This week’s question from Maria
I’m a retired teacher on Medicare and have the HOP Medical and Basic Rx prescription plans. I saved your column from April 15, 2021. You talked about how good the HOP Medical plan is, however, you stated the prescription plan was more expensive than some others whose coverage is the same. I would be happy to save some money on a prescription plan, but I don’t want less coverage.
Answer
What is HOP?
I realize this isn’t a question, but it’s extremely important to address several points here because so many Western Pennsylvanians are on HOP.
HOP Medical for those who get the $100 premium assistance is indeed the best value in all of Medicare in my opinion. The premiums haven’t gone up in 10 years, the benefits are outstanding, and those who choose this option have the freedom to use virtually every doctor and hospital in the country at no additional cost.
As for the HOP Basic Rx prescription plan, which costs $69 per month, I estimate 90% of those who currently have this plan can save a significant amount of money by going on a Medicare Part D prescription plan for 2022. Our two most popular plans range from under $10 to just over $15. Co-pays for Tier 1 and 2 generic drugs generally cost less, and Teir 3 and 4 medications also usually have significantly lower co-pays than HOP Rx plans.
There is a $345 higher deductible on Tier 3-5 medications on all reasonably priced Part D plans vs HOP Basic RX, but when premiums are $600 to $750 more per year, the deductible isn’t an issue, especially when there are also significant savings on medications.
As far as the HOP Enhanced Prescription plan, almost no one gets value from spending the $128/month it costs with one exception; those who come out of the Donut Hole, go into the Catastrophic drug phase, and take medications that retail for $3,000 or more per month.
Coverage
Maria mentioned wanting to ensure she doesn’t get less coverage on Part D vs her current HOP RX plan. That would be a rarity for several reasons. As I already mentioned, drugs normally cost less on Part D than HOP. Also, the Donut Hole doesn’t go away for those on HOP Rx plans, doesn’t postpone it happening, or save those who find themselves there any money.
HOP plans generally have a larger formulary (list of covered drugs). However, we check to ensure all medications prospective clients currently take are covered before we ever advise someone to make a switch from HOP to Part D. T
That being said, there’s no need to pay more money for a prescription plan because “what if I get put on an expensive mediation during the year?” Here’s why. All part D plans are regulated to protect you, the consumer. For example, let’s say in May you’re prescribed a drug that isn’t on formulary. The plan must provide what’s known as an emergency/transitional 30-day supply. This gives the insured time to get a list of alternative medications in the same category the Part D company does cover. It’s a regulation that all companies cover at least two, and most plans include many more. Often, the prescribing doctor has no problem with the patient taking an alternative. But, if none of them are viable due to previous use without success or any legitimate medical reason, an “Exception to Formulary” can be filed. They are almost always approved, and I don’t know of a single instance in my 14 years as a Medicare broker having a client or hearing of anyone who was denied a life sustaining drug that wasn’t on their plan’s formulary.
Protections
There are other protections such as “Tier Exceptions” and the same concept applies as the Exception to the Formulary. Tier 4 medications are extremely expensive, even more costly than when in the Donut Hole with both Part D or HOP. When put on a Tier 4, you can find out what lower Tier drugs are covered by the plan. If none of those can be taken, in most instances, the originally prescribed drug can be moved from a Tier 4 to a 3.
We help all our active clients navigate these situations and get involved to ensure exceptions are filed properly, medical providers submit them in a timely fashion, and they get processed by the insurance company asap.
I want to go back to Maria, who also emailed me a list of both her and her husband’s medications. She’s currently taking two generic drugs. Her husband also uses two generics and another that’s priced as a Tier 3. Their premiums are $69/month each. Maria is paying $30 for a 90-day supply of her meds and her husband, $100.
Based on today’s premiums and co-pays on Part D, Maria would be best on a plan that’s under $10 per month. The cost of a 90-day supply of her medications would be $0, and her husband’s only $45. They would have saved $1,380 in premiums for 2021 and an additional $340 in out-of-pocket medication costs for a grand total of $1,720!
