Idaho Medicare Prescription Drug Plans

CMS Required Statement for Idaho brokers helping residents with Medicare Prescription Drug plans.     

Before you select an Idaho Medicare Prescription plan, firm up your knowledge.   This subject has many details you should understand.

Sections 6 of the document found here will provide part of that foundation.

If you need a refresher on enrollment periods, rules of Part D, etc. this is a good source of information. 

If you get health care from the VA or Tricare, read the information found here.

A more detailed description of Medicare Prescription drug plans is available on the CMS.gov website (here).  

The 2025 Idaho Market for Medicare prescription drug plans

Figures quoted in the material below came from either this resource or this resource.

2025 Synopsis of Plans available in Idaho

All 2025 Medicare prescription drug plans have fill/refill costs for insulin of $35 or less for a 1-month fill/refill.  Remember individual plans have their own list of insulin they carry (as well as all other prescription medications).  This means one or more plans may not cover the specific insulin you take.

Plan premiums. 

2025 plan premiums range from $0 to over $90/month.  

A reminder of how your income may affect your Part D plan premium. 

A good synopsis of this topic is here.  

Have you been in the Coverage gap?  It is gone in 2025.

Your ANOC will describe how your fill/refill costs will be limited to $2,000 for 2025.  You can setup a monthly payment plan in January if you would like to spread out refill costs for the rest of the year.   

What else you need to know about Idaho Medicare prescription drug plans

Plans are offered by private insurance companies that has a contract with CMS to do so.

CMS has broken the USA down into regions where specific plans are available.  If you live in one region and move to a different region, you have the option to enroll in a plan in the region you moved to. You cannot keep your current plan. There is a 63-day window to enroll in a drug plan that is available in the region where you moved to.  You do not want to miss this window. Why? You have to wait for the next annual enrollment period to enroll in a plan.

We live in the region which is made up of Idaho and Utah residents.  This means if we live in Idaho and move to Utah, we can keep the same plan.  If we move to Arizona, we will have to enroll in a plan that is available to residents of that State.

Medicare has other rules for enrolling in prescription drug plans during the calendar year.  These are called ‘special enrollment periods’ (SEPs).  Learn more about SEPs here.

Monthly premium’s are set by the plan and can be adjusted by the ‘income related monthly adjustment amount’ (IRMAA)

IRMAA is set and updated annually by CMS. You can check the current years IRMAA here. Next years figures are announced around mid November and are available at the same source noted above. Your monthly premium for Medicare Part B and your Part D plan is dependent on your gross earnings and your tax filing status on your federal tax return 2-years ago. Learn more about this adjustment here. IRMAA affects higher income individuals.

The 3 phases when your fill/refill costs can change

The 3 phases each Medicare prescription drug plan member goes through annually are:

Deductible phase – the 2025 deductible (set by Medicare) is $590.  Your plan can set it’s deductible anywhere between $0 and the Medicare permitted maximum.  Your insurance company can also specify which, if any, specific drug tiers are exempt from the plan’s deductible.    

Initial coverage level – when your out-of-pocket costs for fills/refills hit the plan’s deductible, you graduate to the ‘initial coverage level’ for fill/refill pricing.  These figures are contained in your plan’s ANOC and ‘Summary of Benefits’.  

Catastrophic coverage – when your out of pocket costs for the calendar year hit $2,000, you enter this phase.  Your Part D covered meds filled through your plan are now $0 for the balance of 2025. 

The Inflation Reduction Act of 2022 will have a significant impact on the above.  Learn more here. 

Help paying for prescription medications.

If your out of pocket costs for your medications does not fit in your budget, there is help getting assistance paying for them.  Read the information found here.  Please do not hesitate to use any of the services on this list.  

‘Extra Help’ also known as ‘Low Income Subsidy’.

If you have limited income and resources, you may be eligible for ‘Extra Help’ . This government program helps those that qualify pay for their plan’s monthly premium and your prescription drug costs. ‘Extra Help’ is sometimes referred to as the low-income subsidy (LIS).

If you qualify for Extra Help, Medicare’s rules on both the coverage gap and the late enrollment penalty will not apply. You will also have a continuous Special Enrollment Period (SEP) and can switch plans once a quarter. Why would you want to do this? To save money. If you change plans, the new plan is effective the first of the following month.     If your medications change during the plan year, you may be able to save some money by switching plans.  Contact us if you want help thinking this through.

GoodRx Coupons and other resources to save money on prescriptions

If you are unfamiliar with this cost savings tool visit their website (available here) to learn how they can save you money.   Their are other companies with similar programs.  You can use ‘google search’ to find them.

Mark Cuban recently launched a company which produces expensive generic medications and makes these products available at noticeably lower refill costs.  You may save on your refills if you take any of these covered medications.  Learn more here. 

