Hi and welcome, I’m Lance D. Reedy, CSA, an independent agent and owner of Northwest Senior Insurance. I specialize in working with Medicare beneficiaries.
The time has come for you to select a Medicare supplement, Medicare advantage plan, and/or Part D prescription plan. The most important decision you will make is selecting a knowledgeable agent who holds your best interests above all else. As an independent insurance specialist, I welcome the opportunity to help you understand your options, find the best value for your situation, and provide you with the kind of service that you can count on.
Maybe you are past 65 and your Medicare supplement premiums have gone up. I’ll do my best to find lower cost options for you. Remember, you can change your Medicare supplement any month of the year.
I specialize with the following Medicare related products:
There are three major mistakes that many people unwittingly make when shopping for a Medicare supplement. Click on the red eagle below to learn more about some of the traps that unsuspecting people have fallen into.
Identifying your shopping type is most helpful when shopping for a Medicare supplement. Understanding your shopping type helps you to avoid the Ten Medicare Supplement Shopping Mistakes. Most importantly, doing so also helps you to get the best buys without paying more than you need to. Click on the blue eagle below to learn more…
Avoiding the Three Major Mistakes and having the correct mindset when shopping for a Medicare supplement will give you the peace of mind that you made the right choice.
The war on traditional foods has taken a disastrous new turn, one that I call an abomination. Big Agra markets their processed “meat alternatives” as a healthier solution to what nature provides.
Plant-based products – marketed as steaks, burgers, chicken patties, and eggs – now appear on restaurant menus and supermarket shelves everywhere. Big Agra wants you to believe these “meat alternatives” are healthier than what nature provides. They’re not.
By definition, plant-based “egg and meat products” are processed, unnatural fake foods. They’re made from more than 50 ingredients that are decidedly unrelated to the animals they mimic. Most plant-based products also contain soy and seitan, which gives them their “authentic” texture.
Despite the media and marketing hype around soy being a source of good health, the GMO frankenfood is one of the worst plant foods you can possibly consume.
Soy is loaded with estrogen mimickers that cause erectile dysfunction, man boobs, loss of bone and muscle mass, and at least half a dozen different types of cancer. Soy also impairs insulin secretion and might actually cause diabetes. And new studies reveal that it may even be connected to dementia and mental illness.1,2 Meanwhile, seitan – also known as “wheat meat” – is a starchy, grain-based concoction made from gluten and is highly processed.
And as you know, I’ve been recommending that you avoid grain-based foods for more than 30 years. If you followed a grain-based diet like the USDA recommends, you’d be diseased, overweight, and prematurely old in no time at all.
These products, despite clever marketing, are anything but good for you. Soy and seitan, while horrible for your health, are at least real foods. The other ingredients hiding in your veggie burger are anything but…
To get these ultra-processed meat-alternatives to look and taste like real meat means they have a whole lot of chemical additives. Here’s a small example of what’s hiding in your plant “burger:”
Tertiary butylhydroquinone. This synthetic preservative is linked to cancer, vision loss, liver enlargement, and convulsions in lab animals. Research suggests that in humans it damages the immune system, leaving you vulnerable to disease.3
Propylene glycol. This water-absorbing synthetic substance is often used in the cosmetic industry. But it’s also an ingredient in e-cigarettes and antifreeze.
Magnesium carbonate. Used as a food additive to prevent caking and retain color, magnesium carbonate is also used in flooring, fireproofing, and fire-extinguishing compounds. Too much of it causes a laxative effect.
Makers of meat alternatives point to studies that declare these compounds are safe. But here’s what they fail to mention…
Independent research has discovered the “studies” have been funded or commissioned by the very same companies that manufacture these fake foods.4
Of course, you’ll never hear from the FDA or the mainstream media that meat alternatives are an unhealthy choice. They’re still pushing the big lie that cholesterol is bad for your heart and your health. As a regular reader, you know I consider the war on cholesterol one of the greatest health food cons of all time.
Despite misinformation repeated endlessly by mainstream doctors, the media, and Big Agra, trying to remove animal fats and cholesterol from your diet is a bad idea. A meat-based diet is what made us the humans we are today.
It’s grains, carbohydrates, and processed foods that cause excessive weight gain, inflammation, and chronic disease – not dietary fat.
Where’s The Grass-Fed Beef?
I consider grass-fed meat to be perhaps the healthiest food you can eat. Compared to grain-fed animals, products from grass-fed animals have 10 times more omega-3 fats, more vitamins B, E, D, and K2, more CoQ10 and zinc and more antioxidants like glutathione and superoxide dismutase (SOD).5
But don’t be fooled by Big Food fakes. To make sure you’re getting the real deal, here’s what to look for:
Make sure the label says “100% grass-fed and grass-finished.” And watch out for labels that only promise “natural,” “organic,” or “pasture raised.” Chances are those cattle were “finished” in a feedlot eating grains, soy, and food waste byproducts. Check out EatWild.com, a national directory of pasture-based livestock producers, and find one in your area you can reply on.
Look for third-party certification. Groups like AGA, A Greener World, or the Global Animal Partnership offer certification labels you can check to verify it is real grass-fed beef.
Choose bison meat. You have another choice when it comes to meat. I’m talking about all American bison meat. Or as I call it, the other red meat. All bison are grass-fed. In fact, this animal would rather starve than eat corn.
To Your Good Health,
Al Sears, MD, CNS
References:
Deol P, et al. “Soybean Oil Is More Obesogenic And Diabetogenic Than Coconut Oil And Fructose In Mouse: Potential Role For The Liver.” PLoS One. 2015 Jul 22;10(7):e0132672.
Deol P, et al. “Dysregulation Of Hypothalamic Gene Expression And The Oxytocinergic System By Soybean Oil Diets In Male Mice.” Endocrinology. 161(2). 2020;161(2):bqz044.
Zagorski J, et al. “Differential Effects Of The Nrf2 Activators Tbhq And CDDO-Im On The Early Events Of T Cell Activation.” Biochem Pharmacol. 2018 Jan;147:67-76.
Santo R, et al. “Considering Plant-Based Meat Substitutes And Cell-Based Meats: A Public Health And Food Systems Perspective.” Frontiers In Sustainable Food Systems. 2020.
