I’m new to Medicare and keep hearing about Open Enrollment. What am I supposed to do during this time? I’m happy with my Medicare but keep hearing that I should compare. What does that mean?
Sally – Fairbury, Nebraska
Open Enrollment, which begins Oct. 15 and ends Dec. 7, is your annual opportunity to evaluate your Medicare coverage and decide if changes need to be made for next year, beginning Jan. 1. Comparing is a good idea because each year Medicare drug plans and Medicare Advantage Plans can make changes to the costs you pay and the benefits you receive. To avoid enrollment problems, you should contact your local Nebraska SHIIP office when making changes to your health and drug coverage.
Here are some questions you should ask when comparing your Part D plan or Advantage Plan:
Will my plan cover my prescriptions next year?
• Each plan has a formulary or drug list of what it will cover. You should make sure your drugs are on the plan’s formulary during Open Enrollment.
Does the plan have restrictions on my drugs (like prior authorization, step therapy or quantity limits)?
• Prior authorization means that you must get approval from your plan before the plan will pay for the drug.
• Step therapy means that your plan requires you to try a cheaper version of the drug before it will cover a more expensive one.
• Quantity limit restricts the quantity of a drug you can get within a given time period.
How much will my out‐of‐pocket be next year?
• Remember that your costs will include your plan’s premium, copays/coinsurance and possibly a deductible, depending on the plan you choose. Your drug cost will be determined by what type of medications you use and where those fit on the plan’s formulary.
What pharmacies can I use?
• Plans have a network of preferred and standard pharmacies. Using a preferred pharmacy should get you the best price for your drugs. A standard pharmacy will fill your prescriptions, but at higher cost than you may pay at a preferred pharmacy. Sometimes a pharmacy can be out‐of‐network, meaning you would pay full cost for your drugs.
I have an Advantage Plan. What providers and hospitals can I use? Are there other rules I should know about?
• Medicare Advantage plans have a network of providers that you will need to be aware of. If your Advantage Plan is an HMO, you will need to go to in‐network providers for the plan to pay. If your Advantage Plan is a PPO, you will have a network of providers to choose from, but you will also have the option to go out‐of‐network. Typically an Advantage Plan will have other rules you should be aware of, such as getting referrals or prior authorization before receiving a service.
I have an Advantage Plan. Is there an out‐of‐pocket maximum?
• Advantage Plans have an out‐of‐pocket maximum that sometimes can be high, but can help protect you if you have expensive health care costs. Note that the plan has rules in place to determine what costs apply to the out‐of‐pocket maximum. Your drug cost will not count toward this maximum.
These are just some of the basic questions you should ask during Open Enrollment to ensure you are getting the best coverage from your Medicare in 2019.
Nebraska SHIIP serves as the State of Nebraska’s source of unbiased Medicare education and counseling and is a division of the Nebraska Department of Insurance. Nebraska SHIIP has locations throughout the state to help you compare your Medicare options. This help is available over the phone or one‐on‐one with a Certified Counselor. You can contact your local Nebraska SHIIP at 1-800-234-7119.
‐ Jonathan, Nebraska SHIIP