Pharmaceutical companies can help too

Many major drug manufacturers offer pharmaceutical assistance programs which help people pay for their medications. Some of these programs are especially designed to help people enrolled in Medicare Part D prescription drug plans.  You can check to see if your medications are available through one of these programs here.

Also, there are other organizations that offer people help paying for their medications. Some of these organizations are national in scope; others are community-based.  Check to see what is available here.

Ask your pharmacist if you can get your medications filled for a lower cost than what is available through your drug plan.  A simple way to do this is to ask ‘What is the cash price?  A law was passed in 2018 requiring a pharmacist’s assistance to find lower pricing, if you ask. Learn more here.

A process for separating wheat from chaff when selecting an Idaho Medicare prescription drug plan

The process below is based on our experience working with these products.  Others may have a different opinion.

Plan Star ratings are important

We ignore any plan with a star rating below 3.0 or are offered by insurance companies new to the prescription drug plan business. Why?  These are plans that either have mediocre reviews by people that interface with the company behind the plan or do not have a track record in the business (no star rating).

Star ratings reflect the satisfaction people have when they interact with the plan. The higher the star rating the fewer complaints.  We also feel management at any insurance company whose plans have a star rating below 3 have been ‘a sleep at the wheel’. They have had time to correct the issues causing the low star rating and haven’t done so.

Our guidelines

We prefer plans whose overall star rating is 3.5/higher. There are over 10 measurements that are used to determine the plan’s overall star rating. If any of these have a rating below 3, it may be a red flag. The individual components that affect a plan’s star rating include:

• Drug Plan Fails to Make Timely Decisions about Appeals (more stars are better because it means fewer delays)
• Fairness of Drug Plan’s Appeal Decisions, Based on an Independent Reviewer
• Complaints about the Drug Plan (more stars are better because it means fewer complaints)
• Members Choosing to Leave the Plan (more stars are better because it means fewer members are choosing to leave the plan)
• Problems Medicare Found in the Plan’s Performance (more stars are better because it means fewer serious problems)
• Improvement (if any) in the Drug Plan’s Performance
• Members’ Rating of Drug Plan
• Ease of Getting Prescriptions Filled When Using the Plan.

Your refill costs can vary widely between plans and pharmacies you use

Other items to be aware of

• The number of medications plans cover can vary. If you developed a short list of plans to consider, this metric could be a deciding factor.
• Read the section 7.1 in your plan’s ‘Evidence of Coverage’.  An example of this document can be found here. This is titled ‘What to do if you have a problem or complaint’.   Be sure you understand this process. This is a situation many people would want to avoid.  Having a plan with a higher number of med’s in its formulary (budget permitting) may help solve this issue.
• As you review the plan’s formulary, notice how many meds are in each of the drug tiers.  You can find these numbers here. Be aware these number can vary widely between plans.  Remember, the higher the drug tier the higher the refill cost. Plans can differ on how they categorize meds between drug tiers.  This means if you had the formularies of 3 different plans in front of you may find some of the med’s you take in different drug tiers for these plans.
• Some plans are passing through the manufacturers rebate in specific medication pricing. This should lower your refill cost.

Additional information for Idaho Medicare Beneficiaries with a Medicare Advantage plan which includes prescription drug coverage.

• Some Idaho Counties had changes to the number of plans available to residents for 2025.  When new plans enter a market, they are typically going after market share. This can mean lower out of pocket cost for the plan member.  If you are interested in saving money, we suggest comparing your plan options annually.
• Are you taking generic medications that are in tier 3, 4, or 5 of your current plan? If yes, we recommend doing a plan compare during the annual open enrollment period to see if you can save money. Why? Because the prescription drug plan market is changing and some plans are more aggressive on implementing changes. We are aware of at least one Medicare Advantage plan that moved generic medications commonly found in drug tiers 3, 4 and 5 to tier 2.  This can mean lower refill cost.  Remember you can change Medicare Advantage plans between January 1 and March 31 in addition to October 15 – December 7.  If you can keep the same doctors/hospitals, consider saving the money by changing plans.

A closer look at documents available for Idaho Medicare Prescription drug plans.

CMS requires insurance companies offering these plans to produce and make available specific plan documents.  These documents are designed to explain the details of each plan the company offers in each region.

These documents are described below.

Formulary

“A formulary is a list of covered drugs selected by our plan in consultation with a health of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and the other plan rules are followed. For more information on how to fill your prescriptions, please review your ‘Evidence of Coverage”.

The above definition was cut/pasted from one of the 23 prescription drug plans in Idaho for 2023. We believe the formulary booklet found here and above definition is representative of the definition of most formularies of prescription drug plans.

The Master Formulary

CMS has the ‘master’ formulary from which individual Medicare prescription drug plans can pick and choose the med’s they want in their own plan’s formulary. CMS has specific rules each plan must follow when they develop their own formulary. Section 30 of this document presents these requirements.

The individual plan’s formulary.