Daley CA, et al. “A Review Of Fatty Acid Profiles And Antioxidant Content In Grass-Fed And Grain-Fed Beef.” Nutr J. 2010;9:10.
The Medicare Prescription Payment Plan (M3P) is a payment option that helps you manage your out-of-pocket Part D costs. You can opt into the program, which allows your prescription costs to be spread across monthly payments that are billed by your plan directly to you.
When you fill a prescription for a drug covered by a Part D plan, you won’t pay anything at the pharmacy. Instead, you will receive a bill each month from your plan sponsor.
Instead of being hit with high costs at the beginning of the year, you can have level monthly payments. It’s very similar to having leveled utility payments across twelve months instead of high bills during the winter.
Note: Anyone on an MAPD plan with drug coverage with cost sharing or a PDP is eligible to use this payment option.
The Medicare Prescription Payment Plan works for a stand-alone prescription drug plan (PDP) or with a Medicare advantage plan with prescription (MAPD) coverage.
However, the M3P is most suitable for those with tier 3, 4, and 5 drugs. If you only have low-cost tier 1 and 2 generics, you likely will receive little or no benefit from the M3P program.
To sign up, please contact either your Part D prescription plan or your Medicare advantage plan. You will be able to sign up for the program beginning October 15, 2024, over the phone, online, or with a paper form. Note: The Medicare Prescription Payment Plan begins for the 2025 plan year, not before.
Now that we’re past October 15, we’re free to discuss more specifics as we head into the 2024 Annual Election period or AEP for short. Reminder: The AEP runs from October 15 through December 7.
As we discussed in our previous issue of Northwest Senior News, much of the turmoil and changes with prescription drug plans (PDPs) and Medicare advantage plans with prescription drugs (MAPDs) is due to the Inflation Reduction Act passed by Congress in 2022.
The Act, among other things, stipulated that Phase 4 or the catastrophic phase of the PDPs was to be eliminated in 2024. That has had a minimal effect on the 2024 PDP and MAPD plans.
Phase 3 or the coverage gap (aka donut hole) will be eliminated in the 2025 plans. Additionally, there will be a $2,000 out-of-pocket cap for covered drugs in place for those that have high drugs costs. The 25% that the plan members paid in the coverage gap will now be picked up in large part by the plans.
Prescription Drug Plan Changes
The standard deductible has increased from $545 in 2024 to $590 in 2025. Several of our clients have commented to us, “My plan increased its deductible.” Comment: All plans have increased their deductible to the new higher limit except for a very few high premium plans that do not have a deductible.
Keep in mind that the deductible generally applies to tier 3, 4, and 5 drugs. Your tier 1 and 2 generics do not have a deductible. The following is a brief update for the plans offered by the five major carriers.
Aetna has consolidated its three SilverScript PDPs into just one plan, the SilverScript Choice (SSC) plan. Many of our clients have had the low-premium SilverScript Smart Saver That plan terminates at the end of 2024. Likewise, those with the high premium SilverScript Plus plan will be merged into the SSC plan. If you currently have the SilverScript Smart Saver plan, please be sure to contact us.
The Wellcare Value Script This has been a very popular plan and will continue to be so. This plan works very well for those that have only tier 1 and 2 generics.
We’re finding the Cigna Healthcare Saver Rx PDP also to be a very popular plan for 2025.
Humana: The Humana Walmart Value plan is now just the Humana Value Rx In addition to Walmart, many other pharmacies are preferred pharmacies with this plan. Humana has lowered the premium for their Humana Basic Rx plan.
UnitedHealthCare or UHC for short: UHC has dropped its branded AARP Walgreens They now offer just two plans, the AARP Saver and the AARP Medicare Rx Preferred plans.
Some states such as Montana and Wyoming have two regional PDPs. These are MedicareBlue RxStandard and MedicareBlue Rx Premier.
PDP Shrinkage
Most states had 20-22 PDPs in 2024. This number is decreasing to 12-14 plans for 2025. Contrast this to 2006 when we had around 50 plans in each state.
Medicare Advantage news
The elimination of Phase 3 has also caused a bumpy road for the MAPD plans. Here are some of the changes we have seen:
Some zero premium plans are still zero premium, but their medical copays have increased. For example, the specialist copay may have increased by $5.00, or the inpatient hospital copay may have increased by $50 to $100 per day or more. Check with your plan’s Annual Notice of Change (ANOC) to see the extent of your copay increases.
Some plans have had modest premium increases to help offset their projected increase in prescription costs.
Some carriers have replaced one plan with another plan.
MAPD plans dropped
Pacific Source has dropped its Explorer 11 MAPD in Idaho and replaced it with their Explorer 18. Their other plans are still available.
Blue Cross Blue Shield (BCBS) of Montana has dropped its Blue Cross Medicare Advantage Flex BCBS maintains its other existing plans.
Summit Health has exited the Eastern Oregon market altogether. That leaves many rural, eastern Oregon counties with no Medicare advantage plans at all.
There are a handful of other companies that have discontinued one of their plans. They still have other MAPD plans to choose from.
Please contact us if you are affected by these discontinued plans.
News for Benewah, Clearwater, Lemhi, and Lewis Counties in Idaho
(St. Maries, Orofino, Salmon, Craigmont Nez Perce, and Winchester)
These four counties have been without any Medicare advantage plans in 2024. UnitedHealthCare (UHC) is now offering MAPD plans in these rural counties starting in 2025. Please check with us if you are interested in one of these new plans. Note: It appears that Butte County (Arco) is the only county left in Idaho with no MA plans.
Idaho Birthday Rule
Since March 1, 2022, we have helped dozens of our clients take advantage of the Idaho birthday rule. The new rule from the Idaho Insurance Department stipulates that you can change your Medicare supplement plan on your birthday from like plan to like plan with no health questions.
Here’s how it works. On your birthday and for two months afterwards, you can change your Medicare supplement with no medical underwriting.
For example, Fred Flintstone has A-fib. Normally, he could not change his Medicare supplement plan because A-fib causes a declined application. With a birthday rule application, the health questions are skipped. In other words, it’s a guaranteed issue plan.
