The Legal Drug Dealer

 
Today you are in for a treat as we will talk about and all that needs to be learned surrounding insurance especially, healthcare insurance. We specifically decided to publish this episode today because the deadline of Medicare Part D holders and beneficiaries is very soon.   
 
Our guest for today is an expert in health insurance, Edward Givens. He is a Licensed Independent Health Insurance Adviser. Licensed in Arizona, Texas, Georgia, Florida, South Carolina, and Maryland.
 
Edward has 15+ years of experience in the healthcare industry. He uses a consultative approach to help educate customers on the current healthcare environment. Allowing customers to make informed decisions about their healthcare choices and provide them with a clear understanding of how their choices will protect their health, their income, and their family for life. 
 
And we will learn about his expertise in this episode. Stay tuned as Edward shares with us his vast knowledge about healthcare insurance. 
 
This episode is not only for older people who need medicare, but also for family members, caregivers, siblings, friends, church groups who wanted to support their loved ones and get them the help they needed surrounding health insurance. 
 
It’s also best for grandchildren who have grandparents in medicare and for pregnant women who wanted to know what they can get from their insurance or what insurance is best for them. 
 
Enjoy the conversation and be ready to learn.  
 
 

What we talk about:

 
  • the different types of healthcare insurance available in the US
  • two types of individual health insurance depending on the states ou live in
  • what is indemnity plan and what do it covers
  • what is medicare and the four parts of medicare
  • four levels of medicare part D
  • what is donut hole, when will you hit it and do you come out of it
  • what options you have to fight the ugly and disgusting donut hole
  • how many times can you change your health insurance plan
  • the biggest misconception of people about health insurance and what independent insurance advisers do  
  • the first 3 things you need to do to take over your situation and have your health insurance the right way  
 

Connect with Edward: 

 
LinkedIn: Edward Givens
Call him at +1 602-551-6623
You can also find Edward in healthmarkets.com
 

Other links mentioned: 

Let me know what you think about our conversation and if you have any questions!!!
 
 

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Transcript:

