Newsletter

DOES MEDICARE COVER WEIGHT LOSS DRUGS?

Medicare does NOT cover medications prescribed only for weight loss but does cover such medications when they are prescribed for a specific medical condition for which the drug is approved by the FDA.

Please note that there has been concern about drug shortages for drugs like Ozempic that cause weight loss but are primarily diabetes medications.

With very few exceptions Part D drug plans have prior authorization requirements for medications like Ozempic and Mounjaro (this means that the provider must submit a request for coverage of the medication, including the reasons for prescribing the medication, and the carrier must approve dispensing the drug before it can be covered by the plan.) If you are prescribed one of these medications and the plan requires prior authorization, you have a better chance of having the drug approved under the plan if the request for prior authorization comes from a specialist (in most cases an endocrinologist) rather than an internist or primary care physician. 

The number of carriers who will dispense these types of medications without requiring prior authorization is exceedingly small. Although there may be others, we are aware of only one carrier in Florida that does not require prior authorization for Mounjaro and are not aware of any carriers who do not require prior authorization for Ozempic. However, we have a system that checks carriers and Part D medications, and please contact us at 786-970-0740 if you’d like us to check to see if any of your diabetic medications require prior authorization.

Please see this article from AARP that contains more information about this issue.

WHY YOUR DOCTOR’S OFFICE IS SPAMMING YOU WITH APPOINTMENT REMINDERS

Going to see the doctor soon? Prepare to be hounded with appointment reminders by phone. By text. By robocall. By email. And in your online “patient portal.”

Doctor's and dentist's offices for years left a courtesy voicemail on patients’ home answering machines giving them a heads-up about their appointment. But now, medical practices are flooding patients with reminders of upcoming appointments — and warnings of cancellation penalties.

The financial pressure for medical practices to keep patients from ghosting them is a major factor. Practices miss out on revenue when a patient doesn’t show up for an appointment or cancels at the last minute and the slot sits empty.

But the notifications are getting worse because new software systems enable medical providers to send automated messages to patients. Health care providers often have multiple notification systems — one for electronic medical records, another for prescription medications, and a different one from the marketing department, for example — that do not coordinate with each other. This can lead to notification overload for patients.

Read the entire article written by Natalia Gdovskaia that appeared on March 16 in CNN Business here.

CMS IS CHANGING STAR RATINGS METHODOLOGY

Star ratings apply to plans covered under Part C (Medicare Advantage) and D (Medicare drug plans). Such ratings are NOT applicable for Medicare Supplement plans. Star ratings are important for two basic reasons: (1) they are one way a consumer can compare Part C and D plans and (2) Medicare pays quality bonuses (i.e., additional payments) to carriers who achieve star ratings of four or more. These bonuses are used, in part, to provide higher benefit levels from carriers who receive them.

Beginning in 2027, the Centers for Medicare and Medicaid Services (CMS) will reward Medicare Advantage plans that demonstrate progress addressing health disparities. At the same time, the agency scrapped a bonus policy that benefited insurers that sustained high overall quality ratings over time.

Without the reward factor, no Medicare Advantage carrier would have earned a five-star rating this year, according to a data review Baltimore Health Analytics performed on its star ratings software platform for Modern Healthcare. That top score qualifies insurers for bonus payments up to 5% and enables them to market Medicare Advantage plans year-round.

Modern Healthcare estimates that Centene (which owns Wellcare) and Clover Health will benefit most from this change in methodology, as these carriers serve a greater percentage of the underserved population than their major competitors.

Read this article that appeared in the March 20 issue of Modern Healthcare and that explains this change in more detail.

About Paul Cholak

Paul is a licensed, independent health and life insurance agent and has over forty years of benefits experience and specializes in helping Medicare beneficiaries obtain health insurance. However, he offers a complete array of life and health insurance products to individuals of all ages.

He guides Medicare beneficiaries through the steps of getting insurance and is available to help clients both BEFORE and AFTER they've made their purchase decision.

Disclaimer for Part C and D plans: "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-2048) to get information on all your options."

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