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Ask the Medicare Specialist

by Arron Zolbrod


Question from Mary Ann: I’m on a Part D plan that only costs $15. Should I get a more

expensive plan in case I get put on expensive medications?



No. All you need to do is make sure you have the most cost-effective plan for 2020 based on the drugs you’re currently taking.

I often get this and similar questions such as, “what do I do if I need a medication that my plan doesn’t cover?”

There are protections for that as well as others when it comes to Part D plans, whether provided by an Advantage Plan HMO or PPO or what is known as Stand-Alone Part D, a separate policy those on Supplements need to purchase.

In the case of a drug not being on your plan’s formulary, there are two protections. Number one, all Part D plans must provide you with a 30- day “transitional supply,” even if the drug you’ve been prescribed isn’t on formulary. Most people don’t realize that. You would need to call your plan to get an override for the pharmacy. When we help our clients with this, we also get a list of alternative drugs the plan covers. You see, another regulation is Part D plans must cover at least two medications for every medical condition. What the transitional supply allows you to do is get with your doctor to see if he or she feels the alternatives are a viable, preferably one that’s available in generic. If the doctor doesn’t feel an alternative is safe due to a medical reason such as an allergy or it’s been taken previously without success, then an “Exception to the Formulary” can be applied for. Your physicianfills out a form that states why the medications on the plan’s formulary can’t be taken.

If it’s a legitimate medical reason, the exception will

almost certainly be approved

There’s one other appeal or request you can make to a Part D plan. It’s called a “Tier Exception.” Often plans price generics as though they were brand name drugs, making them a Tier 3 or 4. If there isn’t another generic available for you to take that’s a Tier 1 or 2, this exception is often granted. Tier 4 drugs can be extremely expensive, from $100 to $250 for a 30-day supply. Getting them moved to a Tier 3 can result in significant savings.

One more important fact people need to understand. You cannot avoid the Doughnut Hole by paying a higher premium! In 2020 you can only receive $4,020 of drugs. This is based on the retail cost and has nothing to do with your co- pays. The average brand name drug now has a retail of $500 for a 30-day supply, regardless of the plan’s premium. This means the Doughnut Hole will be reached by August if that was the only drug you were taking, sooner if there are others. Even if a co-pay for a brand name drug were $25 less in the month’s prior to falling in the Doughnut Hole, you would pay the same after. You don’t need to spend an extra $600 to $1,000 more in premium to save $200 in co-pays.

Once again, paying more doesn’t necessarily get you more when to comes to Medicare Part D, Supplements, or Advantage Plans. For instance, the highest priced Advantage Plan HMO’s and PPO’s next year will be close to $300/month. People on these

expensive plans who receive Chemo, have a lengthy stay in a Skilled Nursing Facility, or get expensive drugs infused or injected as an outpatient will most likely pay the same amount of bills as those who have plans that costs $250-$300 less.

I had a client call me just today, who was paying $60 more per month for Medicare Supplement Plan N with another company and $40 more for a Part D Plan than she needed to. That’s $1,200/ year!

There’s still time for us to evaluate your plan before Annual Election Period ends on December 7th. In a five- minute phone call or a quick email, myself or another agent can let you know if you can save money or get a plan that offers a better overall value in terms of premiums and benefits.

And once you become a client, our staff is always available to advocate on your behalf regarding Part D or any other issue related to your policy.

Feel free to email me at This email address is being protected from spambots. You need JavaScript enabled to view it. with questions. And don’t forget to go online and listen to my live radio show on WMBS Uniontown 590am the first and third Monday of every month from 1:15 to 3. You can also catch the replay of all the shows on our website.


You can follow us on Facebook as well for trends and important information regarding Medicare and prescription drugs.

No-cost, unbiased Medicare plan review and consultation with local, licensed agents 

Email your question to: This email address is being protected from spambots. You need JavaScript enabled to view it.




Laurel Highlands

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