 
MG
Marilena Grittani, RPh
0:10
Hola, and welcome to The Legal Drug Dealer podcast where you would get health and prescription drug education and advice. So you can take control of your own health by making your own decisions. My name is Marilena Grittani. I am a clinical pharmacist with experience in community pharmacy, like the ones that you go and get prescription drugs, stay with me and learn from my experience and the experience of experts that I have invited to educate us. Why The Legal Drug Dealer you might ask well as a pharmacist, ideal drugs and it is a legal job. So I think it’s funny to call myself The Legal Drug Dealer. So that’s the name of my podcast. Here you have the next episode.
Marilena Grittani, RPh
0:50
Hola, today you’re in for a treat. This is a bonus episode that is very timely oriented. We have decided to publish this today as a bonus episode, because the time is right. We are going to have a deadline very soon for all those Medicare Part D holders or beneficiaries. And we need to introduce a lot of information for you and my guest, and myself agreed that this is going to be the best time to publish it. So that’s what we did. So today, I have Edward Givens. He is an independent health insurance advisor. Basically, his job is to tell you what options that they have out there. He doesn’t sell you anything. He doesn’t get a commission by it. He just gets paid by giving you the advice, and that is included in every single policy that you buy. So he’s going to explain more about that. But this person is an expert about health care, insurance, and you’re going to know, the first two minutes you’re going to be like, Oh my God, this guy knows what he’s talking about. And that’s why I brought him in. I need you to be as educated as informed as you can be to make the decisions whether you are a grandchild of somebody that goes on Medicare, or whether you are a pregnant woman that is about to have a baby. And you need to know how the insurance is going to work, if you have a private or Federal Insurance and how much it’s going to pay, and how it’s going to work, how much you’re going to be responsible for all those details we’re going to be talking about right now. So this is not just for older people that need Medicare. It’s also for family members, caregivers, siblings, friends, church groups that support their parishioners to get the help that they need, so they can have the benefits of this help. That is an insurance company, mostly for health insurance. So you’re in for a treat, it’s going to be packed with information. We have a booklet that it’s going to help you with the information as well. So you need to go to the website that is part of the notes on the platform that you’re listening to this episode. You’re going to have a link that is going to take you to my website and then there you’re going to have the option to download it and get the information, you’re going to have concepts, you’re going to have a lot of information that Edward is going to be talking about. So please don’t miss it. First of all, make sure that you need this information. And then when you do, go and get that from the website, because we work really hard for that, because we know you’re gonna need it. Whether if it’s for you as the insurance holder, or if it’s for your grandparents or for your parents or for your elder sister, or brother or whoever that is, so your loved one. So please enjoy the conversation. Be ready to learn. And if you have any questions, you know what to do send them to hello@thelegaldrugdealer.com and I will be happy to answer them or send them to Edward if that is the case. Okay, so here’s Edward Givens with the health insurance information.
MG
Marilena Grittani, RPh
3:51
So, Edward, thank you so much for being part of The Legal Drug Dealer podcast community. We’ve been working together for a long time and it’s about time for you to come to the podcast. So thank you and welcome.
EG
Edward Givens
4:02
Thank you Marilena.
MG
Marilena Grittani, RPh
4:03
So the conversation that we’re about to have is very important for, well, a bunch of people, but specifically because of the timing for those that are eligible for Medicare Part D. So, if you have anybody that is listening, if you have a family member friend or a neighbor that needs help with this, because they’re over 65, then please pay close attention. It’s not just for them, but you might support them. So let’s start with this and because there’s a lot to talk about. So first of all, why don’t you tell us what is your area of expertise and how long you’ve been doing this?
EG
Edward Givens
4:43
Thank you for having me on. I’m happy to be here and hopefully we can provide some good information that will be helpful to people
MG
Marilena Grittani, RPh
4:49
You will. You will. I know you will.
EG
Edward Givens
4:53
Again, my name is Edward Givens I’m an independent health insurance advisor and I have over 15 years of healthcare experience. I’ve worked on both sides. I’ve worked with medical manufacturing, on a device side with pharmaceuticals. And with individuals as far as health care. I have the heart of a teacher, I want people to learn how to be able to take advantage, the things available to them, and basically be better stewards of their time and their resource. So if they have a good understanding of how to use their medical care or their health insurance, then they’re going to make better choices. Usually, when people get frustrated, it’s because they made an assumption. And then they went down a path, and that assumption was false, and they get frustrated. But most of the time, if we know what’s about to happen, we’re usually comfortable with dealing with the challenges that may happen. That’s why I do what I do is to help people better control of their resource.
MG
Marilena Grittani, RPh
5:45
I really like that because health insurance seems to be a luxury sometimes you’re like, yeah, yeah, we’ll have it there just in case but then at the moment that you need it, the level of stress and anxiety that you’re going through, the least thing that you need is, hey, well, that you didn’t sign in for or this is how much you said that you were wanting to pay. And then you of course you don’t remember because he never happens the day after you make that decision. So thank you for that. And being the voice of my listeners and my patients, I appreciate what you do. Because as a pharmacist that works directly with insurance companies, I don’t know what you know, and then we will be able to compliment really well. So okay, let’s start with the meat and potatoes of the conversation. So tell us about the difference or the different types of health insurance available in the US.
EG
Edward Givens
6:40
This current time. In the US, there’s several different options for health care, and they all work slightly differently. And they all have slightly different criteria. You have state run Medicaid, or like in Arizona, we call it access. That’s for low income and for some disabled people. You have group or company insurance with which most people do have insurance paid for, or at least partially subsidized by their employer as a benefit to them. And then you have federal government insurance or state insurance. And that’s a little bit different than group insurance because of the way the state negotiates their rates. That would be for federal employees, state employees, military personnel. And then you have individual health insurance. You have two types of those depending on the state you live in. So across the country, you have what is known as Affordable Care Act. That is a law that Obama passed during his presidency. Some people will call it Obamacare, but those types of plans pre existing conditions cannot, you can’t be denied because you have them. They cover pregnancy, they cover mental health, they cover preventative services, and a whole host of other things, okay. But way people are allowed to purchase this is whether they’re on exchange or off exchange. on exchange means you’re getting a subsidy from the federal government based on your zip code, your family size and your income. exchange basically means you’re not getting a subsidy, you’re paying the market rate for that type of insurance. Then you also have what in some states are called short term plans. And it’s a little bit of a misnomer because these plans can help somebody who maybe loses a job during the middle of the year and not enrolled into an affordable care act style plan. They can have a plan for one month for up to three years to get them to that next open enrollment. These plans do not cover things like pregnancy, they do not cover things like mental health, but they may be good for somebody who’s in really good health, and rarely, if ever goes to see the doctor. Then you also have indemnity plans. These are the plans people need to be aware of because they’re usually the ones that you’ll see that say really cheap insurance.
