Express Scripts Medicare - Value is a prescription drug plan available in Connecticut. This 2018 Medicare Part D plan is approved by the Centers for Medicare and Medicaid Services (CMS) for people with Medicare benefits.
Be sure to have a look at the five most important components of the Express Scripts Medicare - Value plan before finalizing your enrollment decision:
- Premium & Deductible: The premium is the amount you pay to be in the plan. This is the monthly cost of membership. In addition, plans may have an annual deductible. This is an amount that you pay towards your prescription costs before cost sharing begins.
- Co-pays & Co-insurance: This is where many people pay more than they should. Prescription co-payments (what you pay at the pharmacy) vary widely based on the formulary tier your drug is in. It's critical to verify that your medications are covered at the lowest tier possible.
- Coverage Phases: All Medicare Part D plans have an initial coverage phase, followed by a coverage gap phase, followed by a catastrophic coverage phase. The phase you're in will largely depend on the cost of your prescriptions. Some plans offer additional coverage in the gap phase. If you have costly medications, look for a plan with additional gap coverage.
- Medication Cost: One of the most challenging aspects of the Medicare Part D program is finding your prescription at the best price. It has as much to do with the pharmacy you use as it does the plan itself. This is because plans have preferred pharmacies and pharmacies have different contracts with pharmaceutical manufactures. Here's a secret, use our friends at GoodRx.com to find your prescription at the best price in your town.
- 5-Star Ratings: Critical measurements, by Medicare, will help you see how well this plan will care for you.
Detailed Cost Information
Express Scripts Medicare - Value is a cost sharing plan. There are three costs: monthly premiums, an annual deductible, and co-payments or co-insurance.
The annual premium is $400.80 ($33.40 per month), and breaks down like this:
The Express Scripts Medicare - Value plan qualifies for low income subsidies. The following table shows the subsidised premiums:
|Subsidy Level||Monthly Premium|
There is a $405.00 annual deductible with this PDP.
The Part D deductible is capped at $405 (2018 level). A plan with the maximum deductible is not always more expensive than a similar plan with a lower deductible. You must factor in all costs (premium, deductible, co-pay and pharmacy price).
Your Out-of-Pocket Costs: Premium + Deductible + Co-pay
Here's a rundown of your shared costs. Like all other types of insurance, you must pay your premium. The premium has nothing to do with how many prescriptions you have filled. If the plan has a deductible, you must pay one hundred percent of your prescription costs until you reach the amount of the deductible. When the deductible is met, then you pay the copayment amount at the pharmacy. All other costs are paid by the plan until you hit the donut hole (initial coverage limit)
Your Costs May Be Different
There are two situations that change change what you pay. If you're accepted into the Extra Help program, administered by the Social Security Administration, your premium could be lower. It's also possible that your premium could be higher if you have a late entry penalty because you did not enroll when first eligible.
Details of Plan Coverage
Express Scripts Medicare - Value is a Actuarially Equivalent Standard plan. By law, Express Scripts Medicare is required to offer a standard benefit package. The standard benefit has an annual deductible, an initial coverage limit, a gap in coverage (donut hole), and a catastrophic coverage phase. Insurance carriers have the option to offer plans that:
- are an actuarial equivalent to the standard benefit; or
- provide enhanced benefits, as compared to the standard benefit.
Most enhanced plans provide additional coverage in the coverage gap phase. If your medications are costly, shop and compare enhanced plans.
Initial Coverage Limit Phase
Confused about the initial coverage limit? Don't be, because it's straight forward. If you enroll in the Express Scripts Medicare - Value PDP, you share the cost of your prescriptions with Express Scripts Medicare. You each pay your share until the amount spent at the pharmacy reaches $3750.00. That's the initial coverage limit in Connecticut for plan year 2018. After that you are not covered (coverage gap) until your actual out-of-pocket costs qualify you for catastrophic coverage. Keep reading, because you are entitled to automatic discounts.
Coverage Gap Phase
If you go into the coverage gap phase, commonly called the donut hole, you pay for your medications yourself. Most seniors never go into the coverage gap, but it's possible to hit it quickly if you have expensive long-term prescriptions. That's why it is so important to verify that the Express Scripts Medicare - Value plan offers your medications at the best price before you join.
If you reach the ICL (most seniors don't), then you are responsible for 100% of your prescription costs until your out-of-pocket costs hit $4,550 (excluding your monthly premiums and the amount paid by the plan). This is called the coverage gap or donut hole. The good news is that you get a 47.5% discount on brand-name prescription drugs and a 28% discount on generic drugs while you're in the gap. You get to the other side of the donut hole when you've spent $4,550, at which point you automatically qualify to receive catastrophic coverage from Medicare.
Enhanced Gap Coverage
Express Scripts Medicare - Value does not offer coverage gap assistance. If went into the coverage gap phase last year, and you were unable to afford your prescriptions, call your local Connecticut Medicaid office about assistance. The Extra Help program, from the Social Security Administration, may also be available to help you afford your medications.
Catastrophic Coverage Phase
When your out-of-pocket spending reached $4,950 (2018 level), you'll automatically get "catastrophic coverage." With catastrophic coverage you'll pay a small co-insurance or co-payment for your covered drugs for the remainder of the year. Medicare and your plan pay the rest of the costs.
Co-payment & Co-insurance Details
In addition to the monthly premium and annual deductible, the Express Scripts Medicare - Value prescription drug plan has co-payments (fixed dollar amount) and/or co-insurances (percentage) that you must pay when you pickup your medications. Here's the schedule for this plan:
|Tier||You Pay||Tier Description|
CRITICAL: To understand how much you will pay at the pharmacy if you join this plan, you must find the tier of each of your prescriptions in the plan's formulary.
TIP: Use the GoodRx Medicare tools to find your prescription at the best price in your town.
CMS 5-Star Ratings
The annual CMS plan ratings are important. Each year CMS rates PDPs across four categories. Ratings offer a good clue as to the quality of service you can expect if you join the plan.
|2018 Overall Rating|
|Drug Plan Customer Service|
|Complaints and Changes in the Drug Plan|
|Member Experience with the Drug Plan|
|Drug Safety and Accuracy of Drug Pricing|
Express Scripts Medicare Contact Information
Here's the new member contact information for Express Scripts Medicare:
For assistance 24 hours a day, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 or visit www.medicare.gov
If you are entitled to Medicare Part A (enrolled or not) or currently enrolled in Medicare Part B you may join the Express Scripts Medicare - Value prescription drug plan. Unless you also receive benefits from Medicaid, enrollment in a Part D plan is voluntary. This plan is available in Hartford, Bridgeport, Stamford, Norwalk, New Haven, Milford, Danbury, Bristol, Meriden, West Haven, and all other towns and cities in Connecticut.
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