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What’s the Difference Between a Preferred and Standard Pharmacy?

When you transition to Medicare from private insurance, figuring out how much your prescriptions will cost with your new healthcare plan might feel confusing, or even overwhelming. But there are ways to navigate this new world: one of the first, and most important things you’ll need to know when purchasing your prescriptions, is whether the pharmacy where you fill your prescriptions is considered by Medicare as preferred, standard, or out-of-network.

Knowing the difference between a preferred, standard, and out-of-network pharmacy is important because if you don’t choose the right pharmacy, you’ll end up paying a lot out-of-pocket for your prescriptions. So, before you tell your doctor where to send your prescriptions, or switch pharmacies, be sure to check which of the following classifications Medicare applies to your pharmacy.

Preferred Pharmacy

Preferred pharmacies have negotiated rates, so they can offer the lowest copays and coinsurance, meaning you’ll pay the least for your medications at one of these pharmacies. In addition to getting lower prices, you’ll also often be allowed to get 90-day supplies of your medications when you choose a preferred pharmacy.

Standard Pharmacy

gold money sign — *If you get medicine from an out-of-network pharmacy, you might have to pay for the medicine at full price out of pocket.*

You will pay a little bit more for your prescriptions at a standard pharmacy than at other pharmacies, but you will still not pay full price out-of-pocket, because Medicare will cover some of the costs. Unlike at a preferred pharmacy, a 90-day supply of your medication is not guaranteed at a standard pharmacy, which can be a problem for many people.

Out-of-Network Pharmacy

The last option where you can get your medications is an out-of-network pharmacy. Because these pharmacies are not in Medicare’s network, you can expect to pay full price for any medications that you purchase here.

Need Help?

Before having any prescriptions sent to a pharmacy, talk to the pharmacist to see if they know how your plan works with that specific pharmacy. Remember also to evaluate your Medicare options during your Medicare Open Enrollment Period, so you know what plan is right for you and will give you the lowest out-of-pocket costs. Last but not least, you can work with a Medicare agent to figure out your best option when it comes to your Medicare Plan, so you can get all of your medications and any other necessities you need covered.

To save as much money as possible, speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

How You Can Manage Sarcoidosis

This National Sarcoidosis Awareness Month, we want to shed light on this little-understood inflammatory disease. Sarcoidosis remains difficult to diagnose, with limited treatment options and no known cure. It most commonly affects the lungs and lymph glands, and eventually, the inflammation will change the normal structure and possibly the function of all of the affected organs. But how do you know if you have sarcoidosis, and what will it mean for your body if you do?

What Is Sarcoidosis?

two skeletons with organs showing — *Sarcoidosis is an inflammatory disease that causes inflammation and the failure of your body’s organs.*

It’s estimated that between 150,000 and 200,000 people in the U.S. have sarcoidosis, and around 1.2 million individuals are living with it worldwide. Sarcoidosis is an inflammatory disease that is characterized by the formation of granuloma, or tiny clumps of inflammatory cells, on one or more organs in the body. When a person’s immune system goes into overdrive, and too much cell clumping happens, it interferes with how the organ functions. If sarcoidosis is left unchecked, chronic inflammation can lead to fibrosis, or permanent scarring of the organ tissue. It will affect the lungs in about 90% of cases. For some, the disease will go away on its own, while for others it can progress in life-altering ways.

Symptoms & Causes

Researchers believe that sarcoidosis is caused by an abnormal immune response. The latest research indicates that sarcoidosis could be caused by a genetic susceptibility to the disease.

The disease affects more African-Americans in the country than it does any other ethnicity. For Caucasians, the disease appears suddenly, which means it tends to be milder in this group, while African-Americans and Latinos tend to develop a more long-term and severe form of sarcoidosis.

Sudden onset of general symptoms, such as weight loss, fatigue, fever, or just an overall feeling of ill health, usually means that the course of sarcoidosis will be relatively short and mild in severity. Shortness of breath and some types of skin involvement mean that sarcoidosis will be more long-lasting and severe: the disease is considered chronic in people for whom the disease remains active for more than 2 to 5 years.

