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Take Time To Pick The Right Long-Term-Care Facility For A Parent

Take Time To Pick The Right Long-Term-Care Facility For A Parent

By Kimberly Lankford, Kiplinger Personal Finance

When Donna Braley was 79, her family started to notice she was having trouble doing things that she’d always loved to do — crocheting, cooking, doing crossword puzzles. Because her children lived in different states, it took a while for them to piece together their stories and realize that their mother needed help.

The family hired a geriatric care manager, and “her assessment made it obvious to us that Mom would soon no longer be able to live at home without full-time caregiving,” says daughter Kathi Dunn.

The family moved Braley to a semi-independent apartment in a locked Alzheimer’s facility in Roseville, California, near her son Scott and his wife, Amy. But after she was there for a few months, she became combative and difficult to manage. They found another Alzheimer’s facility, “but it was too large,” says Amy. Braley would roam the hallways and go in and out of other people’s rooms, disturbing their belongings.

When money started to run short, the family searched for another option. They heard about a 15-person facility that focused on dementia, which seemed like a better fit and was less expensive. The third time was the charm.

For the past two years, Braley has required total care and uses a wheelchair full-time, but staff at her new home have found ways for her to be as active as possible. When her grandchildren visit, they play in the backyard as if it were Grandma’s house, and the residents’ families watch out for one another.

Start the search

When it’s time to get extra care for your parents, you may be forced to decide quickly, especially if your parent has been in the hospital and needs extra help as soon as he or she is released.

“You’re making a traumatic and important decision under pressure,” says Byron Cordes, a geriatric care manager with Sage Care Management, San Antonio, Texas. “The hospital may say you need to move your dad by the end of business today, then just hand you a magazine about senior-living options and say, ‘Good luck finding a nursing home.'”

Cordes recommends taking the time to find out exactly what your parent needs. That often means talking to the staff doctor, social worker, nursing personnel, case manager and discharge manager. It may mean hiring a geriatric care manager to help coordinate the various care providers.

It can be challenging to balance quality and cost. The median price of a private room in a nursing home tops $6,900 per month, and assisted-living facilities cost more than $3,400 per month, according to the Genworth 2013 Cost of Care Survey. So unless your parents have long-term-care insurance, they — or you, if you’re helping pay the bills — may not be able to afford the ideal setting for long. Medicare covers very little long-term care, and most people aren’t eligible for Medicaid until they’ve spent most of their money.

Now new resources can help you make the decision.

“The landscape has changed for senior housing,” says Andy Cohen, CEO of Caring.com, where people share reviews of nursing homes and assisted-living facilities. “Some are more like college dorms for seniors, with good food, transportation and activities. A lot of children feel guilty, but after they visit these places, they say that Mom’s healthier and happier.”

Assisted living in many cases can take the place of nursing-home care, at least in the early stages of care, says Sandra Timmermann, a gerontologist in Fairfield, Conn. Some facilities have continuing care, and residents can move to another wing in the same facility if they need more supervision.

You can also hire a caregiver to provide extra assistance in an assisted-living facility so you don’t have to move your parent to a nursing home. People with dementia and Alzheimer’s have many options for memory care.

Medicaid generally covers nursing homes but not assisted-living facilities, so your parents can usually choose assisted living only if they have enough savings or long-term-care insurance. (A few states have Medicaid voucher programs, which allow a limited number of people to use Medicaid money for assisted living; see Medicaid.gov for each state’s rules.)

The Medicare Nursing Home Compare tool assesses more than 15,000 nursing homes throughout the U.S. based on inspections, complaints and staffing ratings. But it doesn’t include most assisted-living facilities, which have different licensing requirements in each state.

You can go to the Eldercare Locator or a local Area Agency on Aging for help finding assisted-living facilities, but these resources don’t assess the services. Review sites, such as Caring.com, let you see others’ experience with the facilities.

Several services can help you with your search. CareScout includes ratings and profiles for more than 90,000 assisted-living facilities, nursing homes and home-care providers. For $495, you can work with a care advocate, who helps assess your needs and narrow the list to three or more facilities to visit; the advocate can also negotiate discounts at the facilities. Many Genworth policyholders get free access to CareScout for themselves or their parents, and some employee-assistance programs include access to similar services.

