After a successful program at YMCAs nationwide, Medicare will cover programs that help prevent diabetes among those with prediabetes.

What is Prediabetes?
Prediabetes is the condition when blood sugar levels are higher than usual, but not high enough to be considered diabetes. One in three adults has prediabetes in the United States, and 90% don’t know they have it. Without action, about 15-30% of those with prediabetes will develop Type 2 diabetes within 5 years.

What will Medicare cover?
If approved, Medicare will pay for certain “lifestyle change programs,” where a trained counselor leads a class focused on preventing Type 2 diabetes with eating habits and exercise. These programs were implemented in YMCAs across the country with a federal grant with a CDC-approved curriculum.

The YMCA programs saved Medicare $2,650 per person enrolled in the program over 15 months. Participants lost about 5% of their body weight, which significantly lessened the likelihood of diabetes.

Need convincing? Here are more results:
In one of the first studies on healthy eating habits and exercise on diabetes, the results were so strong that the study was ended early. About 3,000 participants between ages 25-75 were randomly sorted into three groups. Group 1 was treated with a healthy diet and exercise. Group 2 was treated with metformin, and Group 3 was given a placebo medication.

Groups 2 and 3, with medication, reduced their risk of diabetes by 31%. Group 1, with diet and exercise, reduced their risk by 58% and the patients lost at least 7% of their body weight. Those age 60 or older, reduced their risk by 71%. These rates of reduction have been seen in studies since.

The program will likely be covered by Medicare soon, as it doesn’t require congressional approval.

prediabetes-inforgraphicThis infographic is f

You can take the CDC’s quick test online
to see your risk of prediabetes here.

For more on the YMCA prediabetes program,
see this New York Times article.

Doctor stethoscope examLet’s take a look at what Medicare covers in regards to whether your doctor’s appointment is a Physical Exam or a Wellness visit.  The NIH, The National Institute of Health defines the physical exam as when a doctor / health care provider studies your body to determine if you do or do not have a physical problem. This exam would include inspection, feeling the body with hands or fingers, listening to you take a deep breath, while touching your back, sticking out your tongue, and checking your reflexes. Any tests resulting from this physical exam will not be covered under the cost of the exam.

Medicare Part B covers a Welcome to Medicare Visit and Annual Wellness Visits. Your Welcome to Medicare Visit is called an Initial Preventive Physical Exam (IPPE) This benefit is available for a single visit once you are eligible for Part B within the first year of your enrollment.

Services completed by your provider during your IPPE include recording and evaluating your medical history, current health condition and prescriptions. Checking your blood pressure, vision and weight. Making sure your health screenings and any shots are up-to-date, and ordering any further tests. There is no copay for this visit, and Part B does not apply to the cost of the visit. After the visit you may have to pay a co-payment for recommended services, and your Part B may apply.

Your Annual Wellness Visit is developed to provide you with a personalized prevention plan. This visit would include an assessment for future health risks and any preventive measures that may be needed. Your provider will compose a list of risk factors and treatment options just for you. There is no co-payment for your Annual Wellness visit, and they are not a part of your Part B deductible. However, you may have to pay a share of the cost for recommended tests or services.




Medical SymbolsHepatitis C is an infection of the liver. There are many forms of the virus. Symptoms include Jaundice, stomach pain, loss of appetite and nausea. The Baby Boomer population from 1945 – 1965 most often are not aware they are infected and / or need screening for the virus; as noted by senior study author, Dr. Ellen Carmody, an infectious disease researcher at New York University.

Hepatitis C is only spread through exposure to infected blood; which would include sexual contact with an infected person, and sharing needles or equipment to inject drugs. There is no vaccine to prevent the Hepatitis virus, however, new medicines are available that make the virus easier to treat. Left untreated Hepatitis could lead to serious liver problems such as cirrhosis, which is scarring of the liver, liver cancer, or death.  It is recommended by the Centers for Disease Control (CDC) that all Baby Boomers get tested for Hepatitis C at least once as part of their standard medical care. Testing is the only way to detect Hepatitis. Take charge of your health today, and get tested.