Common symptoms of sarcoidosis include:

Shortness of breath
Wheezing
Chronic cough
Fatigue
Irregular heartbeat
Swollen legs
Headaches
Joint pain
Vision problems
Red eyes
Weakness or numbness of an arm, leg, or part of the face
Blurry vision
Arthritis

Diagnosis & Testing

Around a third of people diagnosed with sarcoidosis will require long-term treatment. Common tests used to diagnose sarcoidosis include:

Chest X-ray– This allows your doctor to completely see your lungs and airways. More than 90% of people with sarcoidosis will have abnormal X-rays.
CT scans– A certain type of CT scan that requires a special diet will help show things more clearly to your doctor. During a CT scan, you will be asked to hold your breath so the machine can take pictures of your muscles, bones, and lungs.
Lung function test- Your doctor will have you breathe into a mouthpiece that is attached to a spirometer, which is a device that measures the amount and speed of air that you blow out.
Lung biopsy– After conducting X-rays and lung function tests, your doctor might take a sample of lung tissue for testing.
Blood test– Your doctor might give you a blood test to check for an excess amount of vitamin D and/or a chemical called angiotensin-converting enzyme.
Heart rhythm monitoring– Your doctor might use an electrocardiograph to get information on the function of your heart. Around 50% of people with sarcoidosis will have an abnormal EKG.

Managing Sarcoidosis

There is no cure for sarcoidosis, but the disease can get better on its own over time. In some cases, you will need medication to relieve symptoms and reduce inflammation of the affected tissue. Corticosteroids can help control disease, and if you cannot tolerate steroids, there are other medications available.

You can also make some lifestyle changes to help manage the disease, such as:

Eating a well-balanced diet with fresh fruits and vegetables
Getting 6 to 8 hours of sleep each night
Quitting smoking
Drinking 8 to 10 8-oz glasses of water each day
Getting regular checkups with your doctor
Avoiding excessive amounts of calcium-rich foods, such as dairy products and oranges.
Avoiding excessive amounts of vitamin D in sunlight

In addition, being insured will give you peace of mind, and the coverage you need to make sure you can see your doctor regularly, and get any treatments you might need. If you’re looking for an insurance plan, EZ can help: we offer a wide range of health insurance plans from top-rated insurance companies in every state. And because we work with so many companies and can offer all of the plans available in your area, we can find you a plan that saves you a lot of money – even hundreds of dollars – even if you don’t qualify for a subsidy. There is no obligation, or hassle, just free quotes on all available plans in your area. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Does Medicare Cover Occupational Therapy?

As you get older, you might find that it takes a little longer to heal from an injury or recover from an illness and get back on your feet. This is especially true if your injury or illness was so bad that it required you to be hospitalized: in this case, you could need extra help, like occupational therapy to get you back to your old self. But while Medicare will cover your hospital costs, will occupational therapy also be covered? If it isn’t, you could end up with a huge medical bill, so it’s important to know what Medicare will cover, and what you might need a Medicare Supplement Plan to help with.

Occupational Therapy

Occupational therapy is a form of treatment that helps people recover skills that are needed for everyday work and life after going through an injury or illness; it is also useful for people living with a disability. The goal of occupational therapy is to try and get you back to the way you were before your injury or illness, or to help you navigate life with your disability.

When you begin an occupational therapy program, your therapist will make a custom plan for your sessions, and will also provide you with information so you can continue the therapy at home on your own. Your therapist will measure your progress to be sure that you are on track to meet the goals they have set for you; if you are not, they will help you find ways to quickly get back on track.

Studies show that this type of therapy has a high success rate: for example, according to a 2016 study, 77 of 95 clients in a general occupational rehabilitation program were successful in regaining mobility.

Occupational Therapy Coverage

In the past, there was a yearly cap of $1,840 on total Medicare payments for occupational therapy provided in any setting other than a hospital outpatient department, but now Medicare does not impose any limits on how much it will pay for medically necessary occupational therapy services in a calendar year. Medicare will cover occupational therapy as long as it is deemed medically necessary by a physician or healthcare provider.

