Medicare

Are you turning 65 or did you pay too much for your Medicare Part D deductible last year?

The 2023 Open Enrollment period has ended

2024 Open Enrollment will begin October 15th, 2024

Medicare is health insurance for people 65 years of age and older.

You’re first eligible to enroll in Medicare 3 months before you turn 65, though you may be eligible to get Medicare earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease). 

Click here to be led to the official Medicare website, where you can find and compare plans, get your questions answered, and log in or create an account.

Your Medicare card

Your Medicare card has a Medicare Number that’s unique to you—it’s not your Social Security Number (this used to be the case). This helps protect your identity. If you still have a Medicare card that lists your Social Security Number, leave this card in a safe space at home and contact Medicare ASAP to request that they send you a new card!

The card shows:

  • You have Medicare Part A (listed as HOSPITAL), Part B (listed as MEDICAL), or both

  • The date your coverage begins

Bring this card with you, along with any additional health insurance cards (e.g., for supplemental or prescription drug coverage), to all health appointments.

Open Enrollment

Medicare Open Enrollment takes place every fall season and is an opportunity for you to switch insurance coverage to a plan that best suits your health needs or select a Medicare plan for the first time, if you’re about to turn 65. Open Enrollment for 2024 Medicare insurance plans has now CLOSED. If your selected plan for next year is NOT listed on the spreadsheet linked below, unfortunately, the plan will not be in network at our pharmacy next year. But no fear! We can still fill some or all of your prescriptions out-of-pocket through our Cost Plus self-pay program.

If you’d like to keep informed about Medicare-related updates (and other important announcements!) at St. Paul Corner Drug, consider signing up for our news bulletin, the DOSE.

Are you a Medicare patient at
St. Paul Corner Drug?

The rest of this page includes information about how Medicare works in general and at our pharmacy in particular, as well helpful guidance from us about how we think patients might go about choosing a Medicare plan. Ultimately, you can’t be an informed consumer of healthcare without understanding how it works (and how it doesn’t work, given our broken health system), as well as your options.

Click the button below for a quick reference on what Medicare plans will be accepted at our pharmacy for 2024.

YOUR OPTIONS

YOUR OPTIONS

No

See our spreadsheet of 2024 Medicare plans by clicking on the red buttons above or farther down the page

I’m not sure

Yes

If this is you, keep in mind that there are a number of benefits to participating in Cost Plus, even if it isn’t cheaper than using insurance

If this is you, keep in mind that this will impact our ability to bill your vaccinations to insurance

How Medicare works

The basics

There are different “parts” that together make up a Medicare patient’s health insurance coverage:

  • Part A = Hospital coverage

  • Part B = Medical coverage

  • Part D = Prescription (drug) coverage

  • Part C = Medicare Advantage coverage, which is a “bundled” form of Medicare coverage that includes hospital, medical, and (usually) drug coverage

    • Click here to read about why we we call these Medicare “disadvantage” plans

Additionally, Medicare drug coverage works through 4 stages across the course of a year. Read on for more information about each of these stages. Additionally, you can login to your account at Medicare.gov to see an estimate of when you’ll reach each stage of Medicare coverage on your current or future insurance plan.

  • Stage 1 = Deductible (if the plan has one)

  • Stage 2 = Initial coverage

  • Stage 3 = “Doughnut hole” (coverage gap), when your copays will be their highest

    • Patients usually only reach this stage is they take at least one expensive (usually brand name) medication

  • Stage 4 = Catastrophic coverage, when your copays will be their lowest

    • Patients usually only reach this stage if they take several expensive (usually brand name) medications

Costs for Medicare drug coverage

As part of your Medicare Part D (the “D” stands for “drug”) coverage, you’ll make payments throughout the year covering your:

  • Premium = the monthly fee you pay to participate in that plan

  • Yearly deductible = the amount you must pay each year for your prescriptions before your Medicare drug plan pays its share

    • The standard deductible increased from $505 in 2023 to $545 in 2024

    • Some Medicare plans don’t have a deductible, and the deductible can vary between those that do. No Medicare drug plan can have a deductible greater than $545 in 2024 (it was $505 in 2023).