MG
Marilena Grittani, RPh
8:45
What did you? Would you repeat the name of it again, because it cut off
EG
Edward Givens
8:48
an indemnity plan.
MG
Marilena Grittani, RPh
8:50
Okay.
EG
Edward Givens
8:51
These plans pay specifically they may pay you $1,000 per day for each day you’re in the hospital, but most people know if you have a surgery that’s gonna be far more than if you’re in the hospital for five days and they pay you 5000. But they do exist. They need to be aware of what do they cover, hospitals they cover and what doctors, but for certain instances, it can’t work and be helpful. And then you have Medicare. Medicare are for those people who are disabled for at least 18 months, they may end up going on Medicare, and then for people who have reached the age of 65. Those are the different types of health insurance that we have. And to be perfectly honest, I’ve had a few people even comment, you could go with nothing. And that means being self-ensured. And that means that you’re going to pay pretty much the full cost all on your own. We do not recommend that.
MG
Marilena Grittani, RPh
9:42
Well let me just say this in a very kind way to myself, I had no idea. It was so many. So if you my dear listener that is in the other side of this microphone in your car or working out listening to this thinking about My Lord, I thought I just needed to Google it. And then it will give me the option and it will be just one. So this is overwhelming. I don’t even know what to ask you Edward, because it’s taht complicated. So it would be all of them are depending on certain circumstances. Am I correct? If you are certain age if you just got, you lost your job, if you are in disable, right?
EG
Edward Givens
10:26
Correct.
MG
Marilena Grittani, RPh
10:26
Okay. So,
EG
Edward Givens
10:27
It depends on how you use your healthcare,
MG
Marilena Grittani, RPh
10:30
okay. And then based on that do have options and then you can decide and also it depends on where you live because each state and even counties have differences.
EG
Edward Givens
10:40
Correct.
MG
Marilena Grittani, RPh
10:41
You already overwhelmed people over there because I am. Okay,
EG
Edward Givens
10:45
but here’s, here’s the thing about that. There is a lot of information there. Correct. But it can be deciphered. Anyone can understand what their healthcare needs to do. You don’t need to understand the whole bucket. You just need to understand what yours does for you and your family.
MG
Marilena Grittani, RPh
11:01
Okay. That makes a lot of sense. Because we know what diseases we have, or what treatments we need, or what medications were on there might be chronic or not. And if you’re diabetic, you’re gonna need like insulin for, you know, ever and then you you already know what you start with. So the
EG
Edward Givens
11:19
correct
MG
Marilena Grittani, RPh
11:19
the patient knows their own, and then they need somebody, trust me, I’m not selling him because he- I just met him, okay. But you need someone like Edward because, well, he knows his stuff. As I keep saying in this podcast as well, in my online conference, you need experts to tell you exactly what you need to know. It’s not that you went Google it, and then you just pick the first result because most likely that’s going to be an advertising and they’re trying to fish for people that are doing that. And that might not be the best option for you. And I just want to say I know you’re gonna say it later. But I want to ask you right now because I think it’s a perfect path to do that. How much do you charge for your services Edward?
EG
Edward Givens
12:03
Someone like me who’s an independent agent. Our services are free to you actually already in to the health insurance costs by the insurance provider. In some cases, I say to people, you have free advice that’s already paid for, take advantage of it. You used to go online and look yourself and research things yourself. That’s perfectly fine, because now you have a background to your question. But someone like me, can guide you a little bit more directly. And say, Hmm, maybe I want to go with this particular insurance plan because they have more hospitals near my house.
MG
Marilena Grittani, RPh
12:38
And I didn’t know.
EG
Edward Givens
12:40
Mm hmm. Well, another plan might be a little bit cheaper, but they have one hospital 15 miles from your house.
MG
Marilena Grittani, RPh
12:48
Mm hmm.
EG
Edward Givens
12:48
But you may not know that. And we also know how different plans do their customer service. Some people want to work with an app. There are plans that they have a whole bunch of apps that you can use to monitor things, to pay your bills to talk to doctors. And that works for some people, especially younger people. But then you get to older folks want to see somebody, they want to talk to someone. They want to know that there’s a physical person behind that we can help you with those types of things, as well as the intricacies of the plan. And a good independent agent isn’t just going to sell you a plan, and is it going to tell you Oh, my plan is the best. We’re going to educate you on the options. And then once they help you enroll three months down the road, four months down the road, you have a question, you can go back to that advisor for assistance and help. I’ll give a prime example, I have a customer who had a major surgery a couple of months ago. Before we went into the surgery, he called me up and sat down and said, okay, Edward, how does my deductible work again, walk through it? When should I get a bill? We walk through that? What should it look like? This particular procedure was going to be high enough that he was going to meet his deductible completely. So I told him, this is what it shouldn’t look like, this is how you’re going to get built, this is how the insurance company is going to get bill, so that he’d be prepared for what’s going to happen.
MG
Marilena Grittani, RPh
14:09
And then your fee is already paid by the company because you do not work for any insurance companies, you are independent, you work with all of them, and you can you happen to know all of them because well, that’s your job, right? And then you can tell them based on the location and based on the options that that patient needs, on their personal needs, then you will tell them, okay, these are the options that you might need, but you are not to tell them what to do. Right.
EG
Edward Givens
14:39
Right.
MG
Marilena Grittani, RPh
14:40
Because
EG
Edward Givens
14:42
that’s not my job. My job is to advise, give information, so that you can make an informed decision as a consumer.
MG
Marilena Grittani, RPh
14:50
Yeah, but in two words, and I’m gonna say it because we, when we get overwhelmed with stuff, we just want somebody else to tell us what to do. But that is silly. We are not to tell you what to do not not the doctor or the pharmacy or the hospital or the insurance person, because basically, that might be done for them to take advantage of you. And that’s why it’s illegal. So if you have somebody telling you, you need to choose this because I said, so that person is breaking the law. And you don’t want to trust that person because most likely is going to be a fishy person. So that’s not what you need. Whether you are 29 years of age or you are 95. You keep that in mind. It is illegal for anybody to tell you you need to choose this. This is the only choice that you have. That is not true. is always there’s always choices.
MG
Marilena Grittani, RPh
15:40
Okay, so let’s just talk about the very famous Medicare. Is that a private health insurance because I see my patients that come with Medicare cards that they are AARP or they are Aetna or blue cross blue Shield, but it is Medicare. So how do you explain that?
EG
Edward Givens
16:04