What’s nice is that during any ensuing Annual Election Period, HOP Rx plans are going to be more cost effective for the following year, the member can always move back to one of those plans. When HOP recipients purchase a Part D plan, they’re only opting out of HOP prescription coverage for a year, not a lifetime. It’s a great situation to be in.
Analyzing Medicare Part D, Advantage Plans, or Supplements and moving to plans that offer better value in terms of premiums, co-pays, out of pocket costs, and ancillary benefits is probably the easiest way for seniors to save money during a time when inflation is the highest it’s been in 40 years.
Let us Help
Those who have any plan that wasn’t purchased through The Health Insurance Store should at least contact myself or another of our licensed agents to see if it’s possible to save the kind of money we’re going to help Maria do in 2022. We can tell you in 5 minutes or less if you have one of the four or five Advantage Plans we feel offer the best value in 2022, if you have a competitively priced Supplement, and if you should renew your current plan next year or an appointment to compare benefits and prices on others that are available would be wise. Remember, there’s no cost for consultations, even if you decide to stay where you are.
In addition, if you have a Part D plan or HOP Rx and aren’t a current client, you can give us the name or your plan, address, and phone number. We will then put you in our database and mail you the same annual recommendation letter all our clients receive, which includes a form to list all current medications. Once returned to us, we evaluate all available Part D plans and ensure you get enrolled in the plan that’s most cost effective and covers all your drugs. Please be advised we need that information by September 20th.
We’re now setting up appointments for Annual Election Period, which starts on October 15th and runs through December 7th. If you would like to speak with an agent or set up a time for a consultation, please give one of our offices a call or visit our website.
Thank you!
Please call one of our office locations or email me personally if you have questions regarding this or any other Medicare/ health insurance related topic or to request an appointment for a no cost consultation. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
Erie County Area
1105 West 12th Street, Suite – A
Erie, PA 16501
Phone: 814-920-5275
Fax: 814-920-5276
Fayette/Westmoreland County Area
121 North Pittsburgh Street
Connellsville, PA. 15425
Phone: 724-603-3403
Fax: 724-603-3402
Pittsburgh Area
21 Yost Blvd., Forest Hills, PA 15221
Mailing Address: 128 Forest Hills Plaza, Pittsburgh, PA 15221
Phone: 412-349-8818
Fax: 878-302-3149
Albuquerque/Santa Fe, New Mexico Area
821 Coors Blvd. NW
Albuquerque, NM 87121
Phone: 505-200-0069
Fax: 505-200-0073
Serving These Areas
We proudly serve the health insurance and Medicare needs of the following Pennsylvania areas: Connellsville, Uniontown, Greensburg, Mt. Pleasant, Scottdale, Irwin, N. Huntingdon, Murrysville, Monroeville, Plum, Lower Burrell, New Kensington, Pittsburgh, Plum, Oakmont, Penn Hills, Forest Hills, Wilkinsburg, East Liberty, Lawrenceville, Bloomfield, Natrona Heights, Leechburg, Washington, Morgantown WV, Latrobe, Monnessen, Jeanette, Erie, Edinboro, Northeast, Girard, Fairview, Union City, Harborcreek, Corey, Meadville, Waterford, Ligonier, Kittaning, Somerset, Waynesburg, Fayette County, Westmoreland County, Armstrong County, Butler County, Somerset County, Erie County, Crawford County, Venango County, Allegheny Valley, Pennsylvania
We proudly serve the following New Mexico areas: Albuquerque, Rio Rancho, Sante Fe, Bernalillo, Belen, Los Lunas, Espanola, Moriarty, Corales, Tijeras, Cedar Crest, Edgewood, Soccoro, Sandoval County, Sante Fe County, Bernalillo County, Rio Arriba County, Valencia County, Soccoro County, New Mexico
Not affiliated with the U. S. government or federal Medicare program.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.