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Hire a pro?

A geriatric care manager can help you explore your options. Care managers are also familiar with local facilities and benefits programs, so hiring one can be a good idea if your family has multiple siblings or if you’re researching care options from a distance. Go to www.caremanager.org to search for care managers throughout the U.S. They generally charge $100 to $180 per hour and are not allowed to accept finder’s fees from facilities.

Geriatric care managers have made a big difference for Jennifer Russell, of Tampa. Her mother, Margie Yeagley, who lived in San Antonio, seemed to be doing fine living alone after her husband died. But four years ago, Russell realized she needed more help.

Russell asked Byron Cordes, the geriatric care manager, to have Yeagley evaluated and discovered that she had significantly progressed dementia. Cordes found an assisted-living facility in San Antonio with a memory-care unit, and they moved her mother right away. After two years of traveling back and forth between California, where Russell lived then, and Texas, Russell decided it would be easier to move her mother out to California.

Her first step was to find a care manager in California, who helped identify the best facilities and doctors. When Russell’s husband got a new job in Tampa, they repeated the process again. Russell’s mother is now in a memory-care wing of a large assisted-living facility nearby.

What to look for

After you narrow the list to two to five places, visit and ask a lot of questions. And don’t just talk with the marketing people; seek out those providing the care.

“Go completely unannounced and walk in at whatever time of day you can,” says Cordes. “I’ve been in nursing homes when they’ve announced that a tour is coming in. You see the housekeeping staff spraying the halls with Febreze and closing the doors to patients’ rooms.” See how people are treated at mealtime and how they’re treated at 8 p.m.

Next, schedule a meeting with the marketing director to get more details about how the facility cares for residents. Every nursing home is required to have a care plan. What would be in the care plan for your parent? What activities would the facility offer to your parent? How are the residents’ physical needs monitored? Ask about the patient-to-staff ratio (Cordes usually recommends 18-20 patients per caregiving staffer.) What type of specialized training do the staff have in dealing with your parent’s medical condition?

Ask if your parent will get any time outside the facility, especially if he or she is in a locked memory-care wing of a long-term-care facility (some have courtyards).

Ask for a list of the costs, especially for assisted living. In some facilities, you may get a set number of hours of personal care, and you may be charged extra if your parent needs more. After your visit, ask yourself: Is this a place where you would want to spend time? Is it clean? How does it smell? Are the residents showered, with clean clothes? Is the food healthy and tasty? How would your parent fit in with the other residents?

“Does the staff treat the residents with respect or, better yet, like beloved grandparents?” adds Amy Braley.

Things change

Your parent may start out in assisted living but eventually need care in a nursing home. No matter what, monitor your parent’s care with the same critical eye you brought to the selection process. If the place isn’t a good match, don’t be afraid to move your parent to one that feels like home.

(c) 2015, Kiplinger. All rights reserved. Distributed by Tribune Content Agency, LLC.

Photo: More Good Foundation via Flickr

Your Health Insurer Won’t Pay? Try, Try Again!

Your Health Insurer Won’t Pay? Try, Try Again!

By Kimberly Lankford, Kiplinger Personal Finance

When you’re dealing with a medical condition or disease, you want to find the best treatment without a lot of hassle from your insurer. But insurers may deny coverage for the specialist your doctor recommended, or send you a bill for care you thought was covered.

To help avoid nasty surprises, choose a policy during open enrollment that covers the care you’re likely to need, and vet the list of in-network specialists and participating hospitals. That doesn’t mean you’ll never run into roadblocks. If you do, these steps can save you thousands of dollars while helping you get the care you need.

Other tips:

1. Lock in a specialist

Getting approval for care up front usually means you won’t have to fight for coverage later. But winning that sign-off can be tricky if your doctor recommends a specialist who isn’t in your insurer’s network.

Some health plans don’t cover out-of-network providers at all. Others may provide limited coverage for out-of-network care but at a much higher cost, perhaps doubling your deductible and boosting your co-payment or coinsurance significantly.

Before stretching to pay for the out-of-network specialist, ask your insurance company about your options. Generally, it will try to find an in-network doctor who can perform the procedure. Contact the doctors the insurer recommends and ask about their credentials, experience and proposed course of treatment. (You might also run their names past the doctor who recommended the out-of-network specialist in the first place.)