Medicare has basically four parts you have Part A, which is your hospitals, your skilled nursing ,your home health care, and you have Part B, your doctors, preventative care, diagnostics, DMV type things. C which is the Medicare Advantage. We’re going to put that off to the side. We’ll come back to that. And then your part D, your prescription drug, when someone turns 65, they’re eligible for Medicare, they go to Social Security, sign up for Medicare, and they will be put on Part A and Part B. That is the federal government saying we will pay for Medicare covered services up to 80%. And you can go see any doctor that accepts Medicare if you have Parts A and part B,
MG
Marilena Grittani, RPh
16:49
Part A and Part B.
EG
Edward Givens
16:51
Correct. Okay. If you have worked for 10 years, 40 quarters and then on Part A, you will not pay a premium of any type. If you have not, there basically will be a penalty and you’ll have to pay some sort of premium for Part A. So most people don’t pay a part a premium. Now, B this changes each year right now it’s 2020. It’s $144. There’s a monthly premium for your part B that everyone pays. Now, if you make a certain amount of income, though, you may pay more than that. And that is something that an advisor will let you know, because you’ve had a lot of income so you’re going to pay a little bit more to help the system in your Part B premium. So you have your hospital paid for you have your doctors paid for. Now, you have to pay for your prescription drugs. When you qualify for Part A and Part B, people need to sign up for a prescription drug plan. If they do not have a qualified health care plan that has a prescription drug part of it or else they’re going to end up paying a penalty down the road. If you have Part A Part B and A prescription drug plan your hospitals paid for, doctors are paid for, and your medications are paid for. Governement’s only go to pay 80% of Medicare covered costs. So that 20% you can cover that gap yourself or you can buy a Medicare supplement plan that is provided by private insurers like in Aetna, like a Cigna like the United Healthcare and they are going to pay that 20%.
MG
Marilena Grittani, RPh
18:24
A cover for that.
EG
Edward Givens
18:25
Oh, yes. Okay, there is a premium with that. Okay, depending on what type of plan you get, you pay a monthly premium and you go in to see a doctor. And a lot of cases you will have a very low copay or no copay, because you’ve already paid for through your supplement and through Medicare’s Part A and B. You can again don’t see any doctor in the US who accepts Medicare, which is almost everybody. And your next question is okay you have people come in with AETNA card or an AARP card. That is someone who has a Medicare Part C or Medicare Advantage plan. That is a plan that is followed Medicare rules but it is governed or administered by a private insurance company.So basically the government says you take this particular Medicare person will pay you X number of dollars for that person. And then it’s the plans responsibility to care for that person according to Medicare rules. But in order for the plan to be able to maximize the dollars they have and maximize the care that they give you, they limit people on choices they will give them HMO style or health maintenance organization saying you can go see certain doctors within our network and go to certain hospitals within our network. These Part C plans or Medicare Advantage plans, cover your prescription drugs. So they cover part a hospital, Part B, the doctors and Part D your drug prescription drug benefit. That’s why you’ll see people come in I have a card, that’s your Medicare Advantage. Or you’ll see somebody come in with a red white and blue card and another card. That’s their supplement. That was other thing or their prescription drug benefit? Okay.
MG
Marilena Grittani, RPh
20:04
If you didn’t think that he was an expert. Are you listening to him? Okay? Sorry for interrupting.
EG
Edward Givens
20:09
Now you can see so there’s two different options. Do you want to have choice? People like snowbirds, you know, they might live in Michigan and then come down to Arizona, in the winter time Medicare, a regular Medicare plan with a supplement may make more sense because they can go see any doctor that accepts Medicare.
MG
Marilena Grittani, RPh
20:25
okay.
EG
Edward Givens
20:26
But if you’re a Snowbird and you have a Medicare Advantage plan, that might not work well for you, because if you leave Michigan, you had your doctors in network, they’re your hospitals and network there. That plan doesn’t transfer to Arizona, however, you will be covered for emergencies. If you have an accident or something recovered, but not for care. And that’s something that people need to think about how that process goes, if someone like me can help guide you through which of the two options makes the most sense for you, and which path should you go down. Some people don’t like to look at the Medicare supplement plans because it’s a premium. It’s another premium that they have to pay. But the advantages that some people get there is the sense of pay me now or pay me later. You’re not gonna have to pay a copay later on a Medicare Advantage. Medicare supplement plan, you will have to do that with a Medicare Advantage plan. Some things need to be thought about in that process, and a lot of people see the commercials. Nemeth is probably the most popular one that people see. But they’ll tell you, Hey, I got this rides to the doctor. I got free meals I got XYZ from a Medicare Advantage plan, they are allowed to add different things to their plans help people choose which plan they might want over another, okay, like they may offer meals, those meals are only offered after him or a hospital stay, and only for a certain period of time, might get 14 meals, two meals a day for seven days.
MG
Marilena Grittani, RPh
21:55
But if you say a month,
EG
Edward Givens
21:57
No, so people need to understand what’s being offered. They might say we offer transportation to doctors. Well, one plan might offer 10 one way trips a year. And another plan might say we offer 50 one way trips to you, but you need to understand what those offerings are.
MG
Marilena Grittani, RPh
22:16
And one thing that I wanted listeners to be aware of is that time passes and you are not getting younger. And the older you get, unfortunately, because we don’t take that good care of our own health, the more issues you have. And then if you think no less, you’re just used to I don’t want to go for the 50 because 14 is more than plenty. And then something happens and you need to go 60 times to the doctor, and then throughout the year and then you are stuck with just 14 so you have to figure out or the family or the neighbors or the I don’t know the caregivers, how to help these people. And then of course you feel like a burden already and then now you have to be, you know, taken to the doctor and well this is my criticism to my doctors out there and you know I love you but gosh going to a doctor office is a nightmare you spend three, four hours there, even though your appointment is a 10 you need to be half hour before that and then it’s 11:30 and they still have not called you and then they call you and then you get to the little room and then you spare 45 minutes there for the doctor and then the doctor see you five minutes and boom, off you go and you’re like really all this ordeal for just five minutes, but it is what it is. So that means that whoever is helping you needs to be aware of that okay, I rather have you know, have you choosing something more expensive, but that will cover you just in case. So you will be independent and then I would not be able to drive you around than choosing something that might not be a translation of savings, and then having the, you know, the possibility of not being able to be independent or not to get the service to help you on your own. And you have enough with all what you’re going through so you don’t need to add stuff by choice, I understand that it’s an extra payment. But if my mother tells me that that’s the option, I would say, Mom, I pay for it, don’t worry, how much you need, because I live in across the country, and I cannot help you. And then you don’t want to move from your little town because I respect it because I love it there too. But you don’t have transportation. So we need this service. So think about all those things. That is not just Oh, these people are trying to rip me off. It is not. There options for you to choose based on your needs. Now, if you still drive or you have a driver, well, there you go, you’re fine. Edward where do we go from here? So much, there’s so many directions that we can go from here. But okay, let’s focus on, let’s continue focusing on Medicare. And I want to focus on Medicare Part D, because a and b, you are signing that’s it, no maintenance that you need to do in terms of what plans you have or what is it because it’s basically all one, but when you choose