Medicare Part A

Medicare Part A will cover any medically necessary occupational therapy given in a hospital or rehab facility.

Two-Midnight Rule

Under the ”two-midnight rule,” Medicare Part A can be used to pay for services that you receive if you are expected to stay in the hospital through two midnights. However, Part A should not be used if your hospital stay is not expected to last that long.

Medicare Part B

Medicare Part B will cover occupational therapy when it is received outside of the hospital on an outpatient basis, such as at a doctor’s office, outpatient rehab facility, skilled nursing facility, or at your home. Medicare will cover occupational therapy, physical therapy, and speech-language therapy. With that being said, though, Medicare Part B will only cover 80% of the cost when you go to a Medicare-approved therapist.

Your Out-of-Pocket Expenses

While Medicare will cover a lot of the cost of your occupational therapy, there will still be some out-of-pocket costs that you will be responsible for. You will still be responsible for:

Medicare Part A deductible
Medicare Part B annual deductible before coverage of your occupational therapy begins
Medicare Part B coinsurance of 20% of each treatment

Extra Coverage

Again, Medicare Part B will only cover the cost of your occupational therapy sessions at 80%, leaving you to pay for the other 20% out-of-pocket. This can be quite expensive, especially if you are living on a fixed income, as many Medicare beneficiaries are. Fortunately, though, you can save money on all your medical expenses and get extra coverage by purchasing a Medicare Supplement Plan.

There are 10 different Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans for you in minutes at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Medicare to Consider Lowering Part B Premiums

A few weeks ago, Medicare announced the new Part B premiums for 2022. While the Centers for Medicare and Medicaid Services (CMS) had projected a rise in premiums of 6.7% earlier in 2021, the actual increase in Part B premiums for 2022 is 14.5%, the largest increase ever seen. The huge increase is partly based on the potential cost of covering Aduhelm, a new drug to treat Alzheimer’s disease.

This massive increase will take premiums for beneficiaries in the lowest income bracket from $148.50 a month to $170.10 a month, which could be difficult for many Medicare beneficiaries living on a fixed income to afford. But now there is a chance that Medicare Part B premiums might be reduced.

The Reason For The $21.60 Hike

white round pills on a table coming out from a purple bottle — *Medicare Part B premiums were hiked up to cover the new Alzheimer’s drug that has been approved by the FDA.*

By law, CMS is required to set each year’s Part B premium at 25% of the estimated costs that will be incurred by that part of the program. One of the main reasons CMS gave for the large spike in Medicare Part B premiums for 2022 was that it needed to set aside money to cover Adulhem, the new Alzheimer’s drug that has recently been approved by the FDA. It was estimated that the drug would cost $56,000 a year.

Now the medication’s manufacturer, Biogen, has estimated that the drug will actually cost $28,200 a year. Because of this projected change in price, the Department of Health and Human Services is asking for a re-assessment of Medicare Part B premiums.

The Push To Reduce Premiums

Department of Health and Human Services Secretary Xavier Becerra has ordered the Centers for Medicare & Medicaid Services to reassess this year’s standard premium. “With the 50% price drop of Aduhelm on Jan. 1, there is a compelling basis for CMS to reexamine the previous recommendation,” Becerra said.

Other organizations are also calling for a reduction in Part B premiums. “It is unconscionable for a single outrageously priced drug to drive up premiums for all Medicare beneficiaries – many of whom are already struggling to make ends meet,” said Nancy LeaMond, AARP executive vice president and chief advocacy and engagement officer. “Now that the drugmaker has cut the price in half, the Medicare Part B premium increase should be lowered as well.

“This also highlights the importance of giving Medicare the authority to negotiate drug prices. Without it, we’ll keep seeing sky-high drug prices leading to premium hikes and higher out-of-pocket expenses for older Americans.”

