During the last part of 2019, like every year in the last decade, I spent many hours each week working with patients to determine the best Medicare Part D plan for them in the upcoming year. Open enrollment is an important event for the those eligible of Medicare Part D, but it also has significant implications on the pharmacy as well. For this reason, we actually leave signs up all year long letting people that we can help them navigate this yearly task.
Medicare Part D is very complicated. I hear my patients lament its complexity constantly. It is no wonder that many regularly seek help with this process. A successful open enrollment for a Medicare Part D participant typically is a balancing act between ensuring that they are getting the best total out of pocket costs for their medications and ensuring that they continue to have access to the pharmacies that they want to use.
There are a number of resources available for Medicare Part D enrollee to use during open enrollment. The most obvious is the Medicare.gov website. This site aggregates the data from all of the plans and allows one to compare available options. Unfortunately for everyone, while the site has done a good job making the process as smooth as possible, there are still a number of challenges: the complexity of the task cannot be fully masked by a good user interface. Something as simple as searching for your specific medications on the site, for example, is often confusing to someone without a detailed knowledge of medications.
These difficulties are further compounded by the occasional inaccuracies in the data being loaded by the plans. Several times in the last few years we have found incorrect copays on drugs, or pharmacies listed incorrectly as participating or non-participating on the Medicare.gov site. The data the tool uses is provided by the plans, not Medicare.
It is important to point out that even a savvy enrollee with a good understanding of Medicare Part D and their medications may not be fully comfortable working with this fairly complex web tool. Even these consumers will seek outside help. Family members, insurance agents, and volunteers regularly assist enrollees every year. But all help is not created equal: there can be significant differences in the experience and expertise.
This might be self-serving, but the in my opinion, the best resource for help with Medicare Part D is a pharmacist or pharmacy technician. They have daily experience with the complexities of these plans and have the dded advantage of understanding drug therapy and medications. Pharmacy employees can help patients pick plans as long as they follow the guidelines set up by CMS: they cannot direct a patient to a plan based upon financial benefit to the pharmacy. In other words, we have to be completely transparent when we do this.
When I help an enrollee, I first establish the patient’s choice of pharmacy. My motto has always been to choose the pharmacy first, the plan second. This will limit which plans they see listed, but before we finish we will compare other pharmacies. Because I work with the medications every day, correctly selecting the patient’s medications is not a problem. If they are a current patient, I have access to their medication list. If not, I spend a few minutes collecting a medication history (just like if I were doing a clinical review).
This gives the enrollee their first look at the best plans available for them. The plans that save them the most money are typically plans in which the patient’s choice of pharmacy is a preferred provider. After looking at the best options for their choice of pharmacy, we then go back and use a different pharmacy to perform the same search again. The second pharmacy is chosen explicitly because it has one or more preferred contracts that the patient’s first choice of pharmacy does not have. Alternatively, the search can simply omit pharmacy choice altogether. The result of this search allows the patient to see other plan options, albeit options that would necessitate them changing pharmacies.
This second search also demonstrates a general trait of Medicare Part D plans: out of pocket costs for a given patient and plan are very similar when using a preferred pharmacy. Stated another way, if a pharmacy is a preferred provider for one or more plans, using another pharmacy and a different plan does not impact total out of pocket expense significantly.
It should be apparent that the analysis I do with may patients enrolling in a Part D plan is meticulous. We discuss the plans they are considering, including looking at star ratings and plan policies like mail order. They are shown all of the options, including a look to see if switching pharmacies would save money. Fortunately for me, because we have a few preferred plans each year and we have not lost a customer for this reason. Even more satisfying is the fact that almost every customer I work with is adamant that their number one concern is maintaining their choice in pharmacy providers.
Fallout
Every year I have upset patients calling me. For whatever reason, they used someone else to help them pick their plan. Inevitably, they are surprised by a higher than expected copay, a non-covered medication, or the fact that their preferred pharmacy is NOT a preferred pharmacy under the plan in which they enrolled. They are stuck, even if they were given bad information from the Medicare.gov website!
Unfortunately, there is not an easy fix for these errors. Open enrollment happens only once a year. Changing plans between companies is not currently possible. Even changing plans within a given company is not possible. Every year I lose a few patients to these errors. Every year I also gain back some patients that learned their lesson the previous year. The end result is frustration for both the patient and the pharmacy.
There may eventually be some recourse. According to this report, there is a push from several US Senators to create a “special enrollment period” for Part D for just these types of problems. I know that if this happens, I will have fewer unhappy patients when January arrives.
