Assisting Your Clients With Prescription Drug Coverage

Critical guidance to offer during AEP


Many agents are reluctant to assist clients with exploring the prescription drugs plans that best fit their needs. A growing number of agents are leaving their clients to fend for themselves on the site to research and secure their plans. There is also a fear of allegations due to misrepresentation because of changes in the formularies during the year or errors in the formularies on the quoting platforms at the beginning of the Annual Enrollment Period (AEP). I strongly believe that the Medicare plan-focused agent can assist their clients find the plans (Medicare Advantage or Stand-Alone Prescription) that best fits their needs by thorough research using the drug quoting platforms, the plans’ formularies and knowledge of the various discount prescription drug programs and manufacturers programs for specific drugs.

Tips for brokers when working with clients:

>Make sure to secure the Scope of Appointment and ask if they would like to have you assist in their review of their prescriptions. In Medicare Advantage sales, this is a key consideration in addition to choosing physicians and other providers.
> Make sure the client provides a detailed list of prescriptions, including the name of the drug, the dosage and the frequency. Be firm in securing the right names and dosages.
> Ask if the client must take or prefers taking brand name drugs or takes the generic version.
> Also, you will need the name of their pharmacy(ies) as they may secure their drugs from several.
> Review the different coverage phases of the prescription drug program (Initial, Gap and Catastrophic) and if there is a deductible for the plan, explain how it is applied and how coverage works through phases.
> When using the quoting platforms, confirm that you have the right zip code, the correct input of the drugs with the name, dosage and frequency.
> The quoting platforms allow you to input several pharmacies  this can be helpful when comparing plans.
> If the client has a very expensive drug especially at the non preferred brand tier, you should make a habit of checking the proposed plan’s formulary to see if the drug is being shown correctly.

In reviewing the quotations with the client:

>Make sure you cover the tiers and if there are special requirements such as step therapy, quantity limits and preauthorization.
> When reviewing the progression of the prescription drugs purchase through the year, point out to the client that this is only an illustration. The actual costs vary when moving through the initial, gap and catastrophic phases of drug coverage depending on their actual usage and purchase with the pharmacy’s input in the calculation.
> Always mention that drug formularies may change during the year and along with possible fluctuation in the price of the drugs.                                                                                                                        > In addition, remind clients that if they have a new drug prescribed during the year or there are other changes, you are always available to assist with the review of the formulary. Explain how
the appeals process works for any drugs that are not on their formulary or how to navigate if they need a tier reduction consideration due to the cost of the drug.
> Clients should have a copy or know how to access the formulary for their chosen plan. Explain to them that it is their responsibility to let their physician know if their drug is covered under their
plan. Doctors cannot know every plan’s formulary for each client

Discount programs

The prescription drug discount programs have grown by leaps and bounds the last few years. They offer individuals viable cost alternatives.
However, some may not offer discounts if the individual is on Medicare. For expensive drugs, explore patient assistant programs on manufacturers’ websites.
Here are some discount offerings you may want to explore:

• GoodRx
• RXsaver
• OptiumPerks
• America’s Pharmacy
• WellRX
• Save on my meds
• Internet Drug Coupons
• gogomeds
• SingleCare
• Special pharmacy programs

Be careful about some of the programs. Forewarn your clients that it is a possibility that by using a program’s online platform to obtain discounts, clients tacitly give permission for the program to provide their information to on-line quoting agencies for drug and MAPD plans.

State discount programs

Under the California Senate bill 393 passed in 2000, the State of California also offers a prescription drug program for Medicare recipients. The bill enables Medicare recipients to obtain their prescription medications at a cost no higher than the Medi-Cal reimbursement price for those drugs. Medicare beneficiaries may call the Medi-Cal helpline at 1-800-541-5555 forinformation.

Tip when choosing not to deal with drug plans

If you choose NOT to quote the prescription drug plans, please take the time to at least inform your client about the phases of coverage, how to understand the quoting information, what the star ratings mean and other key information such as when they may change plans.

Tips for offering full service

For those agents who choose to provide the full service of prescription of drug review and plan enrollment, as long as you are selling compliantly and are thorough in your research and counseling,
you should be well rewarded with a happy client and an ongoing relationship.

Recording your calls?

Just a reminder: make sure that you are recording your calls, documenting your conversations and touching base with your clients during the year. You differentiate yourself from call center
agents because as the agent of record, you are there to provide on-going service and support. You truly can and do make a difference for your clients!

MARGARET “MAGGIE” STEDT is an independent contractor/licensed agent and consultant. She is a certified senior advisor and lifetime member of NAHU’s Leading Producers Roundtable at the Soaring Eagle Level. She has over 40 years of experience in essential areas of the insurance industry including sales and sales management, product development and product management. A dedicated leader, Maggie currently serves on the NAHU Medicare Advisory Committee. Founder of the annual Senior Medicare Summit, attendance grew from 200 in 2010 to close to 1,000 attendees in 2022. She served as past president of CAHIP; NAHU Region 8 Membership Chair 2014 – 2018 and past president of OCAHU, serving two terms.