A CMS spokesperson said the agency is “reviewing the secretary’s statement to determine next steps.”

money bills in a black envelope — *You can save hundreds of dollars with a Medicare Supplement Plan.*

Save Money

If you are like one of the millions of Medicare beneficiaries who are living on a fixed income, saving as much money as possible is a top priority. The best way to save money on healthcare is to find an affordable Medicare Supplement Plan – and the best way to do that? Speak to an EZ agent! We work with the top-rated insurance companies in the nation and can help find a plan that will save you money this year – maybe even hundreds of dollars. Let our agents take the stress off you by comparing plans and finding ways to help you save money. And because we want to help you save as much money as possible, our services are completely free- no obligation or hassle. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Does Medicare Cover Prolia?

Osteoporosis affects around one in three women, and one in five men, over the age of 50, meaning that more than 200 million people are suffering from osteoporosis in this country. There are many different kinds of treatments available for osteoporosis, with the current standard treatment being bisphosphonates. There is, though, another drug called Prolia, which clinical trials have found is just as effective as bisphosphonates. How these treatments work differs, so if bisphosphonates aren’t working for you, you might want to talk to your doctor about Prolia. Fortunately, Medicare does cover Prolia, so if this drug is right for you, you will be able to start your journey to healing with the help of Medicare.

How Prolia Works

x-ray of a knee with arthritis — *Osteoporosis occurs when bones become weak, but Prolia can help with it.*

Osteoporosis is a condition that causes your bones to become thin and weak; it typically affects women more than men. Some common symptoms of osteoporosis can include brittle and weak nails, receding gums, and weakened grip strength.

Prolia is a prescription drug that’s used to treat osteoporosis and other forms of bone loss. It works by stopping bone cells from breaking down and by further strengthening the bone. It is given as an injection in the side, upper arm, or belly. Prolia is generally used to treat osteoporosis in individuals who are post-menopausal, and at high risk for bone fractures.

“This drug works by preventing the osteoclasts from maturing or resorbing bone, so it’s a completely different mechanism of action [from that of bisphosphonates]. That said, it appears at the end of the day, in terms of reducing fractures and making bones stronger, the result is about the same as bisphosphonates,” says Nancy E. Lane, MD, director of the Center for Healthy Aging at the University of California, Davis.

The Price of Prolia

The cost of any prescription drug depends on various factors, including the type of coverage you have in addition to Original Medicare. Most Medicare plans will cover Prolia, but it depends on how you take the drug. If you have Original Medicare and self-administer the injection, a Part D plan should cover the cost. But if you have original Medicare and a home health nurse administers your injection, Part B will cover 80% of the cost of the drug, leaving you to pay the other 20% out-of-pocket.

Medicare Eligibility For Prolia Coverage

While Medicare will usually cover Prolia, there are some criteria. To be Medicare-eligible for osteoporosis drugs in general, you must:

Be a woman
Have a bone fracture that a doctor has certified is related to postmenopausal osteoporosis.

Is Prolia Right For You?

As with any drug, you should ask your doctor about the benefits and the risks of Prolia, especially if you have any of the following issues:

Thyroid disease
Kidney disease- Kidney problems can cause low calcium levels, and treatment with Prolia can further lower your calcium levels, which can be dangerous.
Low calcium levels- Same as above. Your doctor might recommend that you increase your calcium levels before you begin taking the drug.
Weakened immune system
Trouble absorbing minerals

In addition, it is important to notify your doctor about any medications you are taking regularly, including over-the-counter medications, so they can inform you of any interactions between these medications and Prolia.

Extra Coverage

If you are interested in receiving the Prolia injection but are afraid of having to pay 20% out-of-pocket every time you get an injection, it might be time to look for extra coverage. Your 20% coinsurance can really add up, especially if you are living on a fixed income, as many Medicare beneficiaries are. Fortunately, though, you can save money on all of your medical expenses and get extra coverage by purchasing a Medicare Supplement Plan.

There are 10 different Medicare Supplement Plans to choose from, each offering different coverage options and rates. It’s worth looking into a Medicare Supplement Plan to save as much money as you can, so speak to an EZ agent for all of your options. EZ’s agents work with the top-rated insurance companies in the nation and can compare plans in minutes for you at no cost. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

More States Adopt The Medicare Supplement Plan Birthday Rule

If you’re about to turn 65, now is the time to think about purchasing a Medicare Supplement Plan. Your Open Enrollment Period for Medicare Supplement Plans automatically starts the first month you have Medicare Part B (Medical Insurance) and you’re 65 or older, and lasts for 6 months. During this time you can avoid medical underwriting and get a much better deal on a plan. Not only that, but you will also have the ability to change plans within 30 days of purchasing your plan if you’re not happy with it.