We’ve seen clients save as much as $20 to over $100 per month in premium.
But the early English believed that they could… and that an owl would turn its head all the way around to watch you until it strangled itself. Some cultures even believed that death would soon come for you if you were sick in bed and heard an owl screech. (And it turns out owls can only turn their heads 270 degrees.)
This folklore probably came from the fact that these creatures are nocturnal, and death was also associated with nighttime. And the term “night owl” likely started getting used to describe folks who preferred the twilight hours in the mid-1800s.
Today, scientists think genetics plays a big part in dictating if you’re a morning person or a night owl. This is called your chronotype – the times within a 24-hour cycle your body prefers to be asleep and awake.
It works with the 24-hour “clock” in your brain that conducts your sleep/wake cycle, or circadian rhythm.
Your body undergoes cyclical biochemical and hormonal changes throughout the day, creating varying environments for a med to act. So the time of the day you take your medication can affect how well the med might work, along with how well you might tolerate the med to minimize side effects.
Recently, research has shown that one widely taken drug might work best according to your chronotype…
Nearly half of all American adults have high blood pressure, or hypertension. Worse, a 2020 JAMA study showed that high-blood-pressure awareness, which had been on the rise for 15 years, was starting to decline. That’s not great news. After all, hypertension is called “the silent killer” for a reason – it can be taking place without producing any red-flag symptoms.
But for those who know they have hypertension, it’s estimated that roughly 76% take some kind of medication for it.
As for making sure your little pill does its job to the fullest, a recent study suggests that it could boil down to whether you’re a night owl or a morning lark.
Your blood pressure is naturally lower while you’re asleep and higher when you’re awake and alert… though maybe not if you’re battling hypertension and on the older side. Studies have found that some types of hypertension meds do a better job of reining things in if you take them at night. Examples include amlodipine and angiotensin-converting-enzyme (“ACE”) inhibitors.
But according to recent research, whether your hypertension meds work better if taken in the morning versus the evening can vary by your chronotype…
Published this month in the Lancet, a U.K. study followed 5,358 hypertensive folks – half took their medication in the evening and the other half in the morning.
Researchers used a questionnaire to determine which chronotype each patient had. They also looked at whether the participants became hospitalized for heart attack or stroke (both nonfatal).
The results showed that the larks who took their meds in the morning and the owls who took their meds at night had a lower chance of ending up in the hospital for a heart attack. Interestingly, the chronotype and medication type wasn’t associated with stroke hospitalization.
More research is needed for other medications and whether they work best by chronotype. But for now, let’s go over some other common medications and the optimal time in the day to take them…
Thyroid and osteoporosis drugs work best on an empty stomach. So they might be more suited to the mornings. Otherwise, make sure to take that pill at least an hour before eating, say, dinner, or two hours after that meal.
Diuretics (or “water pills”) help maintain a healthy blood pressure in folks with hypertension or heart failure by making you urinate. So you’ll want to avoid taking these too close to bedtime or else you might find yourself blearily getting up out of bed to use the toilet.
Steroid drugs like prednisolone are best in the morning. That’s because our “stress hormone” cortisol levels tend to be highest in the mornings. So popping your med with breakfast means you’ll be more in sync with your body’s natural levels.
Once-daily antihistamines for allergies might work better if you take it at night. These meds usually take almost half a day to reach peak levels in your bloodstream. That way, you’ll be armed when you wake up in the morning which is when symptoms tend to be the worst.
One last important note: these aren’t hard and fast rules. That is, they might not be applicable to all drugs. So make sure you check with your prescribing doctor and/or pharmacist if you’re thinking about changing up when you pop that pill or if you take multiple medications.
And whether it’s a “rise and shine” or a before-sleep nightcap, make sure you stay consistent.
Today, scientists think genetics plays a big part in dictating if you’re a morning person or a night owl. This is called your chronotype – the times within a 24-hour cycle your body prefers to be asleep and awake.
It works with the 24-hour “clock” in your brain that conducts your sleep/wake cycle, or circadian rhythm.
Your body undergoes cyclical biochemical and hormonal changes throughout the day, creating varying environments for a med to act. So the time of the day you take your medication can affect how well the med might work, along with how well you might tolerate the med to minimize side effects.
Recently, research has shown that one widely taken drug might work best according to your chronotype…
*****
The Worst Pain Anyone Can Experience
Decades ago, parents would host “chickenpox parties”…
Before scientists developed a chickenpox vaccine, this was a way to expose kids to the virus. A major reason was to “just get it over with” so the child wouldn’t get chickenpox as an adult. One of my researchers remembers that her entire kindergarten class was out with chickenpox (she’d already had the virus years before).
At the time, it seemed like a good idea. Today, we know better.
If you had chickenpox as a kid, that virus never left you… Some of it lies dormant in the nerves along your spinal column.
Later in life, that virus can wake up, triggering excruciating blisters and redness on one side of the body… an infection called shingles. Turns out, shingles afflicts 1 in 3 Americans at some point in their lifetime.
Typically, it presents in a band along the torso, but it can occur anywhere…
I saw a number of shingles patients in my ophthalmology practice. That’s because about 20% of shingles cases develop in the eye and can lead to blindness.
It’s known as one of the most painful illnesses anyone can experience…
Folks who have had it often say their skin felt like it was on fire.
And unfortunately, a third of us will experience it at some point. Each year, around 1 million Americans get shingles.
It’s not surprising that it’s a major concern for our Health & Wealth Bulletin readers… if our inbox is anything to go by. Last month, we answered a reader’s question on shingles and within days, our inbox was full of shingles and shingles-vaccine questions.
So today, I’m answering some of your questions to help you decide if the vaccine is right for you…
Q: I had a relatively mild case of shingles when I was in my 20s. Now I am 75. Should I get the vaccine? – L.R.
A: Unfortunately, shingles is a “gift” that keeps on giving…
People tend to think that if you’ve had shingles once, you can’t get it again. But it turns out the chance of recurrence is about 4.5% in patients younger than 50. But the risk increases to nearly 6% for folks 50 and older.
And your risk increases over time. The older you are, the more likely you are to develop shingles. Also, if you have a compromised immune system (for instance, if you have rheumatoid arthritis or other autoimmune diseases), you’re more at risk of getting shingles.