Keep track of the doctors you call and what they say. Proving that you’ve covered the bases can be helpful later if you have to make a case for out-of-network coverage.

Even if you hope to work with another doctor, it’s a good idea to visit the specialist recommended by the insurer.

“If nothing else, you get a second opinion,” says Tom Bridenstine, the managed-care ombudsman for Virginia, who helps state residents with coverage questions and appeals. You could decide to work with the in-network specialist after all, or the specialist might agree to write a letter explaining that you have a condition that he or she can’t adequately treat, Bridenstine says.

That happened to Robin Mullins Grunwald, 51, of Clintwood, Va. She had several surgeries for breast cancer starting in 2009, including reconstructive surgery, and her insurer paid the claims. But she ended up with an infection from the reconstructive surgery and developed a hernia.

The hernia surgery was complicated because of the infection, so her doctor recommended a surgeon in Greenville, S.C., who specialized in the procedure.

“I loved the doctor in South Carolina and felt comfortable with him,” she says.

When she tried to get preapproval for the surgeon in Greenville, Grunwald was denied coverage. She appealed and lost. Eventually, she got a recommendation from her insurer for an in-network surgeon in Richmond, but went to Bridenstine for help anyway. He suggested she at least meet with the surgeon in Richmond.

“He was fantastic,” she says of her decision to go with him. Grunwald’s advice: “Communicate with the physician and don’t be scared to ask questions.” Another piece of advice: Keep an open mind.

2. Look farther out

If you can’t find a doctor in your network with whom you’re comfortable, have your insurer cast a wider net, says Denise Sikora, president of DL Health Claim Solutions, Woodbridge, N.J. Sikora specializes in helping cancer patients deal with their medical bills.

She recently helped a client who needed a specific type of brain surgery but couldn’t find an in-network doctor in New Jersey with the experience she was seeking. Sikora kept asking the insurer for more in-network candidates and finally found one in Pennsylvania who specialized in the procedure.

You may have more in-network options than you realize. Kathleen Hogue, president of Mediform Inc., a medical billing specialist in Twinsburg, Ohio, recently helped a client with coverage from a small, local insurer in Ohio that gives patients access to a national network of doctors and hospitals. The client ended up going to the MD Anderson Cancer Center in Houston, a world-renowned facility, for the price of in-network care.

If no in-network solution exists, the insurer may consider your situation a “network adequacy gap” and cover an out-of-network provider as if he or she were in network. At Aetna, for example, a precertification nurse researches the options and, if there are no in-network providers in the area who can supply the service you need, the insurer will authorize the coverage.

You don’t have to stand by while someone else makes this decision. Ask the insurer what information you can provide to strengthen your case. For instance, your insurer might be receptive to a statement from your primary-care doctor saying that he has studied the case and, for this condition, he believes you are justified in seeking treatment out of network, says Hogue.

Some people choose to go to the out-of-network specialist despite the out-of-pocket costs. In that case, try to negotiate a deal. Kirsten Sloan, of the American Cancer Society, says that some plans may agree to pay a portion of the bill at the in-network rate and have the patient pay the balance.

It can help to have the physician’s office call and explain that the doctor is willing to accept in-network payment and get a preapproval, she says. Or you can ask the provider for a cash discount.

3. Review the bill

You may think that all of your care was approved, only to receive a surprise bill from the insurance company. Don’t pay it until you get the explanation of benefits to find out why your claim was denied. (These forms can be difficult to decipher; ask the insurer for a translation.)

The doctor may have billed with the wrong tax ID, or you may have used an old insurance card. In such cases, an appeal usually isn’t necessary, says Patrick Shea, a claims specialist and director of MedicalClaimsHelp.org, in Green Bay, Wis. “You can get the errors reprocessed with a phone call.”

Coding mistakes can also cause problems. The provider’s office may have input the wrong code for the procedure or the diagnosis.

“Sometimes the doctor can resubmit it with a different diagnosis and procedure code, and the charge will be paid,” says Hogue.

To spot mistakes from the start, get an itemized bill that breaks down each cost separately, especially for complex procedures and hospital stays.

