in your plan’s information packet (see Chapter 13 for details on this packet). If you haven’t yet received one, call the plan and ask which of your nearest pharmacies are on the list. Or you can call ahead to a pharmacy to check if it’s in your plan’s network.

U Take proof of your Part D coverage with you. These items include

• Your plan membership card (see Chapter 13 for more about this and other cards)

• Your red-white-and-blue Medicare card

• A photo ID (if you have one)

U Have the pharmacist call the plan to confirm that you’re enrolled if you haven’t yet received your membership card. To smooth this process, provide your pharmacist with as many of the following as possible:

• The plan’s name

• The plan’s Medicare identification number (which you can find on the enrollment form you filled out, if you kept a copy)

• A letter from the plan acknowledging your enrollment request (if you’ve received it already)

• A letter from the plan confirming your enrollment (if you’ve gotten one)

• A copy of your enrollment request (if you haven’t yet received the plan’s acknowledgment or confirmation)

U Bring your Extra Help documentation, if you qualify due to limited income. Your plan’s membership card should be enough to confirm your eligibility, but if you haven’t yet received it, bring one of these items with you:

• Your Extra Help confirmation letter from Social Security or Medicare, or any recent letter you’ve received from either agency

• A copy of your Extra Help application, if you filled one out

• Your Medicaid card, if you’re receiving benefits from your state medical assistance program

• Any recent letters confirming that you receive Supplementary Security Income (SSI) or have your Medicare premiums paid by your state

Ensuring you don’t leave without your meds

What if your pharmacist can’t confirm your plan membership? Or says that your plan doesn’t cover one of your drugs, or that you need to get permission from the plan before it will cover a drug? What if she asks you to pay more for your drugs than you think you should? Any of these what-ifs can happen.

But let me give you a direct quote from Medicare. On December 28, 2007, in a statement that offered tips to consumers when filling prescriptions for the first time under a new Part D plan, the agency said: "Don’t leave the pharmacy counter without your medicines." There — that’s straight from the horse’s mouth. But of course the circumstances may be different from person to person. I tackle what to do in certain situations in the next few sections.

If your pharmacist can’t confirm your enrollment in a plan

It takes time for plans to get details of new enrollees into the computer system, especially in early January when many people have just switched plans. If you have no proof of coverage (as explained in Chapter 12) or your pharmacist can’t verify your enrollment on the phone, here are your options:

U Pay for your drugs (at full price), keep the receipts, and send copies to the plan. Doing so is important, even if your plan has a deductible, because the payments count toward your out-of-pocket limit (as explained in Chapter 15) as long as the plan has a record of them. The plan then refunds you any money that’s due. However, if your enrollment is denied (see Chapter 12 for how this situation can occur), the plan doesn’t cover these bills.

U Ask your pharmacist to call Medicare’s dedicated pharmacy hot line, which is used for this purpose if you can’t afford the prescriptions.

If your pharmacist says the plan won’t pay for one of your meds

Your pharmacist will probably tell you if your plan doesn’t cover a drug you’ve been prescribed, or if the med comes with restrictions requiring the plan’s consent before you can get it. (I explain these restrictions — prior authorization, quantity limits, and step therapy — and what to do about them in Chapter 4.) Whether she gives you this information or not, call your plan to find out why your coverage is being denied and what you should do about it.

If you’re newly enrolled in the plan and you’ve already been taking this drug, you have the legal right to a 30-day supply so your treatment isn’t interrupted. Ask your pharmacist to fill the prescription under your plan’s Transition Or First-fill policy. If she’s reluctant to do so, ask her to call your plan for approval. If you haven’t previously filled a prescription for the drug in question at this pharmacy, the pharmacist can call your doctor to verify that you’re currently taking it. Bringing in a current bottle containing this medication may also

Help. But note that this is only a temporary solution. You must take immediate steps to change to a drug your plan does cover or work with your doctor to get the restriction lifted, as covered in Chapter 4.

If your pharmacist asks you to pay more than you think you should

One common explanation for your pharmacist asking you to pay more than you think you should for drugs is this: You qualify for Extra Help, but your pharmacist can’t get immediate confirmation through the system. If you have Medicaid, show your card. If you’re receiving Supplementary Security Income (SSI) payments or your state pays your Medicare premium, tell the pharmacist. In all of these situations, you automatically qualify for Extra Help. If you applied for Extra Help, bring the letter from Social Security that says you qualify. Either way, you should be charged only small co-pays for your drugs (as explained in Chapter 5).

If you’ve applied for Extra Help but haven’t yet heard whether you qualify, you have two options:

U You can pay the plan’s normal co-pays for your drugs and keep your receipts. After you receive a letter from Social Security confirming that you’re eligible for Extra Help, the plan must refund you the difference between what you paid and what you would’ve paid under Extra Help — dating back to the time you applied for it.

U If you can’t afford to pay the usual co-pays upfront, tell the pharmacist, who has the discretion to help you under Medicare rules. (At the very least, if you have less than a three-day supply of your meds left, the pharmacist must allow you an emergency supply.) Don’t be too shy or proud to ask and, just like the Medicare honchos say, don’t leave the pharmacy without your meds.

The following situations may also result in you paying more at the pharmacy than expected, but they’re easy to check before you leave home:

U Your plan has a deductible. In this scenario, you pay the full cost of your drugs until you’ve met the amount of the deductible and your coverage begins. If you’re not sure whether your plan has a deductible, you can find out by looking in your plan’s Evidence of Coverage document or, if you haven’t received it yet, call the plan.

U The pharmacy isn’t in your plan’s network. In this case, you’re asked to pay the full price of your drugs. Fortunately, this situation is easy to avoid — just go to another pharmacy that Is In the plan’s network. Again, you can find this information in your Evidence of Coverage or by calling the plan. However, if this is an emergency or another situation that allows you to go out of network (as explained earlier in this chapter), be sure to keep receipts for anything you pay.

Chapter 15