Highest Premiums & Top Ratings For Medicare Plans Don’t Produce Broadest Coverage of Expensive Medications

Analysis Reveals Difficulties in Shopping for Extensive Specialty Drug Coverage

Mountain View, CA— HealthPocket® released a study of 2018 Medicare Part D and Medicare Advantage plans that revealed the difficulties facing Medicare beneficiaries when trying to find the most extensive specialty drug coverage. Specialty drugs can be very expensive, some costing thousands per month retail, and these drugs have become an ever-increasing portion of U.S. spending on prescription medications. While Medicare drug plans can reduce those costs when a prescribed specialty drug is “on formulary” (i.e. included within the insurance plan’s list of covered drugs), specialty drugs excluded from an insurance plan’s formulary leave enrollees facing full retail price and with no prospect of relief from Medicare’s “catastrophic coverage” provision. Medicare beneficiaries in this situation can petition a plan for a formulary exception but exception approval is not guaranteed and enrollees must still wait for the next enrollment period normally to find a new insurance plan with the drug covered.

For Medicare beneficiaries worried about the potential costs of specialty drugs should they need them, finding a plan with the most extensive coverage of this medication category is not an easy task. HealthPocket examined government data on 2018 Medicare Part D and Medicare Advantage plans and found that specialty drug coverage varied widely within both categories of Medicare drug insurance plans.

The average Medicare Advantage plan had more specialty drugs (635) listed on its formulary than the average Part D plan (531). However, the insurance plan with the largest coverage of specialty drugs in 2018 was a Medicare Part D plan, Educators Rx Advantage (PDP) offered in Utah and Idaho, with 952 specialty medications covered. Likewise, the plans with the fewest specialty drugs listed in their formularies (301) came from the Medicare Advantage category.

When examining the Part D and Medicare Advantage plan costs, HealthPocket found that paying the highest monthly premium did not obtain the broadest specialty drug coverage (though it should be noted that this is not a claim among plans). Blue Cross MedicareRx Plus (PDP) offered in Texas had the highest monthly Part D premium of $197.10 but only covered 642 specialty drugs as compared to the 952 specialty drugs in the plan with the broadest coverage. Among traditional Medicare Advantage plans, Medicare Plus Blue PPO Assure (PPO) from Blue Cross Blue Shield of Michigan had the highest monthly premium at $312.50 and covered 609 specialty drugs. A “Cost Plan” version of Medicare Advantage, HealthPartners Freedom Ultimate with Enhanced Rx (Cost), in Minnesota had an even higher monthly premium at $375.90 and listed 680 covered specialty drugs.

HealthPocket also investigated whether drug plans that received Medicare’s highest rating, 5 stars, had more specialty drugs listed on their formularies. HealthPocket found that the average 5-star Part D plan covered 495 specialty drugs, which is fewer than the 531 average for Part D plans as a whole. 5-star Medicare Advantage plans fared better than 5-star Part D plans. On average, 5-star Medicare Advantage plans covered 606 specialty drugs, fewer than Medicare Advantage plans as a whole (635) but more than the average for 5-star Part D plans (495).

Based on their findings, HealthPocket has recommended that Medicare insurance comparison websites present the number of covered drugs and the number of covered specialty drugs for each Medicare drug plan. Additionally, HealthPocket reminds Medicare enrollees that:

– Not all prescription medications are covered by Medicare drug plans

– The list of which medications are covered by insurance differs among Medicare drug plans

– The out-of-pocket costs for a given drug can vary by Medicare drug plan

The full findings as well as the report methodology can be reviewed at “Neither Highest Premiums Nor Top Ratings For Medicare Drug Plans Result In Broadest Coverage of Expensive Medications.”

HealthPocket.com is a free website that compares and ranks all health insurance plans, helping individuals, families, and small businesses to make their best health plan decisions. HealthPocket publishes health insurance market analyses and other consumer advocacy research. HealthPocket’s research is nonpartisan and uses only objective data from government, non-profit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. HealthPocket, Inc. is independently managed and based in Mountain View, California. Learn more at www.HealthPocket.com.