Don’t get caught in a Medicare Pickle, let Pickle Man help you.

Get ready for a long read. Last week, the Obama Administration announced a five-year program to test alternative payment models for Medicare Part B drugs. The program will try new methods relating to drug prices, patient outcomes and physician payments starting next year.

Currently, Medicare pays doctors an extra 6% of the price of the drug they administer, which gives providers a bigger payment when they choose medications that cost more. This can lead to prescribing more expensive drugs, which sometimes differ from cheaper drugs only in price.

What is a Part B Drug?
Not all prescriptions are filed under Part D. Drugs that beneficiaries don’t take on their own, like those that are administered by injection or infusion at a doctor’s office, fall under Part B.


This image is from

What will the program do?
There will be two phases. The first phase, which would go into effect later this year, would decrease Medicare’s additional payment from 6% to 2.5%, and use a flat payment of $16.80 per drug per day. The Centers for Medicare and Medicaid Innovation are looking to see how these changes affect the way doctors prescribe medications.

The next phase, which could begin as soon as early next year, will include a series of value-based purchasing options, based on price and effectiveness of drugs. Each strategy will be tested in a different geographic area:

  • Decreasing or ending cost-sharing for Part B drugs, so that beneficiaries may access effective drugs more easily
  • Creating tools for providers to choose drugs with evidence of their effectiveness and other information
  • Options for different payments based on the effectiveness of a drug
  • Using a benchmark, or standard rate or payment, for similar drugs
  • Connecting patient outcomes with drug prices by partnering with drug companies

What are people saying?
The Obama Administration, Centers for Medicare and Medicaid Services and advocates say that the decision for which drug to prescribe should be made with factors such as effectiveness, quality, the patient’s need, and price.

Those against the payment models call it an “absurd experiment,” and believe that doctors know what’s best for the patient, and should be free to prescribe without government oversight. Some doctors in certain specialties are concerned about losing major percentages of their profits.

Comments can be submitted on the program until May 9th.

Will any group be negatively affected?
Some specialists will be more impacted than others by the program. Oncologists, Ophthalmologists, and Rheumatologists, who make a significant profit with Medicare’s drug payments, would see the biggest change in money earned. Primary Care and Family Practice Physicians would see a 44% rise in Part B drug payments, as they typically prescribe and administer cheaper drugs than other specialists.

my medicare planner

This image is from


To read more about the Part B payment program, see this NPR article.

The full proposition of the program is available online at the Federal Register.

About 20 new generic drugs will be on the market at the end of this year. The patents on the brand drugs have expired, allowing drug manufacturers to create generic versions. Most aren’t on the Medicare Plan Finder yet, and won’t be released until later in 2016.

Sometimes, companies will try to expand their patent, allowing for more time before a generic can be produced. Revenues for brand drugs drop dramatically when their generic versions are introduced. Generic drugs can take over 90% of a brand drug’s sales.

Here a few popular drugs that will soon have a generic version:

  • Crestor – Rosuvastatin Calcium
    Treats high cholesterol. Available in May.
  • Benicar – Olmesartan Medoxomil
    Treats high blood pressure. Available in October.
  • Zetia – Ezetimibe
    Treats high cholesterol. Available in December.
  • Proair HFA – Albuterol Sulfate
    Treats asthma, COPD and others. Available in December.
  • 1This image is from Click on the image or link to see it enlarged

Fast Facts

  • The price of generics is usually 80-85% less than brands.
  • Once introduced, generics take about 90% of a brand’s sales.
  • Generics must match the brand’s active ingredient, strength, type of medicine, effects, performance, and standards of testing.
  • Generics can differ from brands in color and shape, label and packaging, and flavors and preservatives.
  • There are two types of generics: Generic Equivalents, with the same active ingredients, and Generic Alternatives, with different active ingredients. Generic Alternatives are not prescribed as often, and require a separate prescription to be filled.


