Posted on Saturday, 27th November 2021 by

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“Yes, Virginia, there is a Santa Clause.” Prescription drug copays under Aetna’s Medicare Plans remain the same regardless of whether or not you enter the Part D prescription drug gap. This includes all three of their plans: Self Only (Z24), Self + 1 (Z26), Self and Family (Z25).

I talked to a number of Aetna customer service reps while researching my previous article about Aetna’s Medicare Advantage plans. I received conflicting information on how drugs were reimbursed in this plan. Their pharmacy specialist assured me that the Gap coverage I outlined in the original article was correct! I was referred to the Medicare site for clarification and the information I relayed reflected that guidance.

Susan Allgood, Aetna’s relationship manager for federal plans stated, “the member continues to pay the same co-payment through the entire year.” She referenced Aetna’s Medicare Plan Summary of Benefits and I excerpted the following coverage gap clarification from this document.

Coverage Gap

The Coverage Gap starts once covered Medicare prescription drug expenses have reached the Initial Coverage Limit. Here’s your cost-sharing for covered Part D drugs after the Initial Coverage Limit and until you reach $6,550 in prescription drug expenses:

Your former employer/union/trust provides additional coverage during the Coverage Gap stage for covered drugs. This means that you will generally continue to pay the same amount for covered drugs throughout the Coverage Gap stage of the plan as you paid in the Initial Coverage stage. Coinsurance-based cost-sharing is applied against the overall cost of the drug, prior to the application of any discounts or benefits.

Most insurers have numerous Medicare Part C Plans and many of those plans, not associated with the FEHB, are subject to the Medicare prescription drug Gap. If you are considering a Medicare Part C plan that isn’t associated with the FEHB program, be aware that the prescription drug gap rules outlined in my original article may apply.

Fortunately, Tammy Flanagan forwarded Susan Allgood’s message to me yesterday. Tammy is an exceptional federal benefits consultant and I consider her a good friend. The original article, posted on our blog, has been updated to reflect these changes.

There was also some concern expressed about the increased premiums for higher earner members. The section in the original article about Part D increased costs for higher earners is correct as stated.  According to page 98 of the Aetna Plan Brochure, “You may also see an additional charge if you qualify for the Income-Related Monthly Adjustment Amount (IRMAA). It is an extra amount that you pay for your monthly Medicare Part D prescription drug plan premiums and your monthly Medicare Part B premiums. Social Security makes this determination based on your income.”

According to Medicare, “If your income is above a certain limit ($91,000 if you file individually or $182,000 if you’re married and file jointly), you’ll pay an extra amount in addition to your plan premium (sometimes called “Part D-IRMAA”). You’ll also have to pay this extra amount if you’re in a Medicare Advantage Plan that includes drug coverage. This doesn’t affect everyone, so most people won’t have to pay an extra amount.”

Overall, Aetna Medicare plan costs are reasonable; with the competitive prescription copays, low premiums, and Part B reimbursements it appears to be a viable option for many. If you are considering one of the FEHB MA plans confirm that your doctors and medical facilities accept the MA plan of interest. Higher income earners will have to weigh the increased cost of part D premiums and other factors to see if this plan makes sense for them.

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Disclaimer: The information provided may not cover all aspect of unique or special circumstances, federal regulations, medical procedures, and benefit information are subject to change. To ensure the accuracy of this information, contact relevant parties for assistance including OPM’s retirement center. Over time, various dynamic economic factors relied upon as a basis for this article may change. The advice and strategies contained herein may not be suitable for your situation and this service is not affiliated with OPM or any federal entity. You should consult with a financial, medical or human resource professional where appropriate. Neither the publisher or author shall be liable for any loss or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

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