Once an insurance company has documented a plan’s formulary be aware it can change during the calendar year. Why? The FDA is approving new medications, generic versions of brand named drugs are being released, and medications are being removed from the market. If CMS updates their formulary reflecting these changes, insurance companies can do the same. CMS rules to follow if this is done. Not all plans update their formularies during the calendar year.

Drug Tiers.

Insurance companies offering drug plans categorize the medications they cover into drug tiers. Common tier names include: tier 1: generic; the 2nd ier: non-preferred generic; tier 3: brand named drugs; the 4th tier: non-preferred brand named drugs; tier – 5: specialty drugs.

Your fill/refill price is based on the drug tier classification.

It is not unusual to see the same medications a person takes in different drug tiers in the plans available to them. This is a contributing factor to seeing the annual out of pocket costs for the same medications vary by 300%+/- between plans. The ‘annual out of pocket cost is: ‘plans monthly premium + monthly medication refill cost * 12’.

Part B and Part D Drugs.

Medications can be covered by either Part D and/or Part B of Medicare. Learn more about Part B medications here. If you have a Medigap plan that covers the 20% coinsurance for all Part B services, you will pay $0 for your Part B covered medications. Another Medigap plan covers all Part B cost for services after the annual Part B deductible ($226 for 2023) is satisfied. Keep this in mind if you are or could be taking Part B medications. Getting a Medigap plan could save you money on your medication cost. Part B Medication costs for Medicare Advantage plans are document in the plans ‘Summary of Benefits’ and their ‘Evidence of Coverage’ documents.

If you want help with this, call us.

Medication Management tools for insurance companies

Restrictions can be placed on specific medications by the insurance company. These are noted in each plan’s formulary. Some of these tools are: prior authorization, step limits or quantity limits. Further definitions are reviewed in each plan’s formulary.

Summary of Benefits document

CMS requires each plan to have this document available in the public domain. You can find this on any company’s website. The purpose of the document is to clarify how much it will cost a plan member to belong to the plan and refill costs. Refill costs will vary by the type of pharmacy the member uses, the dosage of the medication, and the fill/refill quantity.

The types of pharmacies a plan has include mail order, standard, and preferred.

This document also identifies other plan rules. For example, which areas of the USA the person must live in before they can enroll in the plan. Additional details of the plan are presented in the plan’s ‘Evidence of Coverage’ (EOC).

An example of the ‘Summary of Benefits’ document can be found here.

This is a document you should review before enrolling in any Medicare prescription drug plan. This document can also be found on the insurance company’s web site.

Evidence of Coverage.

CMS requires each plan to have this document available to current and prospective plan members. It can be found on each company’s website and is specific to a plan. This is a legal document and contains the plans rules and other information that will guide the plan member through various situations that may occur during the plan year.

An example of the EOC can be found here.

This is a document you should be familiar with. Given the 100+ page length of a typical EOC, minimal reading should include a review of the ‘table of contents’ and any section that describes the services of the plan you know you will use. The balance of the document can be read at the members convenience.

Pharmacy Directory.

Each pharmacy available to plan members and in your plan’s region is listed in this document. This will include both national and local/regional pharmacies. Pharmacies are separated into 2 classes. Preferred pharmacies typically have the lower fill/refill costs for plan members. A plan member should use these pharmacies. Standard pharmacies are also available. Depending on the specific plan and your location in the plan’s service area you may pay more for any fills/refills when using this class of pharmacy. Be aware refill costs for pharmacies in the same class may have different refill costs. Some plans do not distinguish between preferred and standard pharmacies.

Some plans may have a ‘hard copy’ of this directory available’; others may refer people to the digital version on the company’s website. The digital version of this document is typically current and should be your reference. Most of these directories have an index by pharmacy name within town, within County, within State.

Should I do this myself or use the services of a broker specializing in Idaho Medicare prescription drug plans?

A recent Kaiser Family Foundation research report (available here) states 10% of Medicare beneficiaries check to see if they can save money by switching drug plans. If you are in the 90% group that does not and are an Idaho resident and want help to see your savings, call us. We would rather see the savings available with your initial plan enrollment or changing plans annually in your pocket.

Remember, insurance companies offering Idaho Medicare prescription drug plans are competing for your business. Companies move their plans in and out of different market niches and adjust plan features that make people want to enroll in their plan. These companies can change their plans on their cycle and they can introduce new plans targeting other niches.

Not all agents or brokers are licensed with all of the plans.

If you choose to work with an agent or broker, be aware agents work for specific companies and may only present the plans they are licensed with. Brokers are often licensed with multiple plans and can give you a broader picture of the market.

Many independent insurance brokers specializing in Medicare will know and understand these annual market place changes. All have to take and pass annual tests on plans they wish to be licensed with. We do this, are an Idaho resident and can help you with this task.

Call us if you would like help with plan analysis and enrollment.