What is Telehealth?
Telehealth is using technology to communicate information and deliver health and health-related education services. It’s a broad term. Even if you aren’t especially tech-savvy, you’ve used telehealth if you’ve ever emailed your doctor or refilled a prescription online or over the phone. Video conferencing with your doctor to diagnose symptoms is an example of telehealth that isn’t widely used now, but could be in the future. Telehealth differs from telemedicine in their scope: telehealth is much wider, encompassing more aspects of health care.

There are four main “domains” of telehealth, from the Center for Connected Health Policy:

  • Live Video: Real-time interaction between two parties: a provider and the recipient of health services.
  • Store-and-Forward: A patient, using e-communication, shares a documented history of health, in videos or images, with a provider. The provider uses the documentation to deliver health services after evaluating it.
  • Remote Patient Monitoring (RPM): A patient sends information to a provider using e-communication for status updates when the patient is released to their home or a care facility.
  • Mobile Health (mHealth): Most often used to reach a broad audience by a healthcare organization or another group when promoting education or health practices. These are accessed through mobile phones and tablets.

The future is now
Last year, UnitedHealthcare announced that it would partially or completely cover video chats with doctors by 2016, though it’s not clear if their Medicare plans would be included. They believe virtual visits could be cheaper and easier than going to a doctor’s office.

Last month, a bipartisan group of U.S. Senators and Representatives introduced a bill that would “expand telehealth services through Medicare,” called the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act. The law would also “improve care outcomes, make it easier for patients to connect with their healthcare providers, and help cut costs for patients and providers.” So far, the bill has not been reviewed by committee. Currently, Medicare doesn’t cover all telehealth costs.

To read about UnitedHealthcare’s coverage of doctor video chats and the doctors who perform them, see this NPR article.

For more information on the CONNECT for Health Act, see the fact sheet provided by the legislators here.

Have you gotten a vaccine recently? A new report shows that most Medicare plans don’t cover them.

Precription Drug Plans
No Prescription Drug Plans use a Vaccine Tier that would cover vaccinations, so most beneficiaries pay cost-sharing fees for vaccines.

  • Average copay: $35 – $70
  • Average coinsurance: 28% – 39%
  • Actual out-of-pocket: $14 – $103

Medicare Advantage-Prescription Drug plans
A small amount of MAPD plans use a Vaccine Tier. in 2015, about 3% of MAPD plans had a Vaccine Tier. In 2012, it was about 2%. Among these plans, the Shingles shot, Zostavax, was the most often covered.

  • Average copay: $42 – $54
  • Average coinsurance: 16% – 27%
  • Actual out-of-pocket: $10 – $72

Actual out-of-pocket prices were based on current costs for vaccines. If  a beneficiary hasn’t reached they would pay the full cost of the vaccine, which can range from $38 – $276.

Why are the payments for beneficiaries have such a wide range? 
The range of prices shows the rage of tiers that Prescription Drug and MAPD plans use for vaccines.


These are the vaccines listed above: 

Boostrix: Booster shot- Tetanus, Diptheria, Whooping cough
Zostavax: Shingles
Varivax: Chicken Pox
Menomune: Meningitis
Havrix: Hepatitis A
VAQTA: Hepatitis A
Energix-B: Hepatitis B
Twinrix: Hepatitis A & B
Tenivac: Booster shot- Tetanus, Diptheria



Tom Says:

“This is something we should all be telling our Congressmen: that all Medicare plans should have Vaccine Tiers to cover vaccinations.”

See the report by Avalere Health here.

For more, read a blog about the report on Modern Healthcare.

Last year, Medicare beneficiaries continued to save billions on prescription drugs since the 2010 introduction of the Affordable Care Act. These are the total savings:

  • 10.7 million beneficiaries have saved $20.8 billion on prescriptions with discounts.
  • Average savings per person: $1,945.