The downside is that people with weak immune systems are also more likely to react poorly to the vaccine. But most folks reported only mild side effects: redness, swelling, pain, and irritation at the site of injection. Otherwise, this vaccine appears to be quite safe, and it reduces the pain and occurrence of the disease by at least 50%.
We recommend talking to your doctor to determine if the vaccine is the right call for you.
Q: Is it true you must have two shots two or three months apart? Is it $210 per shot? – R.M.
A: Here in the U.S., the only available vaccine is the Shingrix vaccine. And you do need two shots to be fully protected (the second within two to six months of your first shot). And it’s not cheap.
For the years we’ve followed shingles vaccines, we’ve never seen the price below $200 per dose. Despite the fact that around 99% of people aged 50 and older carry the dormant version of the virus that causes shingles – and that the U.S. Centers for Disease Control and Prevention recommends people aged 50 and older get the vaccine – the cost isn’t covered for everyone.
Many private insurance policies will cover all or a portion of the cost. But it’s not covered under Medicare Part B. If you have Medicare Part D, your shingles vaccine is free.
And even if you have to pay cash… relative to the pain and suffering this disease causes, it could be the best health care money you ever spend.
Q: I’m 72 and had the Shingrix vaccine (both shots) five years ago. (I had chicken pox when I was in my late 20s.) Is it still recommended to get the Shingrix vaccine renewed every five years? – B.M.
A: The full protection of the vaccine usually lasts about five to seven years. After that, the effectiveness wears off as you age. If you had your vaccine five or more years ago, talk to your doctor about whether or not you should get a second one.
We have spent several installments discussing just how destructive dietary sugar is to our health. When I read and listen to talks from several different and knowledgeable experts in this field, their conclusions are essentially saying the same thing: sugar is detrimental to good metabolic health.
Dr. Robert Lustig (the endocrinologist from the University of California at San Francisco) states in a recent talk that sugar has been proven beyond any shadow of doubt to cause four medical problems:
Obesity
Type 2 diabetes
Dental decay
Non-alcoholic fatty liver disease
Yes, I should know. I have experienced excessive weight gain and too many dental cavities in my previous life. Hopefully, I have been spared the other two.
Dr. Lustig also asserts that there is very strong correlational evidence that suggests that sugar consumption plays a major role is other degenerative diseases such as
Heart disease
Hypertension
Strokes
Cancer
Gary Taubes, a scientific journalist, states in his YouTube video, The Case Against Sugar,
that obesity, type two diabetes, strokes, heart disease, and cancer are all a subset of insulin resistance. Consuming excessive, refined carbohydrates, sugar and high fructose corn syrup in particular, over several decades invariably leads to insulin resistance.
There are many other doctors, authors, medical researchers, and honest YouTubers that are documenting just how destructive sugar is to our well-being. Dr. Lustig describes high fructose corn syrup as a “poison.”
It’s kind of like arsenic. One dose doesn’t kill you. It’s the cumulative effect.
Chapter 6: Metabolic Syndrome
Dr. Fife describes a newly identified deadly disease plaguing the world. It’s called Metabolic Syndrome. Heart attacks and strokes are just two of the end results of this condition.
He continues by explaining that you won’t see “metabolic syndrome” listed as a cause of death on a death certificate. It may be listed as a “risk factor,” but it’s not listed as a cause.
Metabolic syndrome is defined as association between a cluster of five metabolic disorders that commonly occur together, and which greatly increase the risk of heart disease, diabetes, Alzheimer’s, and other chronic degenerative diseases.
Dr. Fife lists the following as signs of metabolic syndrome.
High fasting blood glucose
Abdominal obesity
High blood triglycerides
Low HDL Cholesterol
High blood pressure
Metabolic syndrome is an indication of a body seriously out of whack, chemically, hormonally, and metabolically. It is associated with low-grade inflammation and oxidative stress. Dr. Fife then lists 35 diseases that are associated with metabolic syndrome. See pages 105-106 for the complete list. Among these 35 diseases are:
Alzheimer’s disease
Chronic fatigue syndrome
Coronary artery disease
Diabetes
Glaucoma and macular degeneration
Inflammatory bowel disease, Crohn’s disease
Kidney disease
Obesity
Sleep apnea
Some forms of cancer
Dr. Fife states that a person with metabolic syndrome is at a greatly increased risk of developing any combination of these various 35 metabolic disorders.
For example, the diabetic may also suffer from Alzheimer’s, have vison problems, have hormonal imbalances, and die from heart disease.
Dr. Fife states several factors that contribute to metabolic syndrome:
Physical inactivity
Aging
Exposure to environmental toxins
Medications (think prescription drugs) and recreational drug usage
Smoking
Genetics
And most important, DIET
Of course, by diet, he’s referring the overconsumption of refined carbohydrates and a deficiency of good quality fats, protein, and fresh produce. He stresses that the conditions of metabolic syndrome can be improved by replacing the refined carbs in one’s diet with healthy fats and whole foods.
The following is one if his key points in this chapter:
He describes a study that shows that refined carbohydrate restriction is the single most effective intervention for reducing all the features of the syndrome and should be the first approach in managing heart disease and diabetes. A side benefit is weight loss.
My Comment: Yep, quit the sugar. How many doctors hammer this point home?
Dr. Fife makes a nice summation of this section:
It appears that excessive consumption of sugar and refined starch, not fat or saturated fat, is at the heart of most every chronic degenerative disease that troubles our society. It is no wonder why the sugar industry has worked so hard to distract the facts and confuse the medical community and the general public about its dangers. If you want to age prematurely and suffer the last half of your life with a chronic disease, it appears that consuming a high-sugar diet is the fastest way to get there.
My Comments: Some long-time clients of mine referred me to some friends of theirs, Bob and Sue, fictitious names of course. I called and briefly spoke with Sue.
Sue gave me a rundown of their current situation. They are in their eighties, and both are diabetics. They’re also taking several prescriptions.
Sue expressed concern that her Medicare advantage plan was going to cease covering the very expensive Ozempic. She came across like she was at her wits end.