EG
Edward Givens
25:04
ah
MG
Marilena Grittani, RPh
25:05
Sorry?
EG
Edward Givens
25:06
Well, I was gonna say there is something that people need to be aware of in today’s world, this Part A and Part B, most people go into a hospital situation, urgent care or emergency and they go and we’re gonna put you in the hospital for observation. People need to be aware that an observation is completely different than a hospital admission. And Medicare pays for those in different ways. If you go into a hospital, you could be there for two nights and be in a gown, eat hospital food. But it’s billed as an observation that is not going to be covered under your part A, as you were not admitted to the hospital.
MG
Marilena Grittani, RPh
25:46
So who pays for that?
EG
Edward Givens
25:48
That’s your part B. So you’re going to have a little bit more cost on your end, if that’s how it’s been built. So people need to be aware of certain things. Some procedures are no longer done as an inpatient procedure, they’re done in an outpatient surgery. So it’s not going to be covered by Part A, it’s on your part B, which means you may have copay.
MG
Marilena Grittani, RPh
26:11
Yeah.
EG
Edward Givens
26:11
Yes
MG
Marilena Grittani, RPh
26:12
Oh God
EG
Edward Givens
26:12
People need to understand those differences. And not just because of the way our world has evolved as far as medical care. We don’t have to put you in the hospital for certain things. We can do them in an outpatient setting back home within 24 to 48 hours and in the hospital.
MG
Marilena Grittani, RPh
26:29
Yeah. See, thank you grateful that he’s here telling us all this. Okay. Okay, let’s go to where I wanted to go. Because as a pharmacist, I’m very very selfish. As a pharmacist, this is the part that affects us and I know for a fact how patients get disturbed by the options and the rules and the yes or nos and the donut hole. And all this stuff is Medicare Part D. So, Medicare Part D is a as you said, D for drugs, right? I don’t know if that is the reason, but that’s how we related. So, yeah. So what what are the rules, general rules, you need to sign in every year, you need to make changes one. I mean, it’s so many details and of course everybody’s over 65. So it is very confusing. So give us a little light on this Edward, please.
EG
Edward Givens
27:23
Well, you need to be enrolled in Part A and B, to be able to get prescryption drug benefit if it’s not in a Medicare Advantage plan. And basically, there are four levels to Medicare Part D prescription to have the deductible portion. Some plans will have that some plans, they’ll be noted. But people will have to pay the deductible portion. Let’s say it’s $200 as an example, so you go get your prescription, you go to the pharmacy, and the prescription costs $75. Well, you’re gonna pay $75 Okay, on 125 that you have to meet on your deductible. Okay, so once you’ve met that your deductible has been paid for, then you initially enter your initial coverage stage. In 2020, your initial coverage is $1,130. So zero dollars to $4,130 for Part D will have some sort of copay. $3 might be $10, you pay your copay, and the plan pays the rest until the amount you have paid reaches $4,130. Once you reach $4,131 in 2020 you hit the doughnut hole, it’s called coverage gap. Basically what that means is now manufacturers on brand name drugs manufacturers will pay 75 or 70%, you will pay 25% and your plan will pay 5%. On generic drugs, the plan will pay 75% and you will pay 25% at 25% is more than your copay was in your initial coverage period. That’s where people say, Oh my gosh, my drug prices went up. Once you reach $6,550, you come out of that doughnut hole. But here’s the nice part. I mean, even though it’s a doughnut hole, it’s not just your 25%. Also the 70% that the manufacturer is contributing, that’s the total number that you’re using. While it’s not comfortable with being a doughnut hole, there is an end. Between $4,131 and $6,550, that’s the doughnut hole. Once you come out of the doughnut hole, you’re in a catastrophic coverage. And what happens there is you pay basically 5% of the cost.The plan is going to pay 15% and then Medicare is going to pay 80%.
MG
Marilena Grittani, RPh
29:51
Okay, let’s just talk about that in detail a little bit because that is this is the part that we get blamed for we pharmacist to pharmacies , pharmacy technicians. So let’s say is December of next year, and you’re paying X amount of dollars on this drug, because you are in the catastrophic coverage or because you didn’t reach it or whatever the reason is you’re paying 3510 dollars copayment, then January comes over, which is a brand new year. And that is what it tells you. The brand new year says, Oh, you need to pay your deductible one more time. So it does not matter how much it was in December, November, October the previous year, you need to pay the first $200 out of pocket. Period. It’s not the pharmacy, right Edward?
EG
Edward Givens
30:43
Correct. It is our healthcare system. And that’s a bit of a fallacy or a myth that people have about health insurance in general. They think I have health insurance through my company, or through the federal government. We’ll, I have it forever. No, you only have it from January one to December 31, however you purchase it.
MG
Marilena Grittani, RPh
31:03
mm hhmm
EG
Edward Givens
31:04
okay, and that’s your coverage period.
MG
Marilena Grittani, RPh
31:06
mm hhmm
MG
Marilena Grittani, RPh
31:07
So if you buy something in November, or your health care and you pay your copay, or you pay your deductible, yeah, December you got to pay your copay or deductible again, in January, it starts all over again, you’re back to zero.
MG
Marilena Grittani, RPh
31:23
And then you when we give you those medications, and then we’ll tell you it’s $115 you just want to kill me, because I’m the messenger, not because I charge you that. It’s because it’s part of your deductibles that you need to cover whether it’s $500 $200 $1,000 everybody’s different, and then that didn’t happen in the other pharmacy that it used to go. Why are you charging this now if last month you didn’t? Don’t you know that I’m on a fixed income? Why are you doing this to me? What? No, we are pharmacies, always with medication price is neutral. Pharmacy does not decide how much you have to pay, how much is the copayment is always the insurance company, whether it’s the Federal Insurance or the state insurance, or it’s a private insurance, we do not select that day. We billed online with the one throw the computer and the computer tells them, okay, they need to pay this much. Why? we don’t know. How? we don’t know, based on what? We don’t know. You need to talk to your insurance person or you need to be aware of this is coming whenever you sign in for a plan. So that’s why it is super important that you have somebody that explains all this to you. And that was only with the deductible. Let’s just go now with a doughnut hole that I absolutely hate. For so manny
EG
Edward Givens
32:42
Let me add something to that
MG
Marilena Grittani, RPh
32:43
Oh, go head.
EG
Edward Givens
32:44
Just for you because you’re correct. That’s why you need to check with your insurance company because they do have preferred pharmacies
MG
Marilena Grittani, RPh
32:52
on top of that. Mm hmm.
EG
Edward Givens
32:54
And so you might have gone to pharmacy a routinely and You paid x price, but for some reason, now you go to pharmacy B, and they’re not a preferred pharmacy. So your price is a little bit higher. But that’s not the pharmacists role
MG
Marilena Grittani, RPh
33:12
No, the technician so be nice to them
MG
Marilena Grittani, RPh
33:13
now. I know and the one
EG
Edward Givens
33:18
hospital out of network.
MG
Marilena Grittani, RPh
33:20