These are the numbers for 2015 alone:

  • 5.2 million beneficiaries saved more than $5.4 billion with discounts.
  • Average savings per person: $1,054.

The savings are 12% higher than in 2014, and twice as many beneficiaries saved money:

  • 5.1 million beneficiaries saved $4.8 million with discounts.
  • Average savings per person: $941.

Medicare beneficiaries are also being healthier by taking advantage of their plan resources.

  • Nearly 40 million beneficiaries used “at least one preventative service with no copays or deductibles” last year.
  • About 9 million Medicare Advantage beneficiaries, and 6 million with Medicare supplements, had an annual wellness visit last year.

Last year in Virginia, over 1 million people enrolled in Medicare Part B.

  • 76.2% of beneficiaries in Virginia used Medicare Part B Free Services.
  • 19.5% of beneficiaries in Virginia had an annual wellness visit.

Read the report on Medicare savings here.

For more on the numbers, see this Modern Healthcare article.

Difference can be hundreds of dollars

The formularies of Prescription Drug Plans show if, and how, the plan covers medications. A report by the Kaiser Family Foundation shows how the costs of on-formulary drugs differ between plans.

Of those listed, most generics’ highest cost will be $10, with the median cost hovering around $3-$5 dollars. Atorvastatin spans $0 to $20. Hydrocodone can cost up to $78- double the median cost of $36. Half of these drugs treat hypertension and high cholesterol.


This image is from the Kaiser Family Foundation.

The fluctuation in pricing is more severe with brand drugs. This list includes drugs that treat diabetes, asthma and other conditions. The highest cost of 60% of the top 10 brands is over $100. In the case of Spiriva, the highest cost is over ten times the lowest cost.

How is there such a difference?
The most important questions when looking at drug costs are:
  • Which tier is the drug in? 
  • What’s the cost to the customer per tier? 
  • Is the cost in copays (a flat cost for all drugs in a tier) or coinsurance (a percentage of the drug cost)?
These can make a big difference in the cost to the beneficiary.
This image is from the Kaiser Family Foundation.
What if it’s not on the formulary?
Then costs are even higher. If your drugs aren’t covered, there are alternatives: using websites that compare drug prices and looking into Canadian pharmacies.
This image is from the Kaiser Family Foundation.
✶ In the very near future, Tom will have Word Seek, Crossword and Sudoku books for clients. If you would like one, please respond to this email or call us at 804-788-1965 ✶

Current Advantage and Prescription Drug Plan customers are not affected

The Centers for Medicare and Medicaid Services brought sanctions against Cigna-Healthspring January 21.

Cigna-Healthspring cannot enroll new beneficiaries into its Medicare Advantage and Prescription Drug plans. They are also prevented from marketing efforts. Cigna supplement plans are not involved in the suspension. The sanctions will be removed when the problems are solved, which will be decided by Medicare.

The sanctions are a result of Cigna’s poor responses to customer complaints and appeals, and problems with the Part D formulary and benefits. These problems led to difficulty obtaining and denials of treatment and medications, and increased costs.

What about those in the plans?
Current members of Cigna-Healthspring Advantage and Prescription Drug Plans are not affected. Coverage will remain and the hope is that Cigna, under the oversight of Medicare, will solve the problems that led to the sanctions.

If you’ve experienced problems with your Cigna-Healthspring plan, file a complaint with them or with Medicare. Fill out the Medicare Complaint Form here, or learn more about complaints on

How long will this last?
The sanctions will be withdrawn when the problems are fixed. That could last as long as six months, a year, or possibly into 2017. Cigna must submit a plan to correct the issues to Medicare by January 29.

✶ In the very near future, Tom will have Word Seek, Crossword and Sudoko books for clients. If you would like one, please respond to this email or call us at 804-788-1965 ✶
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