Assuming, of course, that they were eating the SAD way (standard American diet) I emailed her a link to the Quit Sugar Summit which is found at quitsugarsummit.com. She promptly emailed me back and said, “We’re too old to make any diet changes.”
This situation is a real tragedy. They’re faced with degenerative diseases and costly prescription copays. But rather than doing something about it, they’d rather continue their refined carbohydrate diet, take the pills and injections that their doctor prescribes, and then complain about the cost of their prescriptions.
In all likelihood, they’re addicted to the drug called sugar, and like most addicts, they don’t want to quit. Instead, they would rather continue their addiction and have their doctor deal with the aftermath.
One YouTuber doctor called out sugar addiction for what it is: substance abuse. He was spot on.
Continuing:
Insulin Resistance
Insulin Resistance is an essential underlying feature of metabolic syndrome. As insulin resistance begins to develop, fasting blood levels rise consistently above 90 mg/dl. When the number surpasses 100, insulin resistance is advanced and one of the markers for metabolic syndrome. This is now the start or either pre-diabetes or just diabetes.
Full-blown diabetes is diagnosed when fasting blood sugar reaches 129mg/dl or greater; at this stage insulin resistance is severe and health risks become very serious. Uncontrolled diabetes can lead to a myriad of complications such as mental deterioration, kidney failure, heart attack, stroke, blindness, nerve damage, digestive troubles, gum disease, and many other disorders.
Dr. Fife hammers again on the central theme of his writing: The above conditions are all caused by the excessive consumption of sugar and refined carbohydrates and the lack of other, more nutritious foods.
The overconsumption of these refined carbohydrates spikes your blood sugar levels. That, in turn, ramps up your production of insulin. Over time, this constant high demand for insulin takes its toll on your pancreas, and it begins to wear out, and insulin production declines.
For more learning about insulin resistance, please watch these videos:
3) How to Avoid Insulin Resistance and Why it’s Important | Dr. Robert Lustig & Dr. Dom D’Agostino (1:17:17) This video runs more than hour and is somewhat technical as it’s a discussion between two medical doctors. However, it gets to the heart of the problem.
Among others, here is a key quote that begins @ 43:04.
Dr. Robert Lustig:
Here’s the problem. We have this thing. It’s called the American Diabetes Association [ADA], and I’m not a fan (he chuckles and laughs) to say the least. The reason I’m not a fan are two-fold.
The first is that they state, categorically, that diabetes is a chronic, degenerative, unremitting, chronic metabolic disease with no treatment and no cure. That’s what they say. Go to their website. That’s what they say. None of those things are true. (My emphasis)
…..I’ve proven it. The fact of the matter if that type 2 diabetes is eminently reversible. You have to fix the diet, but they don’t say anything about the diet.
What they said was give all the carbs you want but just give enough insulin to cover it, which is also not true.
There are many other terrific videos about insulin resistance, but these three are a good start.
My Comments: One of the guys in a coffee group I attend is Bill (fictitious). He is diabetic and very overweight. At one meeting he went to the coffee bar and picked up a doughnut-type pastry. Somehow in our discussion he mentioned, or maybe I saw the patch on his arm, that he wears a continuous glucose monitor (CGM).
He proudly showed me the CGM app on his phone. The graph showed that his blood sugar spiked up to around 195 (195…yikes!) upon eating the doughnut, but now it was falling. He thought everything was okay and working. His normal was way above 130! He’s a victim of the American Diabetes Association.
I told him about the Quit Sugar Summit.
As a former sugar addict, I can tell you that the only way to beat sugar addiction is to get off the sugary junk, fake foods. You can’t be a recovering alcoholic and fooling yourself by saying, “I’ll only have one beer a day. Folks, it just doesn’t work that way.
Congress authorized the Part D Prescription Drug Plans (PDPs) which was one part of the 2003 Medicare Modernization Act (MMA). Another major aspect of the MMA legislation was establishing the latest rendition of the privatized Medicare plans, known as Medicare advantage.
The original construction of the PDP plans consisted of four phases. Note: I have simplified this discussion for easier understanding.
Phase One: You had to pay the $250 deductible.
Phase Two: You paid 25% of the retail cost of the prescriptions until the retail amount of your drugs was up to a specified amount.
Phase Three: You then paid 100% of the drug cost while in the coverage gap or the doughnut hole.
Phase Four: You paid 5% for name brand drugs if/when you hit the catastrophic stage.
Medicare allowed for some modifications right off the bat in 2006 and in the ensuing years as long as the modifications were as good as or better than the original model. Examples:
Some plans had no deductible but had a higher premium.
Many plans had fixed copays rather than paying the 25% co-insurance.
Some low premium plans had no deductible for tier 1 and 2 generics, but a they had a deductible for tier 3, 4 and 5 drugs.
As common name brand drugs such as Lipitor (atorvastatin), Norvasc (amlodipine), and Toprol (metoprolol succinate) went generic, many plans offered super low copays for these new and existing generics. The following are some common examples:
Tier 1 generics: Zero to $2 copays
Tier 2 generics: $4 to $7 copays
The 100% cost in Phase 3 dropped to 50% somewhere around 2015, and then it dropped by 5% per year until around 2020. The cost for generics and name brands in the coverage gap now stood at 25% through the end of 2024.
Inflation Reduction Act Legislation
On August 16, 2022, President Biden signed the Inflation Reduction Act (IRA) into law. One of the provisions of this act was to lower prescription costs. The following changes were scheduled for the PDPs.
2024: Phase 4 was eliminated. If you went through the coverage gap and hit the catastrophic stage, you no longer paid 5% for brand name drugs.
2025: Phase 3 will be eliminated. There will now be a $2,000 cap on the amount that any PDP member pays for his/her drugs. The $2,000 cap will rise with inflation.
This is all very good news for PDP members with high prescription costs. However, the law of unintended consequences has come into play.
Disclaimer: We are forbidden by Medicare to discuss any specific PDP information such as copays, premiums, and other specific plan details until October 1. For example, we can’t say that the 2025 Acme Good Health Premier plan will be $55 per month and have such and such copays for their various tiers. That’s prohibited until October 1.
We can speak in broad terms about general trends as long as we don’t discuss a specific plan.
