Express Scripts Medicare - Choice is a 2018 Medicare Prescription Drug Plan for Medicare beneficiaries in Connecticut.
We suggest looking at the five most important parts of the Express Scripts Medicare - Choice plan before enrolling:
- 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
This is a cost sharing plan, which includes a premium (monthly), a deductible (annual), and pharmacy co-pays and/or co-insurance.
The premium is $93.10 per month ($1117.20 annual cost). Here's how it breaks down:
You can't join the Express Scripts Medicare - Choice plan if you have low income subsidy (LIS) benefits.
The annual deductible is $350.00.
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
Two conditions may change the amount you pay for this plan. If you qualify for Social Security's Extra Help program your premium could be lower. Also, if did not enroll in a plan when first eligible CMS will impose a penalty on your monthly premium.
Details of Plan Coverage
Express Scripts Medicare - Choice is a Enhanced Alternative 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 - Choice 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 reach the coverage gap phase, or donut hole, as many people call it, you are essentially uninsured and must pay for all of your prescription costs out-of-pocket. When you reach the coverage gap with the Express Scripts Medicare - Choice plan will all depend on your prescriptions. Most people never exceed the ICL and don't have to worry about it. If you are on a long-term medication that's costly, you could reach the donut hole very quickly.
When you're in the donut hole you pay all of the costs for your medications, but at a discounted rate (47.5% off of brand-name drugs and 28% off generics). You continue to pay this until your out-of-pocket costs reach $4,550. At this point Medicare takes over by giving you catastrophic coverage. The $4,550 out-of-pocket figure does not include your monthly premiums or what Express Scripts Medicare pays.
Enhanced Gap Coverage
Express Scripts Medicare - Choice has limited coverage in the gap coverage phase. Call or review the plan's Summary of Benefits for additional information. If you went into the coverage gap phase last year, and could not afford your medications, call with your local Connecticut Medicaid office and the Social Security Administration (SSA). The SSA's Extra Help program helps people who can't pay for their prescriptions.
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 - Choice 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 - Choice 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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