“Anytime you receive a bill from a facility, you should ask for a detailed, itemized bill to know exactly what you’re being charged for,” says Pat Palmer, CEO of Medical Billing Advocates of America, Roanoke, Va. You may have been charged for services you didn’t receive, in which case you can usually fix the error with a phone call or by providing the medical records.

4. Fight two fronts

Kim Jacobs, of Lakeville, Minn., faced both authorization issues and clerical errors. Two years ago, she underwent an outpatient procedure recommended by her gynecologist. She’d been told by the doctor’s office that the procedure was authorized, so was surprised to receive a bill for nearly $10,000.

“The doctor’s office said they got the approval, and you don’t think to double-check it,” she says. Her doctor has since written letters to the insurer explaining why the procedure was medically necessary, in hopes of overturning the denial.

In the meantime, Jacobs contacted Palmer and her colleagues for help. They asked the hospital for an itemized bill and successfully disputed several of the charges, bringing the bill down by nearly $4,000. Disputing errors on the bill is a good strategy for knocking down the cost while you’re undergoing the more complicated process of appealing. Jacobs continues to pursue her appeal with help from Palmer and her colleagues.

5. Win an appeal

If you decide to appeal, your case will likely go through several layers of review–first within the insurance company, then from outside doctors, and finally from the state insurance department (or through the Department of Labor, if you’re covered by an employer’s self-funded plan).

Your explanation of benefits and your insurance policy should spell out the procedure and deadlines for appeals. Sometimes you can conduct the appeal via a conference call with your physician, the insurance person who made the claims decision, and your claims advocate, says Palmer.

No matter how you do it, build a strong case.

“I always prepare my appeal as if it’s the only chance I have,” says Sikora. “You have to do the research and pull it all together.”

The first step, she says, is to find out why the claim was denied. Then gather evidence and focus your appeal specifically on that reason.

“I recently did an appeal for someone whose treatment was considered experimental,” she says. “We researched the drug and included about 15 research articles citing that this drug was a standard of care during the fourth stage of treatment.” The case was won on the proof in the medical record that doctors didn’t use the drug the first time–they used it the fourth time, and the treatment helped, says Sikora.

If your insurer denies your appeal, you can generally file one with your state insurance department. Californians, for example, can request an independent medical review through the Department of Managed Health Care and have the case reviewed by doctors who are not part of their health plan.

“Approximately 60 percent of enrollees who submit independent medical review requests to the DMHC receive the service or treatment they requested,” says spokesman Rodger Butler. Find your state insurance department at www.naic.org.

6. Be patient. It can take several months to go through all the levels of appeal.

“I usually keep the provider in the loop and ask him to keep the bill from collection while we’re working on this,” says Sikora. Keep in mind that it’s difficult to get money back once you’ve paid it. Hold out while the appeal works through the system.

Where To Get Help

A medical claims specialist can help you decipher your bills and appeal denials (go to www.claims.org). Most offer a free initial meeting to review the bills and complexity of the case, after which they charge $75 to $120 per hour. You can meet in person, or e-mail your bills and give the specialist permission to access your insurance-claim files online.

Also seek help and resources from advocacy groups, such as CancerCare.org, the American Cancer Society, or the Arthritis Foundation. These groups can help you research commonly used drugs or procedures, and they sometimes have people on staff who will answer claims questions or help with filing appeals.

CancerCare.org also has information about financial resources if your insurer won’t pay your claim and you end up with big out-of-pocket expenses. (c) 2015, KIPLINGER. ALL RIGHTS RESERVED. DISTRIBUTED BY TRIBUNE CONTENT AGENCY, LLC.

Photo: epSos .de via Flickr

A Little Homework Can Help You Navigate The Medicare Maze

A Little Homework Can Help You Navigate The Medicare Maze

By Kimberly Lankford, Kiplinger Personal Finance (Premium Health News Service)

You’re eligible for Medicare when you turn 65, but these days, the decision to sign up is not a slam-dunk.

For example, after you enroll in Medicare, you can no longer contribute to a health savings account. If, however, you work for a company with fewer than 20 employees, you usually don’t have a choice: Medicare Part A, which covers hospitalization, must be your primary insurance.

The decision to sign up or not also depends on whether you’re receiving Social Security benefits and whether your spouse has coverage through your health insurance. If you miss key deadlines, you could have a gap in coverage, miss out on valuable tax breaks, or get stuck with a penalty for the rest of your life.