Unintended Consequences
As yourself this question: If legislation dictates that the PDP companies will now pay the 25% when members hit the coverage gap, what will that do to the premiums for their plans? Obviously, no company or business can operate at a loss, so the PDP companies have been forced to raise their 2025 premiums. The question is, how much?
A major uproar happened (we can guess) with the officials at the Center for Medicare and Medicaid Services (CMS) when the PDP companies submitted their bids (proposed premiums) for the 2025 plan year. We can only guess that the bids were shockingly higher.
There is also the political aspect. Obviously, this is an election year, and the politicians don’t want to see the senior citizen voting block angered by big price hikes. I don’t think the signees of the 2022 IRA legislation considered this conundrum.
As I write, there is still plenty of behind-the-scenes skirmishing occurring in the halls of government. I suspect that the head honchos are scrambling for more subsidies for the PDP companies to mitigate the higher premiums. Without mentioning any specifics, here are some speculations for 2025 PDP changes.
Premiums will rise. How much is still up in the air.
One major PDP player is calling it quits.
There will some plan consolidation. Let’s say our fictitious Acme Good Health has their Value, Basic, and Premier plans. They may shrink their offerings to just two or even one plan. For example, if Acme decides to go with just their middle Basic plan, then their Value and Premier members will automatically be moved to Acme’s Basic plan. This change may or may not be the right plan for you in 2025.
Agent service renewals are being cut or eliminated by some PDPs. Needless to say, the agent community isn’t too happy about this. Promises are being broken.
Annual Notice of Change
You should receive your plan’s Annual Notice of Change (ANOC) by US Postal Mail during the latter part of September. Previously, some clients reported to us that they received their ANOCs in October or even never at all.
PLEASE READ YOUR ANOCs! They will disclose the following:
If your plan will be cancelled at the end of 2024 and your company is quitting the PDP market.
Your 2025 plan premium.
If you’re being moved from one plan to another within the same company.
Your copays and/or coinsurances for 2025.
Your 2025 deductible amount.
Tier changes.
Changes in the formulary or changes of important prescriptions or even dropped scripts.
Please feel free to contact us with any questions regarding your ANOCs. You can share with us the info on your notice prior to October 1, but as mentioned earlier, we are forbidden to provide any specific information about plan details before that date.
Our Promise to You
We will continue to provide you with our high level of service in securing your best buy for your 2025 PDP. With so many looming changes, we expect things to be unusually busy to say the least.
We hope that your 2024 plan will remain your best buy for 2025. For sure, that simplifies matters.
Since many popular plans will not be working with agents, we’ll likely be doing less paper or e-applications. If, for example, the Acme Health Basic plan is your best buy for 2025, we’ll provide you with their toll-free call center number to sign yourself us. Alternatively, we’ll be happy to sign up as many of you as possible on Medicare.gov, time permitting.
The following are some tips to help us do an accurate search on your behalf for the next year’s Prescription Drug Plans (PDP). Our goal is to find the PDP that will be most suitable for you.
Step 1
Please enter your name, phone, email address, your zip code,
and your county of residence. Some zip codes span multiple counties, and that’s
why we request your county of residence. This means where your
residence sits.
Next, please list your top pharmacy choices. We also ask you
if you would be willing to use Walmart, Walgreens, or a mail order pharmacy if
that will save you money.
Step 2
In this section, only enter your pills, capsules, or tablets. Liquids, gels, creams, insulin,
eye drops, patches, etc. are in the next steps.
Enter the name of your prescription, the dose, and the
quantity you buy. Important, is the quantity you buy per one month, per every
two months, per every three months, or per every twelve months? If you take
something as needed, estimate how many pills you buy and how often you buy it.
Your estimate does need to be exact. Just get it as reasonably close as you
can.
Example #1—Betty take two, 500mg metformin tablets
every day. She buys 60 every month.
Name of Prescription: Metformin Dosage: Enter 500mg Quantity: Enter 60 Frequency: Enter month
Example #2—John take hydrocodone/apap, 325/10mg, as
needed for back pain. Some days he takes none but other days he takes two or
three. He estimates he takes around 45 per month
Name of Prescription: Hydrocodone/apap Dosage: Enter 325/10mg Quantity: Enter 45 Frequency: Enter month
Step 3
The section is for Insulin, Inhalers and Nebulizers
Example #3—Alice uses insulin. She checks “yes”. She
enters her information as follows:
Name of insulin: Lantus Solostar pens Size: 3 mL Quantity: 5 pack or just 5 Frequency: per 2 months
Example #4—Shirley uses Advair. She checks “yes” for
the category: “Do you use any inhalers or nebulizers?” She enters her
information as follows:
Name of inhaler: Advair Size: 250/50 Quantity: 1 Frequency: 1 month
Step 4
This final step is for Eye Drops. Gels, Creams, Lotions or
Salves, and Other Prescriptions.
Example #5—Mary uses eye drops. She checks “yes” for
this category and fills in her information. Please do NOT attempt to say “2
drops per eye each day.” We need to know the size of the bottle, usually
2.5 mL, 5 mL, or 10 mL and how often you fill your prescription.
Name of eye drops: Latanoprost SOL 0.005% Size: 2.5 mL Quantity: 1 Frequency: 1 month
When finished, please hit the submit button. Thank you in advance for using PDPhelper.com. End
Every fall, your Part D prescription plan (PDP) or Medicare Advantage (MA) plan sends you what’s called the Annual Notice of Change or the ANOC for short. It’s important to carefully read it, as buried in the verbiage are sometimes substantial changes in your plan.
When this happens, every year without fail, we receive a call in January from a disgruntled member that’s unhappy about being hit with a large premium increase or more costly copays. Let’s be pro-active and see if we can deal with this issue BEFORE the October 15 to December 7 Annual Election Period (AEP) ends. There’s little we can do after December 7th!
Going into 2024 we have another potential train wreck loaming on the horizon. Because of compliance issues, we can’t use an actual company’s name. Therefore, we have at hand our fictitious and popular Acme Value Prescription (AVP) plan.
Here is their 2023 copay structure.
Tier 1 drugs: $1.00 copay
Tier 2 drugs: $5.00 copay
Tier 3 drugs: $47 copay*
Tier 4 drugs: $90 copay*
Tier 5 specialty drugs: 33%*
*Tiers 3-5 are subject to the $505 deductible
Now watch carefully…
Here is their 2024 copay structure.
