Perspective               

Formularies Vary Between Medicare HMOs

Carefully research the prescription drug coverage your Medicare HMO offers, warns a new report recently released by the United States General Accounting Office. The report finds that it is often hard for people on Medicare to understand how prescription drug benefits differ in different HMOs. HMO prescription drug information is often confusing.

To begin to understand the differences between prescription drug benefits, remember the following facts about Medicare HMOs:

One - many HMOs use a formulary, which is a list of prescription drugs HMOs prefer their doctors to prescribe. HMOs manage their formularies in different ways - some HMOs do not cover any drugs that are not on their formulary, while other HMOs cover non-formulary drugs, but charge a higher copayment for them. Other HMOs only pay for generic drugs.

Two - Medicare HMOs use very different methods to calculate their prescription drugs benefit caps. Some calculate coverage yearly, while others calculate it quarterly. And some HMOs calculate coverage caps based on the retail cost of drugs, while others use the wholesale cost. A yearly benefit of $3,000 will pay for a lot more drugs if the cap is based on wholesale prices.

Finally - Medicare HMOs are allowed to change the drugs on their formularies. So even if your heart medicine is on the formulary when you join the HMO, it may be taken off the formulary at any time.

If you are planning to join a Medicare HMO and its prescription drug benefit is important to you, do your research first. Find out which of your medications are on the formulary. And find out how much you will need to pay out-of-pocket for your drugs. Ask the HMO how you will learn about formulary changes. Does it send a letter or make a phone call, or will you have to wait for your pharmacist to tell you that the medicine you take for your chronic condition is no longer covered?

To find out more about Medicare HMO prescription drug coverage in your area, look in the Medicare&You 2000 booklet you should receive in the mail in September or October. If you don't get a copy, call 1-800-MEDICARE. This booklet lists the Medicare HMOs in your area and explains their prescription drug coverage. You can also get this information on the Internet at www.medicare.gov. Always call the HMO and make sure the information is correct before you join.

If you need additional help making a Medicare choice, call your State Health Insurance and Assistance Program, or SHIP. The number is listed in the back of the Medicare&You booklet.

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