The Social Security Rule

If you enroll in Social Security before age 65, you’ll automatically be enrolled in Medicare Part A and Part B when you turn 65. Part A covers hospital costs and is premium-free if you or your spouse paid Medicare taxes for at least 10 years. Part B covers outpatient care, such as doctor visits, x-rays and tests, and costs most people $104.90 per month in 2015. Part B premiums are deducted from your Social Security benefits.

You’ll receive your Medicare card in the mail three months before your 65th birthday. If you’re still working and don’t want Part B yet, you can send back the card and have it reissued for Part A only, but you can’t turn down Part A if you’re enrolled in Social Security. Call Social Security at 800-772-1213 with details about your situation to make sure you won’t be penalized for enrolling late in Part B.

If you haven’t claimed Social Security benefits, enrollment in Medicare isn’t automatic. If you’re still working and neither you nor your spouse has employer health coverage, you should sign up for both Part A and Part B. Go to SocialSecurity.gov to sign up three months before or after the month you turn 65–even if you aren’t signing up for Social Security.

If you miss the seven-month window, you’ll be able to enroll in Medicare only at limited times during the year (from January through March, with coverage starting July 1), and you may have to pay a lifetime late-enrollment penalty of 10 percent of the current Part B premium for every year you should have been enrolled in Part B.

If You Have Employer Coverage

If you have coverage through an employer with 20 or more employees, you don’t have to sign up for Medicare when you turn 65 because the group policy pays first and Medicare pays second. (If your spouse is covered under your policy, the same rules apply.) Most people with employer coverage enroll in Part A at 65 because it’s free (unless they want to contribute to a health savings account). But you don’t have to sign up for Part B if you’re happy with your existing coverage. You’ll avoid a future penalty as long as you sign up for Part B within eight months of leaving your job.

If you work for a company with fewer than 20 employees, however, Medicare is considered your primary coverage and your employer’s insurance pays second. You generally must sign up for Medicare Part A and Part B at 65, although sometimes small employers negotiate with their insurers to provide primary coverage to people over 65.

If your employer says it will cover your outpatient costs first, “it’s really important to get that in writing,” says Casey Schwarz, of the Medicare Rights Center.

Only coverage from a current employer with 20 or more employees counts as primary coverage. Retiree health insurance and coverage under COBRA, the law that allows a temporary extension of employer benefits, don’t count. So if you don’t sign up for Medicare Part A and Part B at age 65, you could have coverage gaps and face the lifetime penalty.

Medicare rules for federal employees who are 65 and older and still working are the same as they are for employees still working for other large employers. But the rules are different for federal retiree coverage than for other retiree coverage. If you haven’t signed up for Medicare, federal retiree coverage is the primary insurance (Medicare pays first if you have it). But if you change your mind and miss the window for signing up after you leave your job, you will face a late-enrollment penalty.

If you didn’t enroll in Part B at 65 because you had coverage through your employer (even if you signed up for Part A), you’ll need to sign up within eight months of leaving your job to avoid the penalty. You won’t be able to enroll online, because you’ll need to provide evidence of “creditable coverage” from your employer from the time you turned 65.

Joan Baraba, of Chesterfield, Mo., was still working as a banking executive when she turned 65 in July 2013. She and her husband, Edward, had good coverage through her employer, so he signed up for Part A at 65, and she waited to sign up for benefits. A few months before she retired in July 2014, she applied for parts A and B and Edward applied for Part B. Doing so was complicated because they had to provide evidence that they’d been covered by her employer since age 65.

“It took several months to go through the process,” she says. She recommends starting the paperwork six months before you plan to retire, so you don’t have a gap in coverage.

Health Savings Account Vs. Medicare

A Health Savings Account, which must be paired with a high-deductible policy, offers tax advantages, and some employers contribute money, too. But you can’t contribute to an HSA after you sign up for Medicare Part A or Part B.

Before you delay signing up for Medicare to continue contributing to an HSA, do a cost-benefit analysis to determine whether the HSA tax breaks, employer contributions and other benefits are more valuable than free Part A, recommends Elaine Wong Eakin, of California Health Advocates.

