Medicare Advantage Plans Prescription Drugs
Everyone talks about the importance of prescriptions, and their high cost. Some of your friends and family members hit the “donut hole.” But not you! The city’s five health plan choices provide seamless coverage over that gap. All five plans offer benefits much more generous than Medicare Part D.
You enjoy one of the richest prescription benefits around – fixed copayments for most covered prescriptions. Those benefits are costly. We expect to spend over $39 million in prescriptions in 2008. That’s about 22 percent of the total health plan cost. Over half that cost is for retiree prescriptions.
The plan features chart describes the prescription coverage from all 5 city health plans. Use this chart, the list of prescriptions, and the formulary list from each plan to determine which prescription benefits are best for you. Many of your fellow retirees say this is the most important factor when considering a new plan.
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Prescription benefits
The chart on page 4 describes the prescription benefit provided by TexanPlus and Texas HealthSpring. It includes coverage for Part B and specialty drugs. Under TexanPlus, Part B drugs used for catastrophic illnesses require you to pay 20 percent of the cost up to $1,500. Texas HealthSpring requires you to pay 15 percent of the cost until your 15 percent reaches $1,000.
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What is Medicare Part D? – a brief overview
Part D is the prescription drug benefit for Medicare members. Medicare is contracting with many pharmacy vendors around the country to provide the benefit. Not all plans are offered in every area of the country. You are receiving many advertisements in the mail and on the phone that want you to enroll in a drug plan. There are many variations, but all plans offered have to be at least “equivalent” to the Medicare Part D benefit. That means some plans offer only the required benefit, and some plans offer additional benefits. These plans will cost different amounts, since the benefits are not the same.
We strongly suggest that you do not enroll in a Medicare Part D program if you intend to remain in a city-sponsored health plan. Medicare will not allow you to be enrolled in Part D and an MA plan at the same time. You will be dropped from the MA plan. You do not need to enroll in Part D to retain the prescription coverage offered by the city’s health plans.
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What effect will Medicare Part D have on the city’s health plans?
Part D will not affect the city’s prescription benefits. Prescription coverage will be available without enrolling in a Part D plan. In fact, if you enroll in a stand-alone Part D plan and you are enrolled in one of the city sponsored MA plans, Medicare will cancel your medical coverage in the Medicare Advantage plan. The only coverage you will have is your Part D stand-alone prescription plan. Your city-sponsored retiree health plans provide equivalent or better prescription coverage than Medicare offers in 2008. In November of each year, you will receive a letter from the city informing you that the city’s prescription benefits plans are (or are not) equivalent to Medicare Part D.
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Top ten retiree prescriptions
The chart below shows the top 10 medicines taken by retirees as of July 31, 2007, and their coverage tier under Aetna, TexanPlus, Texas HealthSpring and the HMO.
Drug, Therapy Class |
Aetna |
TexanPlus+ |
Texas HealthSpring+ |
HMO Blue Texas |
Retail cost |
|
Formulary Tier |
(30-day Supply) |
Lipitor Cholesterol 20 mg tab |
2 |
2 |
2 |
3 |
$121.99 |
Nexium GERD 40 mg capsule |
2∆ ∆ |
2 |
not covered |
2∆ |
$161.99 |
Enbrel Arthritis 50 mg/ml injection |
3** |
3** |
2** |
2* |
$1,529.99 |
Actos Diabetes 30 mg tab |
2 |
2 |
2 |
2 |
$196.99 |
Tracleer Primary pulmonary hypertension |
2** |
3 |
3** |
2 |
$4,120.44 |
Prevacid GERD 15 mg capsule |
2∆ ∆ |
2 |
2 |
3 |
$164.99 |
Diovan High blood pressure; 80 mg tablet |
2 |
2 |
2 |
2* |
$70.09 |
Coreg High blood pressure; 25 mg tablet |
2 |
2 |
2 |
2 |
$139.99 |
Protonix GERD; 40 mg tablet |
2∆ ∆ |
3 |
2 |
2∆ |
$128.99 |
Fentanyl (generic) pain; 50 MCG patch |
1 |
1 |
1 |
1 |
$243.99 |
+ Indicates closed formulary.
* Included in step therapy program.
** Requires prior authorization.
∆ Dispensing limits.
∆ ∆ Prior authorization and quantity limits.
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Retiree prescriptions as a percent of total prescriptions
In this plan year, the city expects to spend more than $39 million on prescriptions for all plan members. Retiree prescriptions are projected to be 51 percent of that amount, over $20 million.
![Retiree pres](../oe07/images/retiree_pres-chart.gif)
Note: Beginning with 2006 - 2007, BCBSTX data is reflective of the 5/1 - 4/30 plan year, and Medicare Advantage data is reflective of the calendar year, 1/1 - 12/31.
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What is a formulary?
A formulary is a list of covered drugs. Each plan’s formulary is different and can change each year. The drug formulary established by Medicare for 2008 serves as the model for Medicare Advantage formularies. View the 2008 formularies at these three Web sites:
Aetna PFFS
www.aetnamedicare.com
TexanPlus
www.sctexas.com
Texas HealthSpring
www.texashealthspring.com
HMO Blue Texas
www.bcbstx.com
Formularies may change each Jan. and May.
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Mail-order pharmacy benefit
If you are on maintenance medication that you will be taking for more than 30 days, you should try the mail order drug plan. It’s convenient and saves you money. You can order over the phone or on-line and receive a three month supply of your medication for 2 months copayment. If you are using a non-preferred drug, the mail order plan will save you $180 per year, per non-preferred prescription.
Plan |
Aetna |
Texas HealthSpring |
BCBS HMO & PPO |
Mail-order vendor |
Aetna Rx Home Delivery |
Walgreens |
Prime Therapeutics |
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