    • An annual deductible is why many patients have a few high copays at the beginning of the year; since their insurance isn’t yet contributing to any cost sharing on their prescriptions, even though prescriptions are being billed to their plan, the plan isn’t “covering” any of the cost.

  • Copayments or coinsurance = the amounts you pay for your covered drugs after you’ve met your deductible (see above), if your plan has one

    • Copay = a set rate you pay for prescriptions, clinic visits, and other types of care

    • Coinsurance = the percentage of costs you pay after you've met your deductible

    • These amounts may vary because drug plans and manufacturers can change what they charge at any time throughout the year. The amount you pay will also depend on the tier level assigned to your drug (click here to read more information about how drug tiers work). Your copay and/or coinsurance rates can increase throughout the year if a manufacturer raises the price of a drug you take or if you continue taking the brand name form of a drug when a generic becomes covered by your plan (i.e., is added to their “formulary”). Check out the video above to understand how your drug costs can change over time.

  • Costs in the coverage gap (“doughnut hole”) = a stage of Medicare drug coverage in which there’s a temporary limit on what your plan
    will cover for prescriptions

    • Most Medicare drug plans have a coverage gap, but not everyone will enter it during the course of a calendar year. The coverage
      gap begins after you and your drug plan have spent a certain amount for covered drugs; in general, we find that many of our
      Medicare patients taking expensive brand name drugs reach this gap about 3/4 of the way through any given year (the coverage
      gap is the third of four stages of Medicare coverage and the final one before entering the “catastrophic” stage, wherein your costs
      to fill your prescriptions will be at their lowest).

  • Costs if you get Extra Help = a Medicare program to help people with limited income and resources pay for Medicare Part D premiums,
    deductibles, coinsurance, and other costs

  • Costs if you pay a late enrollment penalty = an amount that can be added to your Medicare drug coverage (Part D) premium if, at any
    time after your Initial Enrollment Period is over, there's a period of 63 or more days in a row when you don't have Medicare drug coverage
    or other creditable prescription drug coverage

The out-of-pocket spending threshold increased from $7,400 in 2023 to $8,000 in 2024 (equivalent to $12,477 in total drug spending in 2024 compared to $11,206 in 2023). Your actual drug costs will vary depending on:

  • Your prescriptions and whether they’re on your plan’s list of covered drugs (“formulary”, which, notably, is determined by your insurance plan’s Pharmacy Benefit Manager (PBM))

  • What tier the drug is in (see above)

  • Which drug benefit phase you’re in (like whether you’ve met your deductible, or if you’re in the catastrophic coverage phase)

  • Which pharmacy you use (whether it offers preferred or standard cost sharing, is out of network, or is mail order). Your out-of-pocket drug costs may be less at a “preferred” pharmacy because it has agreed with your plan to charge less, but this isn’t always the case; the use of the terms “in-network” and “preferred,” frustratingly, DOES NOT always equate to cheaper care.

  • Whether you get Extra Help paying your Medicare drug coverage costs

The above information is adapted from Medicare.gov, the US government’s official website for Medicare. Click here to read more detailed information on costs for Medicare drug coverage on their site.

Our thoughts on choosing a Medicare plan

Understanding Medicare prescription plans can seem daunting, but it doesn’t have to be. Below are the things we at St. Paul Corner Drug want you to know as your embark on the process of selecting a Medicare health insurance plan for next year.

Do your research

Choosing a health insurance plan should NOT be something you do based on the recommendation of fellow seniors. Rather, it’s important to, as our teacher friends say, “do your homework” and research available options that will best suit YOUR healthcare needs. Similarly, it’s important to research available plans EVERY YEAR, rather than continuing to select the same plan you’ve been on… just because. Jay Norberg, a fellow independent pharmacy owner in Minnesota, recently crafted a short but sweet summary [audio recording available] on why researching Medicare plans every year is not just recommended, but necessary, to ensure you’re not overpaying for your prescriptions and pharmacy care. Like Jay, we’re not legally an insurance agent who sells insurance nor can we recommend a particular insurance plan; however, we CAN help guide you in your choice of a Medicare drug plan for this coming year.

