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Your Medicare support system: What a pharmacist can teach you about prescription drug coverage

By Karla Pope

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For most of us, a pharmacist is someone who fills our prescriptions and answers questions about dosage and side effects. But these trained professionals can also be an invaluable member of your health care team. They can share tips to help you better understand your Medicare prescription drug coverage, get the most out of its benefits, and more.

“Your pharmacist is there to be a resource,” says Erin McKenna, an Aetna pharmacy director. “Pharmacists certainly have vast clinical knowledge, but also a lot of general drug cost knowledge. Let’s say someone says, ‘I can’t afford this medication. Is there anything that works similarly that I can talk to my doctor about?’ A pharmacist can be there to support them. Also, if members can’t seem to remember to take their medication or if it makes them sick to their stomach, pharmacists can offer solutions and answers to help in those situations, too.” 

Here, McKenna explains the importance of signing up for prescription drug coverage, the difference between brand name and generic drugs, and ways your pharmacist can help you trim medication costs.

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Let’s start with prescription drug coverage. Do members need to sign up for it even if they’re not taking any prescription medications?

McKenna: Yes, they should. Having the coverage is about being protected, and if nothing else, gives you peace of mind. After all, how do you know what’s going to happen with your health a day from now or a year from now?

Also, if you don’t sign up for prescription drug coverage when you first qualify for Medicare, you may end up paying more for it later. And the longer you delay, the more you could pay once you do sign up for drug coverage. This means signing up early can be cost effective, even if you aren’t taking any prescription medications right now.

So you’ll have to pay a penalty for not having prescription drug coverage?

McKenna: That’s right. If you don’t have a form of health insurance other than Medicare that includes drug coverage, and you don’t sign up for drug coverage when signing up for the rest of Medicare, you may pay a penalty. And the longer you delay signing up, the higher that penalty could be. Even if you don’t think you need coverage now, you can sign up for a prescription drug plan with low or even zero-dollar monthly premium. This will keep you from paying the penalty later.

But this goes beyond just avoiding the penalty. I can’t emphasize enough that you really need some form of drug coverage. After all, you don't drive your car without at least minimum insurance coverage, so why go without minimum drug coverage?

I keep hearing the term “formulary” when people talk about prescription drug coverage. What’s a formulary, and what are some things everyone should know about it?

McKenna: A formulary is a list of medicines that are covered by your plan. Formularies are designed by clinicians, and there’s a lot of expertise that goes into creating them. By Medicare requirements, members must have access to their plan’s formulary. If you wanted to, you could read about all the drugs in your plan’s formulary, almost like a booklet.

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Formularies include both brand name and generic drugs. What are the basic differences between brand name and generic drugs? How can members know which to choose?

McKenna: Think of the brand name drug as the innovator. It’s often the first version of a drug. For a certain period of time, the company that developed the innovative drug is the only one that can make it.

But after enough time has passed, other companies can also begin making generic versions of that drug. Generally, brand name drugs and generics have the same effects, and both are produced in a safe manner under stringent manufacturing regulations.

As for knowing which one to choose, consult with your physician, pharmacist and formulary to see what’s best. If you have a choice between multiple drugs that are both brands and generics that do the same thing, you may be able to get the generic version for less money based on your formulary.

What can members do to save on prescription drug costs?

McKenna: Oftentimes, members experience sticker shock when it comes to what they pay for a drug. So I think it’s important to have a conversation with your pharmacist. Say, ‘This is more than I'm expecting to spend. Are there other choices that are good for me?’ Pharmacists know the prices of medications, and in many instances can recommend generic versions that cost less. Pharmacists may even offer to help facilitate these lower costs by calling members’ doctors directly to discuss lower-cost versions of a drug.

You can also ask your pharmacist if there are assistance programs that can help with the cost. There are low-income subsidy support and assistance programs for those with limited incomes. Help is available. It’s important to ask your pharmacist what type of assistance you might be eligible for based on your income level.

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I’ve heard that you can also save money by going to a preferred pharmacy. What's the difference between a preferred pharmacy and a regular pharmacy?

McKenna: Aetna has preferred relationships with certain pharmacies. What does that mean for a member? It often means a lower out-of-pocket cost on certain copays. In this case, copay refers to the amount you pay when you get a prescription filled.

For example, at a standard pharmacy, a copay could be $10, but at a preferred pharmacy, it could be $5 or even $2. When you sign up for coverage, your insurer will send you information about an online document that lists your plan’s preferred pharmacies. You can also request a paper copy if you prefer. When members get their new benefits information each year, it shows expected copays at a preferred pharmacy versus expected copays at a standard pharmacy.

If you’re an Aetna member, you can find more information about preferred pharmacies on our website. You can see which pharmacies are in network and which are preferred.

What do you think members can do to build a stronger relationship with their pharmacist?

McKenna: I think people should ask their pharmacist any questions they might have about their medications, whether that’s how their medicine works or how much it costs. You should also talk to your pharmacist if you're having problems remembering to take your medicine or are experiencing unexpected side effects. They'll be able to help identify what issues might be attributed to your medication therapy and ways to manage those side effects.

Having an honest conversation with your pharmacist can be beneficial in other situations as well. You may be struggling to afford your medication, for example. Though difficult, having that conversation is important. You should be able to share your situation with your pharmacist, so they can work with you.

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What’s the most gratifying part of being a pharmacist?

McKenna: I think pharmacists are just like anybody in a job. We want to do things that feel rewarding. To be able to say at the end of the day that you filled 400 prescriptions isn't rewarding. But when you help make somebody healthier or help with an issue they were having with their medicine, that's really what it's about. Our job is to be part of a team to help folks live a healthier life. We want to talk to you so we can help you. Invite us in to be part of your health care team.

About the author

Karla Pope is a longtime writer, editor and lifestyle blogger who enjoys exploring New York City with her two young children. When she’s not visiting the many cultural attractions the city has to offer, she’s relaxing at home with her husband. Karla’s also trying to expand her healthy meal plan beyond her daily seafood, rice and veggies.