That’s what Ken Kleban, a lawyer in St. Louis, did before he turned 65 this year.

“It was going to cost me thousands more dollars to go on Medicare,” he says. He kept his company’s high-deductible plan for himself and his wife, Jackie, and delayed signing up for Medicare so he could continue making pretax contributions to the HSA.

Kleban will reassess his decision to choose the HSA instead of Medicare every year. But he plans to use the HSA for his post-retirement medical expenses. He’s paid out of pocket rather than tap his HSA for many medical expenses so the money in the HSA would grow tax-free.

Kleban has several manila folders with eligible medical bills he incurred since opening the HSA six years ago, for which he can withdraw funds tax-free even after he signs up for Medicare. You can also use HSA money tax-free to pay Medicare Part B, Part D, and Medicare Advantage (but not medigap) premiums.

Adding Up The Cost Of Medicare

Before you decide to sign up for Medicare or stay on an employer’s health plan, compare all the costs. Your employer’s coverage may be less expensive.

You don’t pay a premium for Medicare Part A, which covers hospitalization. But for Medicare Part B, which covers outpatient care, most people pay $104.90 per month. Single enrollees earning more than $85,000 and married enrollees filing jointly and earning more than $170,000 pay $146.90 to $335.70 per person per month.

Unless you have retiree health insurance, you’ll probably also want a medigap policy to help cover co-payments and deductibles, and a Part D drug plan to cover prescription drugs. Part D averages $32 per person (plus a high-income surcharge that boosts premiums by $12.30 to $70.80 per person if income is above $85,000 for singles or $170,000 for couples). The most popular medigap policy, Plan F, has a median premium of $172 per month, according to Weiss Ratings.

Even without the high-income surcharges, your monthly costs to sign up for Part B, medigap insurance and Part D will run about $309 per person per month. You may be able to save money by buying a Medicare Advantage plan, which offers medical and drug coverage through a private network of providers; you pay the Part B premium plus an average Medicare Advantage premium of $33.90 a month.

You can get help with Medicare decisions from the Medicare Rights Center (www.medicarerights.org; 1-800-333-4114) or your local State Health Insurance Assistance Program (www.shiptalk.org; 1-800-633-4227). (c) 2015, KIPLINGER. ALL RIGHTS RESERVED. DISTRIBUTED BY TRIBUNE CONTENT AGENCY, LLC.

Photo: Connor Tarter via Flickr

Reduce Your Drug Costs Instantly With These Simple Changes

Reduce Your Drug Costs Instantly With These Simple Changes

By Kimberly Lankford, Kiplinger Personal Finance

As health insurers shift more of the cost burden to consumers, the average U.S. worker with employer-provided coverage now pays $9,695 per year in premiums and out-of-pocket costs for a family of four — a 118 percent increase over the past decade, according to the Milliman Medical Index. If you buy coverage on your own, you may be spending even more.

Prescription drugs are a recurring expense that can really add up throughout the year. Insurers are increasing your share of the tab for certain brand-name drugs, and you’ll pay even more if you don’t follow strict rules, such as using specific pharmacies with which insurers have negotiated discounts.

Now for some good news: You can slash your out-of-pocket spending on Rx drugs if you learn the secrets of health insurers and know how to navigate the health care marketplace.

Here are 11 easy ways to reduce your drug costs right away:

1. Know the rules for prescriptions

Many health plans are adding new hurdles that you must clear before you can get certain medications. For example, you might have to try step therapy (which requires you to try other medications first, if possible) or seek prior authorization (the insurer asks your doctor a detailed list of questions about your condition and your treatment before it will cover the drug). Understand the rules for getting your drugs covered, and get your doctor involved to help explain to the insurer why you need the medication or to file an appeal if it’s denied.

2. Get a prescription for over-the-counter drugs

You can no longer use tax-free money from a flexible spending account or health savings account for over-the-counter drugs without a prescription (except insulin). To get reimbursed from your FSA or HSA, ask your doctor for a prescription for any medications you use regularly, such as pain relievers, allergy medications, anti-fungals and cough-and-cold medicines, says Jody Dietel, of WageWorks, which administers FSAs for employers.