Exactly and understand that the one that makes those decisions is you when you sign for it. It’s not us. It’s you. You might not be aware of those details, as Edward has been explaining throughout our conversation, but it is your responsibility, and you were the one that signed for it. And then you have to run what is it roll with it, because sometimes there is not a chance for you to make changes until the next year or a period or whatever. So let’s just talk a little bit more about the doughnut hole because we didn’t start. So the doughnut hole occurs as Edgar said, after you have paid in form of copayment, whatever you want to describe it as $4,130 so the first dollar after that is going to go super higher. So let’s say that your drug is normally $150. And you’d be paying a copayment of $4. Then you’re going to pay maybe 30, maybe 50, maybe $100 for that medication because you are in the dougnut hole. So dependent of how many medications you have, how frequently you use them, how costly they are, you need to organize yourself and plan and talk to an adviser and a pharmacy technician and then plan it for the following year. Why are we saying all this right now and this is so important because the enrollment time is coming up. So I’m, we’re giving you a heads up so you get ready. So what it is, is that you can go to the pharmacy until the pharmacy tech or call them and say hey, I just want to know what have been used in all this year. I need to know In a printout or in an email, tell me how much have I used, what are these drugs? How much do they cost and how much the insurance have covered? Whether is Medicare Part D, whatever it is, or if it’s a private, please do it. And then with that, you go to your advisor and you said, this is what I take. This is how much I pay. What, How does it look for me in the next year? What options do I have based on this? Because it might be that the previous year you were not using a drug and now you are and then things changed. And if there’s a prescription drug that is on top of that a brand name because there’s no generics? I don’t want to tell you details because they’re going to be awful and I don’t want to ruin your day. We just wanting to inform you. And again, the doughnut hole does not get a preview like the movies that it tells you that doughnut hole is coming, get ready. No, no, it just shows. It’s boom right there and it doesn’t go away until you reach the $6,550 which for some people might be suffocating and for others might be just one drug. So we need to be aware of all this. So you handle and please, I truly want to tell you this as a human being to another human being you my dear listener, that is in the US. After September, in the pharmacies, everywhere in the US, we are in a level of stress that you have no idea because it’s when normally regularly the doughnut hole starts to kick in all the way to December, and we get screamed at, cursed at, insulted, degraded through thrown things in our faces, and it’s never our fault. It is your doughnut hole nd this is why we’re talking about this because there is a way for you to prevent it. There is a way for you to work through it. And there’s a way for you to most importantly, get educated so you understand what it is and you can have alternatives. Now, if your indicator You choose not to buy anything extra, which is your choice. And you know that it’s not the pharmacist or the pharmacy technician that is doing this to you. It is that bad in any pharmacy all over the US from September to December. And when we see those big numbers, we are ready to be screamed at. And that is a hazard that we have when we’re just trying to help you. So please, Edward, tell us what options do they have to fight the ugly and disgusting doughnut hole?
EG
Edward Givens
37:31
There’s a couple of options. A good advisor should be able to tell them if you share, if you choose to share what medications you’re taking, but it can give you an idea what time of year you will probably hit the doughnut hole. And if you hit doughnut hole early in the year, you will come out of that doughnut hole.
MG
Marilena Grittani, RPh
37:48
Hmm. That’s good news,
EG
Edward Givens
37:50
the cost of your drugs. But as Marilena was saying a lot of people it’s later in the year so the last three months of the year they’re just in the doughnut hole. So the one way to do it is have a good adviser to tell you when it’s gonna possibly happen to you, if you choose not to go with an advisor, you can go to medicare.gov. And you can search the different options that are out there. But in your medications, make sure you put your prescription strength in and how many pills you pay on a monthly basis. And they’ll give you an estimate on the different plans about when you’re going to hit the doughnut hole. So you can have that as well. I also happen to meet some financial classes in my church. And so I advise people as well, what you can to start to create a rainy day fund a savings fund is if you know that you have expensive drugs, maybe you can’t do it this year, but you can start building that fund up for the next year in the year after that. It’s really, it’s roughly a little over 2500 bucks that is the dougnut hole. So if you and your family can figure out how to save that and just habit waiting for September, October, November will won’t be as painful because you’ll be prepared for it. Or you can look at other options, other potential generic options that could work or could suffice for you. Going back and talking to your doctor about what is my prescription plan, and can we do something that maybe stretches it out?
MG
Marilena Grittani, RPh
39:24
Mm hmm.
EG
Edward Givens
39:25
So that you can be more proactive in how you care for yourself.
MG
Marilena Grittani, RPh
39:29
One example and that wanting to, one thing that I want to say here, and I’m sorry, that I’m interrupting is, what would work is let’s say that it’s November and you reach the doughnut hole and you need help through December. It’s just one month. You can talk to your physician and say, sir, is that or lady ,ma’am, whoever. Is there a way that you can help me with samples for this month, because sometimes they do have that option and they have their piled up and It could benefit to take advantage of that, because the doctors will do that for you. If they have, of course, if it’s three, four months, I’m sorry, it’s not going to happen. But if you need, you know, just one month supply or but I mean, you can work it out. The point is, and that’s what I want to reinforce here is that information is power. And that’s what we’re bringing to you. We’re giving you the information, the education so you know what it is, and then you can look for the alternatives, how to work it out. That will work for your particular case, because everybody’s different, whatever worked for you doesn’t work for your sister, or for your neighbor or for your church friend. Everybody’s different. Sorry that I interrupted. But I wanted to say that there because I think doctors are never utilized for that. And they’re open to do it because they’re very nice people, even though they make you wait forever. They’re nice people.
EG
Edward Givens
40:51
And even some pharmaceutical companies will have options and discounts that you can use. But you do have to ask folks, we have to ask the question, worst that can happen? They say no, and you’re in the same boat. But if they say yes, things, get a little bit easier.
MG
Marilena Grittani, RPh
41:08
and talk to your pharmacy technician as well. And the last thing, don’t wait until the last minute. So what I’m trying to say is, if you know that the doughnut hole is coming for the next refill of this particular prescription, and you have 30 pills in your hands, you have a month to figure it out. But if you wait until the day that you have one bit left or non, to start finding out what to do, it’s not going to be a good thing for you, because you will end up not taking some doses. And that is the worst case scenario. That’s not something that you want to do because you might end up in the hospital. And that is going to be way more expensive. And so planification organization and information are the three keys during this process. And then communication to the doctor office or to the pharmacy. Hey, please tell me what can you do, what can be done to the doughnut hole. I know it’s not you lady. I’m not gonna scream at you. They will smile at you and they will help you happily because then one less that scream at me. Thank you. Okay, so then you can say, Okay, this is the doughnut hole, what can you do for me? To help me? What options do you have and based on the drug based on the area that you live based on the manufacturer, you might have a bunch of options, and I’m telling you, I work with a ton of them. technicians are the kindest, and sweetest people in the world. But if you scream at them, and you insult them, they would not be that kind. So try to handle it and understand that is 99.9% not them because some of them are rude. I’m not gonna say that they’re not, but their job is to help you. Their job is to serve you. That’s their career. So they will do it because that’s what they sign in to do. But if they don’t know what’s wrong, it didn’t know what the problem is. They would not know what to help you with. So take that, again in consideration. Anything that I miss for Medicare Part D? Oh, the date, would you tell us the date for joining?
