What Tests or Procedures Are Covered Under Medicare?

A doctor tells you that you may need a test or procedure done and, after leaving the office, you begin to worry if that test is covered under your Medicare plan.  This is a worry for everyone but especially for new people coming into Medicare.  Having seen many things denied, or having gotten into a fight with their commercial insurance company prior to joining Medicare,  it is understandable that this worry comes up.  Did you know that there is a Medicare app called “What’s Covered?” that is available on both the Apple Store and Google Play?

This app allows you to search procedures and tests already listed in their database and allows you to type in procedures by name.  It also covers preventive services and the frequencies in which you may have them done.  Some services do require your Medicare participating physician to get a pre-authorization before the service is done.  It never hurts to make sure they have done so.

As for coverage with your Medicare Supplement Plan – if Medicare covers the service and has pre-authorized it for you (again check with your doctor) then your Medicare Supplement plan must also pay the remaining balance.  The Supplement cannot say “No!”, to a Medicare approved service.

Medicare Advantage plan members are the exception...

If you are covered under a Medicare Advantage plan, this application won’t be accurate for you.  While you are still part of the Medicare system, it is up to the commercial insurer who offers you coverage under the Part C Medicare Advantage Plan, whether it will be covered or not.  In that case always check with your physician and your insurer if you have any questions on whether a test or procedure is covered and how it will be covered.

by susan

Ways To Help With The High Cost Of Prescription Drugs

Have you ever felt that your money was being ripped out of your hands when you had to fill prescriptions at pharmacies? While there are no fool proof answers to the problem, whether you have individual insurance, Medicare prescription insurance, or even many group plans, the costs are prohibitive for many of the most commonly prescribed brand name and high-cost generic drugs. There are some options to look at however though some may mean having to do a bit of work.

It takes people making noise to make a difference.

Most people are now familiar with drug discount programs like Good RX, Single Care, and Script Saver. Many have also heard of “Cost Plus Drug”, an online pharmacy began by Mark Cuban that is actually starting to team up with insurance companies in Pennsylvania like Capital Blue Cross**. This may be something that you would want to write to your current health insurance or prescription drug plan about. It takes people making noise to make a difference. I keep running into too many people being willing to say, “What can I do about it?”. You can make noise about the ridiculous pricing of medications in the United States not only to your insurer but also to your representatives in both the state and federal Congress! They will listen if enough people complain but they won’t do anything if you keep silent!

Another big suggestion I constantly make to my clients is to form a relationship with a small independent pharmacist. You cannot help yourself more than by doing that. A small, independent pharmacist has more control over their costs than a pharmacist in a “big box store” that is corporately owned. Studies over the years have consistently shown that small, independent pharmacists overall cost the public less versus the major corporate pharmacies and big box stores when it comes to more expensive drugs. The reason for this is that they can set their own pricing. They will never come out the lowest in cost on Medicare.gov comparisons because you can’t negotiate pricing on that site.

Form a relationship with a small pharmacy

My suggestion is to form a relationship with a small pharmacy and then ask them what they would charge you if you didn’t use your prescription drug card from your insurance at all for your medications. It may not work out the best for very low-cost drugs, because the big box stores negotiate those low-cost drugs at little to no cost to consumers as a way to attract business. Unfortunately, they often have very high pricing for mid-level and higher drugs. Smaller pharmacies may offer home delivery, medication consultations, will talk with your doctor about alternative medications that may be less costly, and have the time to spend with you because they are not under corporate pressures.

Call or email me with any questions. I hear over and over again that the cost of medications are just too high and the government is not doing enough, fast enough, to make the costs less for Americans.

Just a few months since announcing our collaboration with Mark Cuban Cost Plus Drug Company (Cost Plus Drugs), we’re expanding it! Starting January 1, 2023, Cost Plus Drugs will begin accepting Capital Blue Cross prescription drug coverage.

Capital Blue Cross was the first health plan in the country to collaborate with Cost Plus Drugs, helping our members and communities gain greater access to low-cost prescription drugs and transparent pricing. Now, our prescription drug plan members will be able to add their Capital ID card number to their Cost Plus Drugs online account to apply their benefits. Using Cost Plus Drugs is easy.

Cost Plus Drugs is affiliated with billionaire Mark Cuban, who’s working to disrupt the drug industry by offering substantially discounted pricing on a wide range of commonly used generic drugs. Discounts can be as large as 80% below retail!

All costs (except expedited shipping) are included in the cost of each drug on the Cost Plus Drugs website. Pricing is consistently based on: the cost they pay for a drug; plus 15% (to pay for running their business); a pharmacy charge for dispensing the drug; and a charge for standard shipping.

by susan