Senior Life Matters

Question; My current drug coverage sent me a letter telling me about the new premium rate, which didn’t change too much. I noticed that for a couple of my medications, they are recommending alternatives, or the “Tier” has changed. What does that mean? What should I do?

Question; My current drug coverage sent me a letter telling me about the new premium rate, which didn’t change too much. I noticed that for a couple of my medications, they are recommending alternatives, or the “Tier” has changed. What does that mean? What should I do?


Answer; Each year, your current Medicare Insurance plan must send you a letter by October 1st, describing how the coverage changes for the New Year. This is called an Annual Notice Of Change (ANOC). This letter (sometimes a packet) is the first opportunity you get to see what your insurance company will be offering in the new year. The first couple of pages usually hit the high points for you, including the premium, co-pays for your medications & treatments, and changes in coverage to the medications that they know you take.

If you have Medicare + Medicare Supplement + Prescription Drug Plan (PDP), you received an ANOC for the PDP. Medicare sent you the Medicare & You handbook to inform you of Medicare related topics. The Medicare Supplement coverage does NOT change unless you change the current plan you are in. The most important information is probably your Prescription Drug Plan’s (PDP) coverage.

If you have a Medicare Advantage Plan the ANOC also includes information on the Health & Medical benefits the plan covers. So there is a lot more to the booklet to review.

Your premium probably changes (most went up or down). The Deductible changed, most went up a little bit. The plan also can change the medications it covers, and how it covers those medications. If you have filled any medications during the year using this plan to help pay for them, the plan knows the medications that you take. That letter/packet included the changes to how your medications are covered. This may have been a change in the Tier it is listed in, it may have added or taken away a prior approval, quantity limit or step therapy. These last three are special rules you must work through to get the medications your doctor has prescribed. The first change listed is the Tier it is listed on. This has to do with how the company classifies the medication. There are usually five (5) tiers, but this year for the first time I have seen a Tier 6.

Usually the Tiers are; Tier 1 Preferred Generic; Tier 2 Generic; Tier 3 Preferred Brand; Tier 4 Non-Preferred Drug; Tier 5 Specialty Tier; Tier 6 Select Care.

Now these tiers are simply categories that YOUR insurance places medications in, that it covers. There are many times when we see generic medications placed in a Tier 3, 4 or even 5. The Tiers are a way of clarifying the costs you will pay as you pick up your medications. Usually as you progress up the list of Tiers, as the numbers go higher, so do your costs. But this is not always the case. It also depends on how much your medication costs.

To give an example; Synthroid is a name brand and I have found it almost always listed as a Tier 3 or 4 medication. These tier costs are usually higher than Synthroid actially costs full price. Say your plan makes Synthroid a Tier 3, and your insurance lists Tier 3 medications as costing $47 per month, but Synthroid only costs about $26 per month. In this case, you would only pay the full $26. Yet another medication, Asmanex is also a Tier 3 medication, which WOULD cost you the full $47 per month because Asmanex full price is much more than $47.

There are also deductibles to consider. During the deductible period of coverage you pay full negotiated cost for your medications. There are some plans that give you a lower cost for generic (Tier 1 & 2) medications during the Deductible phase of coverage.

Many of the plans are stating they added more medications to the Tier 1 & 2 lower cost structures, but you really need to look at your medications.

The plan may also suggest alternatives to the medications you currently take, and this is usually to steer you into medications that would cost the plan less to cover (and may save you money too). Many times, they would like you to consider taking generic medicine instead of brand name drugs, which usually cost more. If they are not going to cover a medication you now take, they have to notify you of this in writing, and that can happen any time during the year. So it is important that you check now to see that they are continuing to cover your medication for 2019, and if not, you may want to find an alternative with your doctor, or switch to a different insurance plan that does cover it.

The ANOC you received from your insurance company is a very useful tool to use in the evaluation of your plan. What it doesn’t allow you to do is compare it to all the plans available in 2019. The best way to do that is use the www.medicare.govwebsite. This website compiles all the data from all the plans and allows you to compare your medication list and your pharmacy in all the plans. That is useful data!

You can also call 1-800-medicare (63342273) to have their staff compare this data for you. The difficulty with the phone call is interpreting the data they give to you verbally. The call center is using the exact same website, to gather the data and then tell you what they see. That is a harder task to interpret.

Both the website and call center are available 24-hrs a day. So you can do this evaluation when it is convenient for you!

There are also agencies & programs that can help with this process. Senior Life Matters definitely does this; Office For the Aging has staff to help with this; Southwestern Independent Living Center has staff to help with this. There are also insurance brokers who can help with this process. Some of those brokers use programs that others have designed to evaluate the options. Most brokers are more likely to recommend Medicare Advantage Plans which can include your Prescription Drug Coverage. Brokers can only provide you with information on the plans they are contracted to sell (broker).

This time of year can be confusing. You are getting a lot of mail and every plan thinks they are the best plan out there. Be sure to evaluate your medications, your pharmacy and your medical situation before you let your plan roll over into the new year or decide to change your plan to a new one.

You have until 12-7-18 to make your 2019 plan choice. Any change you make any day between 10-15-18 and 12-7-18 begins 1-1-19. So don’t feel rushed to make that decision too quickly.

Happy Insurance Season!!

To contact Janell Sluga, GCMC with questions or concerns, please call 716-720-9797 or e-mail her at