3. Use tools to comparison-shop prescriptions

Many insurers and employers have tools that help you compare prices for your medications, showing brand-name versions, generics and therapeutic alternatives. They also offer smartphone apps to look up the lowest-cost pharmacies before you leave the doctor’s office.

4. Use preferred pharmacies

More health plans are introducing preferred pharmacies, which cost even less than regular in-network pharmacies. For example, the Humana Walmart Rx plan for Medicare Part D charges a $1 co-payment for a 30-day supply of certain generic drugs purchased at Walmart or Sam’s Club (or a $0 co-payment through RightSource mail order), but the plan charges a $10 co-payment for the same drugs purchased at a nonpreferred network retail pharmacy.

For pricier “Tier 4” preferred brand-name drugs (there are a total of five pricing tiers), you’d pay 39 percent coinsurance through Walmart, Sam’s Club and RightSource but 50 percent coinsurance at nonpreferred network pharmacies.

5. Get your drugs through the mail

Mail-order pharmacies may provide a three-month supply of drugs for the same price as a one-month supply at a local pharmacy. Some plans require you to use mail order for maintenance drugs.

6. Switch to generic drugs

Generic drugs can cost as much as 80 percent less than their brand-name alternatives. The lower list price makes a huge difference when you’re in the plan’s deductible period and paying the full price out of your pocket. And the coinsurance rates are usually lower, too — often 10 percent to 15 percent of the cost for generics, 25 percent for preferred brand-name drugs, and 50 percent for nonpreferred brand-name drugs.

Some plans no longer cover certain brand-name drugs. For example, one popular health plan doesn’t cover Lipitor, which costs $180.75 for a 30-day supply of 10 mg tablets. But the generic equivalent, atorvastatin calcium, would cost $13.92 under the same plan, says Jim Yocum, executive vice-president of DRX, which provides Web-based prescription-drug comparison services to health plans and employers.

You may also get a good deal on generics at certain stores, such as Walmart and Target, which charge as little as $4 for a 30-day supply of certain drugs or $10 for a 90-day supply.

7. Keep an eye out for new generics

The patents for several popular brand-name drugs — Celebrex, Copaxone, Nexium, Actonel and Exforge — are scheduled to expire soon, which will open the door for drug companies to manufacture generic alternatives.

“It takes some time after patents expire for manufacturers of generics to receive approval from the U.S. Food and Drug Administration, make the drug and get supplies on drugstore shelves. Litigation can also delay expected patent expiration dates,” says Yocum.

You can look into generic alternatives now for Cymbalta, Maxalt, Maxalt MPT, Micardis, Micardis HCT, Twynsta and Xeloda, whose patents expired recently and for which generics are on the market, says Yocum.

Most insurers have Web tools or apps to help you look up generic alternatives to your drugs.

8. Pay for generics yourself

Some stores, such as Walmart and Target, charge as little as $4 for a 30-day supply of some drugs or $10 for a 90-day supply, while some insurance companies charge a $10 co-payment for a 30-day supply.

“Most generic medications cost less if you don’t use your insurance,” says David Belk, a physician in the San Francisco Bay area who lists drug prices and strategies for saving money on medical expenses at truecostofhealthcare.org. Belk especially likes Costco because it has an even longer list of generic drug deals.

9. Split your pills

Ask your doctor if you can save money by cutting your pills. Your physician will have to write a new prescription for twice the strength and half the quantity, noting your intent to split the tablets.

10. Get help from special drug programs

Go to the National Council on Aging’s Benefits Checkup site (benefitscheckup.org) and anonymously input basic information about your income, assets, medical conditions and drugs. You’ll see whether you qualify for any special programs to help with drug costs, such as drug manufacturers’ patient-assistance programs for low-income patients.

11. Find theraputic alternatives

Some brand-name drugs don’t have a generic equivalent but may have a “therapeutic alternative.” That means a medicine that’s in the same class of drugs but is chemically a little different. For example, Diovan is a blood-pressure drug with no direct generic substitute. In one popular plan, the monthly cost for a 30-day supply of 80 mg tablets is $149.66. But you could spend $1 per month for a comparable dose of iosartan potassium, or $2 per month for irbesartan, or $20 for a monthly supply of Benicar, says Yocum. Ask your doctor about any switch that isn’t a direct generic substitution.

Photo: The Javorac via Flickr