EG
Edward Givens
43:04
So the the Annual Enrollment Period, those people who are not aging in to Medicare, you have one time of year that you can change your Medicare Advantage, or your Medicare prescription drug plan. That’s called the Annual Enrollment Period. And that’s from October 15. November 7,
MG
Marilena Grittani, RPh
43:27
to December 7, yes.
EG
Edward Givens
43:29
And during that timeframe, you can change your plan many times as you want. after December 7, whatever the last plan was, that’s it.
MG
Marilena Grittani, RPh
43:39
And you’re stuck with it literally until the next October the 15th.
EG
Edward Givens
43:44
So you’re stuck with it for the year but you can make a new choice,
MG
Marilena Grittani, RPh
43:48
the next October. That will kick in in January.
EG
Edward Givens
43:52
Correct. I do not recommend people bounce around between plans unless something happens you know you if you’re early in your life, want to be prepared and you get your plan, you find a new plan on October 15, or October 16. But then you get a prescription from your doctor that’s new. At the end of October or in November, you’re like, wow, this drug is more expensive than maybe it’s an opportunity to reevaluate was the plan, you chose a right plan for what you have now. And then you might want to make a change. But pretty much you should have a good idea of what you’re going to need, what new drug you’re on this year as opposed to last year, find a good plan. The other thing is don’t always assume the lowest cost prescription drug plan is the best plan for you.
MG
Marilena Grittani, RPh
44:40
It is not
EG
Edward Givens
44:41
because depending upon the drugs you’re taking, and the formulary or group of drugs that particular insurance company is covering slightly more expensive plan may actually be a reduced cost to the prescription drug you’re using or paying $10 maybe as an example dollars per month more than the cheapest plan, your drug is lower overall. So now your expenses are lower, maybe you hit the doughnut hole in December rather than September. And now you put yourself in a better position. It is important that you take a look at what your options are, and do not always go on the lowest cost. Sometimes the lowest cost is the most expensive plan.
MG
Marilena Grittani, RPh
45:28
And you cannot afford it. You don’t have to be in that position. You need the education. So let’s just say it also applies this time for you that last year didn’t know all this that Edward is explaining so perfectly to us today. And now you’re like Hold on, but that’s what happened. That’s why scream at the pharmacy take in September because of whatever whatever but I have the opportunity to make the changes which day October the 15th enrollment starts. So then you have a period from that October 15 to December the seventh to make changes. And so what I would suggest is, first of all, if you’re happy with what it is, if it’s nothing important change, you’re fine. But if it’s not the case, find somebody that knows right now before the enrollment time starts and start digging or finding out start understanding, start planning and getting organized and start looking for help. And this is the time where anybody that is not medicare part d age, which is under 65 years of age, have to help. If you’re a daughter, a sister, a relative, a neighbor, a church acquaintance, even a friend of somebody that is going through this process. You already learned how complicated it is. So if you have problems, health problems, and on top of that you are 78-90 years old, and you have issues to deal with all this information. It’s going to be a mess for them. So I am asking you for compassion and for time and support. If you’re a teenager, listen into us, volunteered to your church, volunteer to a adults group in town, volunteer to your grandma. Okay, grandma let’s check it and you want to see it online. Okay, let me just find a website for you and do it. You might not know a lot of details about their health and I’m not saying that you need to be part of it. I’m just saying the little help that you can give them I know they will appreciate it because for them the internet is not a thing. It’s not always it’s not for me, and I’m not. I asked my kids that are you know, 20 and 18. Hey, what do I, how do I do that? And they of course roll their eyes to me like oh my God, we just help you. Oh, yeah for you it’s second nature but for us and for them, it’s not so. That is a skill that you have, that they don’t and they will appreciate if you help them and if you’re a little bit older and your 40s in your 30s and you still have grandparents and you have parents and you have aunties and you have anybody that you can give them a hand just to guide them not to make decisions for them not to tell them what to do, but at least to support them with the stuff that they are frustrated with. Please do listen to this episode one more time, you just rewind the whole thing and listen that again and again if you need to, but we have given you a wealth of information here. And of course, you gonna have all Edwards information and I’m sorry, if you get 1000 millions phone calls Edward, because most likely, if I were in their position, I would be like, hold on, what’s his number? I’m gonna call him right now or email him. So try to find that help that you need. Try to be focused on that. And I want to talk about two more things. I know we’ve been over the time that we normally dedicated to this, but this is how important this is how adore in your opinion. COVID-19 is going to affect the next enrollment for Medicare Part D.
EG
Edward Givens
48:55
I have a feeling covid’s going to affect it a lot because there are a lot of rules that are on advisors like myself and how we can communicate Medicare information to customers and to Medicare eligible individuals. and we are required to go through a lot of detail, but because of the restrictions with COVID, and people not being able to travel, and people who are Medicare eligible, generally speaking, being in a high risk group, having that face to face interaction, may be very limiting to some, and if it’s not limiting to them individually, it might be limiting to them from the family standpoint of saying we don’t want to risk you getting sick. So there are some options out there that you can still meet face to face with people. But if you have a family member who has access to a computer who can help you, a good adviser will be able to go online and do a zoom call with you, or do a google meeting with you. show you everything that you’re talking about who can see it so you can make an informed choice and even be able to share a screen with you so you can be your application and sign up. Bear as you’re getting the information, so it is possible for you to do it face to face over zoom, or through a phone call, as long as that call is recorded. Again, we can’t start any of this 2021 until October 15. October 1, we can talk to you about 2021. But we cannot put any applications in until October 15. So you have time, time to figure out a strategy time to set up with a family member to be able to go through the process, but just because you may be inside and you may not have gone out and seeing your friends or be able to go to restaurants or go to the park or go to the senior center. Don’t allow that to limit your ability to make a good decision for you and your family. Because there are options out there to get the information you need. And remember, it’s your choice. Somebody shows you something and you don’t like it. You can say no