Tier 1 drugs: $0.00 copay
Tier 2 drugs: $5.00 copay
Tier 3 drugs: 25% co-insurance*
Tier 4 drugs: 50% co-insurance *
Tier 5 specialty drugs: 33%*
*Tiers 3-5 drugs are subject to the $545 deductible.
It all looks very similar, right? Well, not exactly.
The Analysis
Tiers 1 and 2 are almost the same, and they are both excluded from the 2024 $545 deductible. So far, so good.
Hmm, tier 3 is now a 25% co-insurance.
Here’s the Good Part About this Change…
For 2023, Ramona Homestead has taken hydrocodone/acetaminophen 320-10mg 3 times per day. Even though this is a generic, AVP lists this drug as a tier 3 on their formulary. She has met her deductible, so she has a $47 copay for her med. However, the $47 copay is more than the $32 cost for hydrocodone at her pharmacy, so she receives no help from her plan.
In 2024 she pays just 25% for her med after she has met her deductible. Assuming that she has met her deductible with other prescriptions, she now pays 25% of $32 or just $8.00 for her hydrocodone. That is an improvement compared to the 2023 copay structure.
And Now the Bad and the Ugly…
Ramona also takes Eliquis, 5mg, 2x per day. To make our math easy, let’s says that the retail cost of Eliquis is $600 per month.
In 2023 she pays $47 after her deductible has been met.
In 2024 she pays $150 (25% of $600) after her deductible has been satisfied. Her cost sharing has gone from $47 to $150 or tripled!
If she doesn’t take any action, she might faint from sticker shock when she sees her pharmacist in February 2024. She’s expecting a $47 copay once her deductible has been met, but instead she’ll be hit with $150!
How Do I Know if this Change Helps or Hurts Me?
Any tier 3 drug that is less than $188 per month will benefit you. At exactly $188 it’s a wash as 25% of $188 is exactly $47. However, once you’re above $188, AVP’s plan change is going to cost you much, much more. There are plenty of tier 3 drugs with a monthly retail cost of $400 to $1,000.
The Solution
Most of you already know this one. Have us update your list of prescriptions and re-shop your PDP for 2024. Please see our companion articles, The House Always Wins and PDPHelper.com. End
The Part D Prescription (PDP) plans and Medicare Advantage plan were authorized by the 2003 Medicare Modernization Act passed by Congress in 2003 during the George Bush II administration.
2024 will mark the eighteenth year that I have been involved with the afore-mentioned plans. I have seen some reoccurring themes of what the PDP companies do to maintain their profitability, and that is the theme of this article.
The Original Structure of a PDP
Before discussing some of tricks of the trade that the PDP companies use to boost revenue, let’s look at the original plan design.
Phase 1: The member had to meet a $250 deductible.
Phase 2: The member paid 25% of the retail cost of the prescriptions up to the coverage gap limit.
Phase 3: The member was responsible for 100% of the costs when in the coverage gap (aka the donut hole).
Phase 4: This is the catastrophic phase where the member in general paid 5% for the cost of his/her meds. Note: In 2024 this is now zero percent.
Here are some takeaways:
The 25% co-insurance that I referenced in my companion article for the fictious Acme Value Prescription (AVP) plan is nothing new. However, most plans have gone to a flat copay system for several years. As several new expensive drugs have hit the market, the PDP companies are resurrecting the 25% coinsurance schedule.
Medicare has allowed the PDP companies to create alternative plans to the original design. This could consist of flat copays instead of the 25% coinsurance, no deductible plans, or reduced deductible plans. For several years we have seen plans where tiers 1 and 2 drugs were excluded from the deductible.
As many formerly expensive brand names have gone generic, we have seen some plans offering $0.00 or $1.00 copays for many of these low-cost generics. The following are a few examples of expensive brands that have gone generic. The brand name is followed by its generic equivalent.
Statins:
Crestor—Rosuvastatin
Lipitor—Atorvastatin
Zocor–Simvastatin
Blood pressure:
Norvasc–Amlodipine
Toprol– Metoprolol succinate
Cozaar—Losartan
Diovan–Valsartan
Diabetes:
Glucophage—Metformin
Actos– Pioglitazone
Others:
Plavix—Clopidogrel
Singular—Montelukast
and dozens more.
Expensive New Brand Name Drugs
What has changed the dynamic regarding the PDPs are the new generation of brand name drugs. Before going generic, many of these older brands listed above used to have a retail cost ranging from $100 to $200 per month. We used to think that these were expensive drugs.
Now we’re seeing brands with a retail cost of $500 to over $1,000 per month. Some popular examples are Eliquis, Xarelto, Mounjaro, Trelegy, and Ozempic.
The writing is on the wall. Many of the low premium PDPs will be phasing out covering these drugs with a fixed $40 to $47 tier 3 copay. Another popular plan made this change a year ago. Where we’ll likely see a continuance of the tier 3 and 4 fixed copays is with the high dollar PDPs. These premiums typically start at $70 per month and go up from there.
The PDP Companies’ Tricks of the Trade
First, it’s important to understand how the PDP companies are financed.
The government subsidy: We could dig though online documents of over 200 pages to feret out every last detail as to how the PDPs are financed. Let’s do the simplified version. According to KFF.org, Medicare (the Federal government) finances 74% of the PDP costs. Your premium covers 15%, and the states kick in around 11%. These percentages may vary from plan to plan, but this will give you the gist of how the financing works.
Even if your plan premium is zero, the PDP companies derive most, or all of their funding from state and federal governments. I fielded a phone call from a concerned client who read in her Annual Notice of Change (ANOC) that her 2024 PDP premium was dropping to less than a dollar. She thought something must be amiss.
She was relieved when I explained where the bulk of the financing comes from. In addition, I discussed how her Acme Value Prescription (AVP) plan was changing its tier 3 copay structure.
Trick Number One
A prescription drug company comes out with a super low premium plan. Because of the low premium, the plan gains more market share. After three years, give or take, the members have a substantial rate increase. Many members will change, but the companies understand senior psychology which is that people don’t like making changes. In the end, the member that doesn’t shop ends up paying the higher freight.