Comparing plans

The best way to find a plan that is the most cost-effective given the medications you take and will allow you to receive care from your current providers (including us!) is to visit Medicare.gov and utilize their plan comparison tool. Additionally, you can click the button below to view a spreadsheet listing the Medicare plans that will be accepted at St. Paul Corner Drug for 2024. As expected, the variety of Medicare plans we are able to accept at our pharmacy continues to dwindle as PBM abuse worsens (the reason we don’t accept plans is because it would be financially detrimental for us); popular Minnesota plans that we won’t be accepting next year include Blue Cross Blue Shield, Humana, and Medica.

Plans that will be accepted at our pharmacy in 2024

In other words, these are plans that we will be “in-network” for (as mentioned above, watch out for words like “preferred” / “not preferred”) in 2024. If you’ve already researched and selected a plan that is NOT listed on the spreadsheet linked to the button below, please be aware that you’ll need to either re-select one of those listed before the Open Enrollment period ends on December 7th, 2023 OR plan to fill your generic prescription(s) through our Cost Plus self-pay program in order to continue filling prescriptions at our pharmacy next year.

How your choice affects vaccination services

If you ultimately select a plan that isn’t accepted at our pharmacy, the kind of Medicare plan it is will determine whether we can bill your vaccines to insurance:

  • If you have traditional Medicare with a Part D plan for your drug coverage, we will only be able to bill COVID, flu, and pneumonia vaccination to your insurance (because these vaccinations are currently covered by Medicare Part B).

  • If you have a Medicare Advantage (Part C) plan, we won’t be able to bill ANY vaccinations to your insurance.

The cost of any vaccine paid for out-of-pocket includes the raw cost of that vaccine plus an administration fee (similar to how Cost Plus charges the patient the raw cost of the drug plus a dispensing fee). This can range from tens to hundreds of dollars, depending on the vaccine.

Our take on available plans

Regardless of what medications you do take (cheap generics vs. expensive brand-name drugs), you may want to consider the value of selecting the most affordable plan available to you and, additionally, consider participating in our Cost Plus self-pay program. While this may give you cause for concern (doesn’t that mean my pharmacy care won’t be covered?), we suspect this approach might make the most sense for a majority of our Medicare patients when considering the intricacies of insurance in our nation. Unfortunately, the American insurance industry is for-profit and benefits financially from a lack of transparency and preventing patients from being informed consumers; this is why health insurance plans can change drastically from year to year (and even within the coverage year). Additionally, we can assure you that, if you’re taking any number of brand-name medications (common ones include Advair, Eliquis, Ozempic, and brand-name insulins like Humalog and Novolog) either because these medications don’t have a generic alternative (common), your insurance requires that you take the brand-name version (common), or because your body responds best to this version of these medications (uncommon), these are going to be expensive no matter what plan you select. By choosing a plan with a more affordable monthly premium and deductible, you’re keeping more of your money in your own pocket to fund your care how you choose instead of surrendering it upfront to an insurance company that (if we’re being honest) probably doesn’t have your best interests at heart.

Consider Cost Plus

Keep in mind that we now offer a self-pay program called Cost Plus, wherein we bypass patients’ insurance and instead charge them the raw cost of their medication plus a dispensing fee that accurately reflects our operating costs. Even if the Medicare Part D plan you select for 2024 is accepted at St. Paul Corner Drug, this could be a great way for you to:

  1. Save money

  2. Avoid the hoop-jumping often required when using insurance and/or

  3. Support us financially as we, like all other independent pharmacies in the US who accept insurance, struggle to stay open while waiting for legislative action to address Pharmacy Benefit Manager (PBM) abuse

And, if the Medicare Part D coverage you select for 2024 is NOT accepted at our pharmacy, this is a way for us to continue filling your generic prescriptions.

How can Cost Plus save me money?

For many patients, the price they pay to fill their prescriptions through Cost Plus (in general, the raw cost of the drug plus a dispensing fee) will actually be less than what they would pay if using insurance. This is because, as time has gone on, the insurance industry has become more about making money than taking care of patients. The complicated nature of the industry and intricacies of each health plan further muddy the waters, making it easy for patients to think they’re paying less when using insurance even though this turns out not to be the case when we crunch the numbers. See below for a few real life examples from actual SPCD patients.