MG
Marilena Grittani, RPh
50:59
fire them and find somebody better is that simple.
EG
Edward Givens
51:02
Yes.
MG
Marilena Grittani, RPh
51:03
Now, this is another part where you the younger person that can help them can work with, you can do it from your home, maybe you live in California and your parents live in Massachusetts. And then you just do a zoom conversation that you are connecting with them. And you just send the link to your parent or your grandparent and they just have to click on it and it all works. And then you’re there to help to support to hear what are the options and then to give that loved one support however they need it also for those church groups for those senior citizens groups or classes or caregiving facilities. Think about this too, because they do need this. Of course, it must be individual because you cannot share personal information in a group but if it’s a family member, that the person that needs, the help allows to be or one To be then that changes it and then they can participate and be part of it. But the person that must make the decision is the patient. Always, if not, that is illegal, that simple. Anything else that you want to say about covid, Edward?
EG
Edward Givens
52:15
that just people need to keep that in mind and don’t let it restrict what you can do, there are options for you. And I do have a feeling based on some of the Sneak Peek or first looks that were offered. There are going to be some options in there that people may want to look at going into the next year. Right now, almost every Medicare companies offering telemedicine so that people can talk to their doctor through a zoom call or on the phone.
MG
Marilena Grittani, RPh
52:41
And pharmacists do. Did you know that? Yeah, you can consult your pharmacist as well via telemedicine. Finally, we get to in one
EG
Edward Givens
52:49
and for this year, that was something that was applied to the COVID scenario. So it’s something to take a look at, to see if it’s going to make sense into the next year for people
MG
Marilena Grittani, RPh
53:00
We’re about to finish because we have taken a lot of your time that you have graciously given us. And you have no idea how much I appreciate it. And I know they do too, because well, you do know you’re saying you’re an expert. And we, we don’t read clearly don’t know anything. So thank you for that. So let’s just give you the last two questions. The first one is what would be in your opinion, the biggest misconception between health insurances, and people that do what you do.
EG
Edward Givens
53:29
One of the big misconceptions about health insurance is that people think that health insurance pays for everything and health insurance does not pay for everything. That’s by definition is simply a transfer of risk. One party transferring their risk to another party for a fee or premium. And that risk is determined by your contract or your statement of benefits that you’re getting from the insurance company. That’s why you have Medicare Part A hospitals, Medicare Part B doctors outpatient DMA portion, and then a prescription drug portion. They’re all different aspects that make our whole people provide for their care. So the more you know about your insurance, the better you can understand what risk is the insurance companies accepting and what risk Am I accepting and how to deal with it. Most people don’t know that’s like me, my services are free. Again, the insurance companies have built in to pay a modest commission to advisors, okay? and manipulate that I can’t change that. I can’t negotiate with them, raise it or lower it is what they set it out. So you have the resource of using an advisor, someone you feel comfortable with and trust, to guide you to give you the information to make a wiser choice, you and your family.
MG
Marilena Grittani, RPh
54:48
And if you choose not to do it, you’re already paying for it. So you’re leaving that money on the table that the insurance takes it and you get no benefit. So hello, what’s the point?
EG
Edward Givens
54:58
And then the other thing is that you Good advisor is not going to just sell you a plan, they’re going to help you make a good choice. And then as you move on down the road, they’re going to be there with you, to help you with customer service issues or questions about the policy, so that you can move forward with an advocate on your side to give you enough information at what you need and get the fullest out of the benefit that you have. If someone’s just selling you a plan, I would recommend that’s not the direction you should go. If someone’s going to provide you the service, that would be a better direction.
MG
Marilena Grittani, RPh
55:34
And also would be the person that you call saying, hey, the pharmacy just told me this and this, is that true? Can we work it out is any way that I can work around it. And if it’s not unfortunately, you have no positive outcome from it. That person will remember it when you’re planning your insurance coverage for the next year and say remember in February when you call me and ask me about this and you were stuck with us, well, let’s just work to for the next year. So you don’t have to be in that position anymore. Because that’s what they do. That’s their area of expertise. You’re not going to know that by asking Dr. Google Hey, Google, tell me what insurance should I pick? Because based on all what Edgar have says, there’s no way that Google can’t tell you all that. And most, even worse for yourself for as an individual, because it’s not a general thing. Each person is different.
EG
Edward Givens
56:26
Think about it this way. You’re the same person today that you were when you were five years old. Are you the same person today? As you were when you were 18?
MG
Marilena Grittani, RPh
56:35
I wish no but no.
EG
Edward Givens
56:37
My daughter is 16 and we’ve been driving and she’s got a permit and I can think back when I was 16. I’m not the same person today that I would smoke. Are you the same person today as you were when you were 25 when you were 35. Your life changes so situations change so there is no one size fits all.
MG
Marilena Grittani, RPh
56:56
And same applies for members of the same family. It’s not because Your husband has x&y, the wife is going to have the same or siblings or mother and daughter, because every person has a different medication and different health a different situation and all changes and even something that it was a surprise for me the first time that I talked to Edward if you move within the same state, but a different county syncs change. I know ridiculous. Yes. unfair. Absolutely true. It is. So be mindful with all this when you need to take in consideration for your insurance decisions. Okay, so after based on all this master you made in our head, just thinking about all this details and all this information, my goodness, overwhelming. What are the first three things that you think anybody that is interested in taking over this situation and do it the right way, whether it’s with help or not, should take what are the first three things that they need to do in your opinion?
EG
Edward Givens
57:56
Let me start with this. Because yes, it can seem like there was a lot. There’s a lot of information we talked about, but how do you eat an elephant bite? Okay, so that’s all you need to do is take this one bite at a time, understand how you and your family use healthcare. You go to the doctor once or twice a year, that’s completely different than somebody who maybe has diabetes and goes to the doctor every month or something else may have happened. You need to understand that because that’s going to determine your choice. Ask questions of your doctors and your hospital system. Your hospital should be able to give you a detailed bill and an abbreviated bill, a detailed bill who did what for you and how much it costs. That way, if you have questions, you have information and ammo to fight back. Was this a part of my care? Was this covered in my plan? Because you can see everything that’s there, because that’s what insurance companies gonna ask you for anything. And you know, your doctors are practicing medicine, of the practice of medicine, but they’re taking a shot. They’re offering you advice, but you haven’t say you can say I’d rather do this than your record. Is there another option? ask those questions and seek advice from an independent advisor