Roger, a Medicare beneficiary, had prescription drug insurance that he liked. He liked it, that is, until his doctor prescribed a drug that the insurance wouldn’t cover.
The pharmacist told Roger that the newly prescribed drug was not on the insurance company’s formulary, which is another way of saying it didn’t pay for that drug. By law, though, insurance companies must cover at least one drug in every drug classification.
Roger was talking with a Senior Health Insurance Benefits Assistance (SHIBA) counselor. A call to the company identified another drug with presumably identical benefits that was covered.
Even if Roger’s doctor later told him that the covered drug wouldn’t work for him, the doctor could then ask the insurance company for an exception to its drug formulary. If that wasn’t granted, Roger could check with the Oregon Prescription Drug Program (800-913-4284) or, with a limited income, NeedyMeds.org (800-503-6897).
To make a free SHIBA Medicare counseling appointment, call 800-722-4134. To ask a question to be answered here, please see the end of this column.
Last year I tried to get a SHIBA appointment during open enrollment to get help with my Medicare insurance. No appointments were available. If that happens again this year, what can I do?
Annual open enrollment for Medicare Advantage insurance and Prescription Drug Plans began on Oct. 15 and runs through Dec. 7. If you are unable to get a SHIBA appointment, try one of these options:
*Go online to Medicare.gov. Below Find a 2021 Medicare plan click on either Log in or Create Account OR click on Continue without logging in to review 2021 Medicare Advantage plans or Prescription Drug Plans. But if you are new to Medicare and instead want to review 2020 plans, then after you get into the site click on Show me 2020 plans at the top of the page.
*Call 800-MEDICARE (800-633-4227) to speak with a person who can help find insurance options for you. This line is answered 24 hours a day, seven days a week.
*During weekday business hours call the SHIBA helpline at 800-722-4134, where a representative can help you find Medicare insurance. When you call don’t enter your ZIP code and someone will come on the line to help you.
*Speak with a state-certified insurance broker. To find one, go online to healthcare.oregon.gov, click on Find local help, then enter your information (including that you are interested in Medicare Agents) to see a list of brokers with their contact information. You aren’t restricted to agents in the county where you live.
I’m hopeful the pandemic will have passed by next summer and I am making international travel plans. If I have a health issue will I be covered?
It depends. If you have straight Medicare — Part A and Part B without additional insurance — you will have no coverage outside of the U.S. You will be expected to pay all out-of-country medical expenses yourself.
If you have Medicare Advantage insurance, you will most likely be covered if you experience a medical emergency but not for routine doctor visits. Check with your insurance company to ask about coverage outside the U.S.
Eight of the 10 types of Medigap “supplemental” insurance policies will pay 80 percent of emergency care costs outside of the U.S. These are Plans C, D, F, M, N, F high-deductible and G high-deductible. If you plan to seek reimbursement from an insurance company, keep all paperwork associated with your medical services and expenses.
You have written about programs that help people save money on prescription drugs. I checked, and neither could help me. Can I do something else to try to reduce my drug costs?
The programs you reference are the Oregon Prescription Drug Program (800-913-4284) and NeedyMeds.org (800-503-6897). If neither is helpful, check to be sure that your insurance is covering all of your drugs. Your pharmacist or your insurance company can tell you. Ask your insurance company whether you are using one of its preferred pharmacies. If not, check whether using a preferred pharmacy would save you money.
For any brand-name drug, ask whether a less-expensive generic is available. If you are getting a 30-day supply, asking your doctor to write 90-day prescriptions should save you a little on pharmacy dispensing costs.
Jim Sellers of Salem is a certified Medicare counselor with the Senior Health Insurance Benefits Assistance (SHIBA) program. To ask a question to be answered in this column, e-mail [email protected]. To schedule a free SHIBA phone appointment with a volunteer Medicare counselor, call 800-722-4134.