But what if those 30 days are up, and your plan has changed or no longer fits your needs? What if a year has passed, or even a couple of years? Did you know that, in some states, you can change your plan every year without medical underwriting? In states that have adopted what is known as the Medicare Supplement Plan Birthday Rule, Medicare beneficiaries can change plans around their birthday each year. Find out which states have this rule, and how it works, so you can save money and find a plan that suits your needs.

The Birthday Rule

The Medicare Supplement Plan Birthday Rule applies to people with Medicare Supplement Plans, and not to those with Medicare Advantage Plans. If your state has this rule, you will have an Open Enrollment Period each year on your birthday that allows you to change your Medicare Supplement Plan to a different one that meets your budget and medical needs.

Each state’s birthday rule is different, with some allowing you to change to another plan or insurance carrier, while others only allow you to change plans from the same insurance carrier. You can make these changes without going through medical screening or having a new waiting period.

Which States Have The Medicare Supplement Plan Birthday Rule?

Currently, California and Oregon have birthday rules; Illinois and Nevada will be adding the rule in January of 2022, and Idaho will be adding it in March of 2022. Each state has its own sets of rules:

California: You can change to a plan that is of equal or lesser benefit from any carrier 30 days before your birthday, and the 60 days following it.
Oregon: You can change to any insurance carrier or plan of equal or lesser benefit 30 days before your birthday and 30 days following it.
Illinois: If you are between the ages of 65 and 75, you will be able to enroll in any plan from your current insurance carrier starting on your birthday, and for the following 45 days. Your new Medicare Supplement Plan’s benefit level cannot exceed that of your current plan.
Nevada: Starting on the first day of your birth month, and for the 61 days following your birthday, you will be able to change your insurance carrier or plan to one that offers equal or lesser benefits.
Idaho: Starting on your birthday, and for the following 63 days, you will be able to enroll in another plan of equal or lesser benefit from any insurance carrier.

Why Change Your Plan?

time for change written on a chalkboard — *There might be a need to change your Medicare Supplement Plan, depending on the changes in your life, whether medical or budget.*

Life changes, and so can your budget and medical needs – and the Medicare Supplement Plan that you purchased when you were 65 might no longer meet those needs. That means it might be time to assess your plan and consider switching if you can, so you can get more coverage, or save some money. The best way to find the Medicare Supplement Plan that is right for you is to assess your needs and budget, and then compare all available plans in your area. Working with an EZ agent will make the process quick and easy, because we give you quotes in minutes. No hassle or obligation, just free help finding and comparing plans. To get free instant quotes for plans that cover your current doctors, simply enter your zip code in the bar on the side, or to speak to a licensed agent, call 888-753-7207.

Tag: medicare

What’s the Difference Between a Preferred and Standard Pharmacy?

Preferred Pharmacy

Standard Pharmacy

Out-of-Network Pharmacy

Need Help?

How You Can Manage Sarcoidosis

What Is Sarcoidosis?

Symptoms & Causes

Common symptoms of sarcoidosis include:

Diagnosis & Testing

Managing Sarcoidosis

Does Medicare Cover Occupational Therapy?

Occupational Therapy

Occupational Therapy Coverage

Medicare Part A

Two-Midnight Rule

Medicare Part B

Your Out-of-Pocket Expenses

Extra Coverage

Medicare to Consider Lowering Part B Premiums

The Reason For The $21.60 Hike

The Push To Reduce Premiums

Save Money

Does Medicare Cover Prolia?

How Prolia Works

The Price of Prolia

Medicare Eligibility For Prolia Coverage

Is Prolia Right For You?

Extra Coverage

More States Adopt The Medicare Supplement Plan Birthday Rule

The Birthday Rule

Which States Have The Medicare Supplement Plan Birthday Rule?

Why Change Your Plan?

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