Patients and pharmacies are currently in the middle of the 2017 Open Enrollment period for Medicare Part D Prescription Drug Plans. Pharmacies must follow Medicare guidelines if they are helping patients choose a plan in 2017: they cannot guide patients to specific plans that are better for the pharmacy. Pharmacies are limited to providing non-biased facts to the patient. In practice, pharmacies can show the patient all of their options and answer questions about the process. Our pharmacy uses a product called iMedicare to enable us to do this quickly and accurately for our patients. Unfortunately, the same rules do not appear to be applicable to the plans themselves, and this is frustrating to pharmacies

The Scenario: Next year, our pharmacy will move from being a preferred provider with a plan to simply being a provider. The implications are that patients on that plan will pay higher copays when using a non-preferred pharmacy. The plan is calling patients that use our pharmacy and telling them that we are not going to be a preferred pharmacy next year and (I’m paraphrasing here based on conversations with many patients) they need to switch pharmacies to achieve the maximum savings they are eligible to receive.

Now while this statement is factual, it is also conveniently incomplete and misleading to the patient. It incompletely addresses possible courses of action for the patient, mentioning only on those that benefit the plan. If I did something like this in my pharmacy, I would be investigated by Medicare and likely subject to sanctions or monetary penalties.

The problem is simple: the patient has three possible courses of action for the 2017 plan year:

  1. Keep the current plan and pay higher copays at the pharmacy of the patient’s choice
  2. Keep the current plan and switch pharmacies to a preferred pharmacy
  3. Choose a different plan entirely based on cost and pharmacy of choice.

The plan’s phone calls cover only the first two options, and as it turns out it doesn’t address any of the various permutations of these choices. We have done impartial analysis on dozens of our customers that have received these phone calls, and this is what we have found.

Using a non-preferred pharmacy does not necessarily mean the patient will pay more. The plan making the phone calls urging patient to switch pharmacies is not actually looking at the patient’s medications and situation. As it turns out, using a non-preferred pharmacy does not change copays for patients on a Low Income Subsidy (LIS). Additionally, patients taking some very expensive medications that result in the patient reaching the catastrophic coverage phase also end up paying almost exactly the same amount out of pocket at a preferred and non-preferred pharmacy. In short, several of our patients that have received calls could continue to use our pharmacy despite us not being preferred, and not be financially impacted.

Staying with the current plan and switching pharmacies is not always the least expensive option for the patient. One of the first things we do when helping a patient consider plans is to look at all plans without respect to a given pharmacy. This gives us a baseline for the lowest possible cost plan with respect to yearly out-of-pocket expense (this includes the plan premiums plus medication copays). Once we have established a baseline, we can add in the patient’s preference for pharmacies and compare this to the baseline. What we routinely find is that often patients better are off, compared to their current plan, choosing one of several different 2017 plans. What’s more, the patient can often achieve this savings without sacrificing their choice of pharmacy. By not broaching the possibility that the patient’s current plan may not be their lowest cost option in 2017 during its calls, the plan is withholding critical information and misleading the patient. This is fraud, in my opinion. 

There is actually a fourth option available to patient, but it is rarely discussed: Medicare Part D is optional, and the patient can simply not participate. This does invoke a 1% per month penalty on future premiums for each month that the patient does not carry creditable (comparable) coverage for prescriptions drugs, and I always discuss this if a patient is considering opting-out.  Choosing a Medicare Advantage plans is also a possibility, but this further complicates the discussion, and is better discussed with a license insurance agent.

So the take home point is that patients have to be careful about what they are being told by others. In our case, we have identified all of our customers on the plan making these calls, and we are contacting each one to discuss all of their options. We do this completely within the Medicare guidelines, and we have occasionally have to recommend (reluctantly, of course) a plan in which we are non-preferred, possibly leading them to use a different pharmacy. But by working with each patient, we are making each and every encounter count.