How does Cost Plus help me avoid the hoop-jumping?

Using insurance means being subject to the various “hoops” the industry has developed to avoid having to cover the cost of patients’ medications. These include things like Prior Authorizations (otherwise known as “PAs,” which must be applied for and approved when a drug isn’t covered on a patient’s plan), vacation overrides, and lost medication overrides. Additionally, the logistics of interfacing with the insurance industry further complicates the filling of prescriptions: long wait times for phone calls with insurance companies, unhelpful phone operators, the provision of misinformation, and billing challenges, to name a few. When filling your prescriptions via a self-pay model instead, these hoops become irrelevant—you can fill your medication whenever you want, for the quantity you want, within the constraints of the prescription itself.

How does Cost Plus support us financially?

As you’ve probably heard, we (and probably every other independent pharmacy in America that accepts insurance) currently lose money dispensing prescriptions. In short, this is because of the pervasive, abusive conduct of PBMs (the middleman between pharmacy providers like us and payers like insurance companies and the state/federal government). Our industry, unfortunately, is unique in the fact that we are told both what we have to pay for a drug that we want to carry in our store and what we will be paid when we fill it—often just cents on the dollar, or even sometimes a negative amount that puts us in the red. At this time, approximately 60% of prescriptions filled at retail pharmacies—both chain and independent—are paid out by insurance companies below cost, which makes it nearly impossible for us to remain viable businesses in our communities. Additionally, prescriptions billed to Medicare health plans carry an additional complication in the form of a DIR fee (colloquially known as a “clawback”). These clawbacks are fees that we must pay back to PBMs every trimester and are part of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) legislation that created the Medicare Part D program and Medicare Advantage plans, which went into effect in 2006. They’re non-itemized (i.e., calculated with zero transparency), collected retroactively, and have grown exponentially with time (in 2022, our pharmacy paid out $368,000 in DIR fees—an amount that would cover the annual salary and benefits of two full-time Pharmacists). While these fees will now be collected on a daily basis starting in 2024, they remain a legal way for PBMs to steal monies already paid out to pharmacies like us for pretty much zero reason other than… They can. And they will continue to without significant legislative reform (and probably a lot and a long road of growing pains, too). By becoming a Cost Plus patient, you’ll be helping us subvert the financial burden we currently carry from doing our essential work filling prescriptions and, hopefully, help us remain a thriving community-based business and healthcare provider for many years to come.

If you decide that you’d like to participate in Cost Plus, please give us a call and ask to speak with one of our Pharmacists or Pharmacy Technicians about Cost Plus (alternatively, you can send us a message here). If they don’t have time to chat with you in the moment, they’ll give you a call back when they’re able. When you eventually connect with the Pharmacist or Technician, they’ll answer any remaining questions you have and educate you about next steps for participating in the program, including completing our Patient Authorization for Self-Pay (HITECH) form, which is required for most Cost Plus participants.

A note on Medicare Advantage plans

We also want to caution patients about the option of selecting Medicare Advantage (also known as Medicare “Part C”) plans, which are advertised as a brilliant “bundled” option for all Medicare-covered services, but in reality often severely limit a patient’s care options and then prohibit patients from further supplementing their coverage where needed (for this reason, we often call them “Medicare Dis-Advantage” plans). For example, these plans are notorious for denying the coverage of claims for Medicare-required services and getting away with it, likely due to a lack of oversight from entities like the US government and patients’ inability—for a variety of reasons—to fight denied claims.

In other words, if a Medicare plan seems too good to be true—such as covering “all” of your health services with a $0 premium—it probably is. In a for-profit healthcare system like ours, you’re going to end up paying for your health services one way or another. If you have questions about this, feel free to give us a call and we’d be more than happy to talk with you about it.

Did you know that all Medicare plans send their covered members a monthly statement?

These statements detail exactly where you’re at across the 4 stages of Medicare Part D (drug) coverage and are a great way to keep track of your expenses as well as help you decide what plan might be the best fit for you in the coming year.