Sunday, October 16, 2016


You’d better
Shop around

WHEN IT COMES TO MEDICARE ADVANTAGE plans, Smokey Robinson and the Miracles got it right: “You got’ta shop around.”

This scrivener seconds that emotion.


I had an “regular” AvMed plan when I was working for a now-defunct company called DMR. When I signed up for Medicare years later I ended up with an AvMed Medicare Advantage plan. We had a decent relationship until AvMed cancelled my PCP, a doctor who was an excellent diagnostician.

Miffed, I signed up with Humana – for a year.

With Humana I discovered “capitated” PCPs.

Capitated & Decapitated

With AvMed, my PCP could refer me to ANY specialist on AvMed’s Providers’ List.

Not so with Humana.

While Humana had a lengthy Providers’ List, the doctor who became my PCP had a very much reduced list of specialists to whom he could refer.

Humana was unable to tell me which doctors could refer me to my vascular surgeon (Abdominal Aerobic Aneurysm, FemPop Aneurysm); it was left to me to contact PCP prospect after PCP prospect until I found a PCP whose personal specialists list included my vascular surgeon.

Fortunately, with Medicare, a patient can change PCPs every month. I did. During the year I was a Humana client I changed PCPs three times.

As soon as October rolled around, I signed up once more with AvMed.

Prescription “tiers”

Medicare Advantage programs have multiple “tiers” for prescriptions. “Tier 1” usually are free to the plan client. These typically are low cost generic medicines. Publix, a supermarket chain in Florida and Georgia, fills some prescriptions for “Tier 1” drugs at no cost to plan or plan client; consequently Publix gets ALL my prescriptions.

I started the year with a Tier 2 medication. The next year, AvMed jumped it from Tier 2 to Tier 4. Tiere 2 cost me $7 for a 30-day supply of pills; AvMed now demands a $75 copay for the same number of pills. Quite a jump.

I checked some discount pharmacy offers and discovered that a number of sources offer the medication at prices LESS THAN AvMed’s $75 copay.

Did all Advantage plans list my medication as a Tier 4? I already knew Tier 4 copays varied by plan provider.

Turns out different plans put the medication at different tiers. I found one – HealthSun – that showed the medication as a Tier 1 (no copay) on its Formulary list. Others listed the medication as Tier 2 or 3.


When comparing Medicare Advantage plans, ask the competing providers for

    EVIDENCE OF COVERAGE; this commits the plan to provide the things it promised Medicare to provide. Skip any overviews; they are just marketing.

    FORMULARY; this lists all the medications the plan covers. If your medication is missing from the list, ask why; is there an alternative. The Formulary also tells you the medication’s tier level. (The Evidence of Coverage sets out the copay for each tier level.)

    PROVIDERS’ LIST; this identifies all the physicians who work with the plan - BUT CHECK FOR “CAPITATION” - as well as hospitals, urgent care centers, pharmacies, and other suppliers.

In most cases, the information is online. You may have to contact the plan to find out the URLs, but usually they will be provided quickly. AGAIN, check about capitation.. If you have specialists who have been treating you and you want to keep them, this is a critical question. Some plans have a mix of capitated and non-capitated PCPs and many plan Customer Service reps will tell you which are capitated. If you select a capitated PCP, you need to call the doctor and find out if you can be referred to your preferred specialists. (HealthSun, ibid., has both and CSR Malissa Soriano has proven to really provide “customer service” in sorting out who is and who is not capitated.)

Medicare Advantage programs can be wonderful things, but as with any insurance – home, health, auto, etc. – keep in mind what Smokey Robinson and the Miracles advise: “You better shop around.”

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