Trying to pick the best Medicare prescription drug plan for an individual beneficiary can be an overwhelming task, since there are so many plans to choose from, and various factors you need to consider.

Fortunately, CMS (the Center for Medicare and Medicaid Services) has developed a very helpful online "planfinder" tool which you can access at www.medicare.gov -- you can run a general or personalized search of all the drug plans offered in your service area, and obtain detailed information about plan formularies (including utlization requirements), co-pays and monthly premiums, network pharmacies and more.  If you want to get more information about a specific Part D plan, planfinder can link you to that plan's website.

If you are new to planfinder,  you may want to view the online demonstration on the various planfinder functions, which you can usually find on Medicare's home page.   In 2010, prior to the enrollment period for 2011, CMS made major changes in the Planfinder tool, which are summarized in this PowerPoint presentation created by CMS.  

Here are Planfinder Tips issued by CMS in November 2010. 

Here is a link to the new CMS Medicare Plan Finder Training Website, a list of Plan Finder test scenarios and a timeline for the planned updates to the Plan Finder for the 2011 Enrollment period that began Nov. 15, 2010. 

You can even use the planfinder tool to enroll in a Part D plan if you want.  However, it's probably best to doublecheck first on the Part D plan's website or call the plan directly to make sure their information matches what you found in planfinder.  (Especially at the start of the new annual open enrollment period, planfinder may not be completely up-to-date and occasionally you may find slight glitches or discrepancies.)

The Health Assistance Partnership has produced a helpful tutorial on using PlanFinder monthly cost estimates to pick the most affordable plan.  Also see this article from the Medicare Rights Center on how to select a Part D plan.

Generally, the top plan listed by PlanFinder will be the cheapest one for an individual beneficiary.  However, there are some factors that PlanFinder does not consider:

• Utilization Management

  • Although PlanFinder will tell you whether a plan imposes utilization management on an individual's drugs, it only tells you about the existence of these obstacles - not how to overcome them.  PlanFinder indicates for each drug whether the plan imposes Prior Authorization (PA), Step Therapy (ST), or Quantity Limits (QL), but does not indicate what criteria are used to approve PA or ST requests, or what the Quantity Limit is.  CMS guidance (at § 60.5.4) requires all plans to post this information on their websites, but few plans comply with this directive.

  • As a result, advocates have created a web-based spreadsheet listing utilization management criteria for various plans (see below), based on information they uncover by calling the plans directly.  They have shared this information with the public so that others don't have to keep calling plans to get the same information.

• If you find out information about other plans that post their utilization management information online, let us know!

• Other Drug Coverage

  • State Pharmaceutical Assistance Programs, including EPIC, are not factored into the PlanFinder cost calculation.  As a result, if someone has both Medicare Part D and EPIC, the costs shown on PlanFinder will not accurately reflect their real-world drug costs.  EPIC subsidizes the premiums and co-payments, and provides wrap-around coverage during the deductible, coverage gap and with utilization management and non-covered drugs.  It can be difficult to figure out how EPIC will affect an individual's drug costs as shown by PlanFinder.  Generally, the most affordable plan will still be best.  The main pitfall to watch out for is individuals who have Deductible EPIC.  If the individual's EPIC deductible occurs at the same time they reach the Part D coverage gap (aka "donut hole"), then they will have no drug coverage even though they have two different drug plans!  For people in this situation, call EPIC to find out if their EPIC anniversary can be shifted so as not to coincide with the Part D coverage gap.

  • The same issue applies for other types of drug coverage, such as private employer or union coverage, and Veteran's Health Care.

This article was authored by the Empire Justice Center.