Recently, we have seen a new trend, and that is decreasing premiums. That’s good but keep the big picture in mind.
Trick Number Two: Tier Juggling
A tier 1 generic is moved to a tier 2 generic. Generally, this means that a $0.00 to $3.00 copay goes to a $4.00 to $8.00 copay. Even worse is when a tier 2 drug is kicked up to tier 3. Even though tier 3 drugs are called “preferred brands,” there are often many generics included as a tier 3 drug. For example, the generic equivalents to the brands Diovan and Micardis are Valsartan and Telmisartan respectively. Some of the low-premium PDPs have moved these generics from tier 2 to tier 3.
Trick Number Three: Dropping an Expensive Drug from the Formulary of a Budget PDP
Let’s say that the AVP plan used to carry the popular blood thinner Eliquis on its formulary. Buried in the verbiage of its ANOC is the list of drugs no longer included in their formulary for the next year. Who reads every word of their ANOC? Worse, some members say, “It’s all Greek to me, and I don’t understand any of it, so it goes into file 13.” PLEASE TAKE THE TIME TO CAREFULLY READ YOUR ANOC!
Trick number Four: Changing a Tier’s Copay Structure
Going from a flat copay to a percent (usually 25%) co-insurance: I have discussed this one in detail in my companion article, This Tier 3 Copay Change Could Cost You Hundreds of Dollars.
Trick Number Five: Disenrollment Confusion
A few years ago, our fictitious Acme Insurance Company carried these three plans:
Acme Pharmacy X Plan: $26 per month
Acme Regular Plan: $38 per month
Acme Premier Plan: $56 per month
They made changes to its Acme Pharmacy X Plan and renamed it to the Acme Value Prescription (AVP) plan. Because there were so many changes including formulary changes, Medicare required Acme to send out disenrollment notices to its Acme Pharmacy X Plan members.
Buried in the ANOC verbiage was the statement that those who remained in the Acme Pharmacy X plan would automatically be migrated to the Acme Premier Plan. Notice that this caused the premium to more than double.
Between emails and phone calls, we did our best to alert our clients to this issue. Unfortunately, there were those who we were unable to reach who were unaware of what was happening. Sadly, they were shocked when they were hit the big rate increase in January.
I don’t believe the companies are being malicious when this happens. As I understand it, when companies want to make major changes to their plans, Medicare requires them to migrate their members to the plan with a formulary that is at least as robust as the one in the outgoing plan. This inevitably winds up being the highest premium plan.
However, I think the companies could be more diligent with even a second or third communication alerting their members to an ensuing train wreck. The bottom line is this: PLEASE BE SURE TO READ EVERY COMMUNICATION FROM YOUR PRESCRIPTION OR MEDICARE ADVANTAGE PLAN. If you are not sure of what those notices mean, please contact us.
Conclusion
When it comes to casino gambling, most people understand that the House always wins. Slot machines have a payout ratio of around 83 to 95%. Sure, some gamblers hit the jackpot and win big, but it’s at the expense of the others that lose.
The Part D prescription companies lose on some members that are high prescription users. However, they are extremely profitable with those that are either non or minimal users. No matter how they structure their plans, they will be profitable. And that’s fine as long as it’s not too big of a profit. Just keep in mind as with the casinos, the House always wins. End
The fall Annual Election Period (a.k.a. Medicare open enrollment) is upon us. We have already started discussing 2024 plans as of October 1st. We can start taking applications October 15th for the 2024 plan year. December 7 is the closing date of the AEP. Please help us to avoid the last-minute rush.
Please Ignore the Medicare-related TV and Clicky Internet Advertising
Note: This article was originally published in 2021. We have updated it to reflect current changes.
We received an email from a client with a copy of an internet click-bait ad that stated the following:
“$2,041 SS payment—All seniors are due a large $2,041 Social Security benefit this week.”
This verbiage has scam written all over it. All seniors? Really? Why $2,041? Where does this money come from and who’s paying for it? This is classic click-bait that entices the greed and gullible person to click on it.
Let’s revisit the psychology of advertising. Most advertising is designed to create anxiety, apprehension, and discontent. It also presses your fear and greed buttons. The ads are purposely choreographed to upset your equilibrium and peace of mind. Please remember that this is all done very subtly, and that’s the cleverness and deceptiveness of advertising. This is why advertising copy writers get paid big bucks.
Another element of advertising is to create fear. Misguided Medicare advantage advertising creates fear that you might be missing out on something really important such as a big payment or some other Medicare benefit. The bottom line is that the advertising by design is manipulative.
A more sinister aspect of advertising, especially television advertising, is to bombard your senses to the point where your ability to differentiate between truth and fiction is broken down. Your senses are dulled. The trickery is to “push your feelings button rather than your intellect button. Be assured, there are no pots of gold sitting at the end of the rainbow!
For more understanding about the scamsters and click-baiters, please view our companion article, Medicare ‘boiler room’ Scams Prey on Senior Citizens Ahead of Open Enrollment
If you have questions, doubts, or concerns after viewing a Medicare-related TV or internet ad, please call or email us FIRST! Please keep in mind that we are swamped this time of year and will get back with you as fast as possible.
IF YOU ARE HAPPY WITH YOUR MEDICARE ADVANTAGE OR MEDICARE SUPPLEMENT PLAN AND IT’S WORKING WELL FOR YOU, THERE IS NO NEED TO CHANGE!
Part D Prescription Plans: Many people have us re-shop these plans for them every year. We need to change these plans to stay current with the best buys.
The Types of Changes You Can Make During the Fall AEP
Abbreviations:
Medicare advantage plan = MA.
Medicare advantage with prescription drugs = MAPD
Prescription Drug plan = PDP
For those where a change is appropriate, the following list are changes that you can make.
You can change from one PDP to another PDP.
You can add a new PDP if you never had one but need one now. A late enrollment penalty may apply.
You can change from one MA/MAPD to another MA/MAPD plan. Remember, the MA plan only does not have a prescription plan embedded in it.
You can drop your Medicare supplement plan and switch to a MA/MAPD plan if one is available in your county of residence.
You can drop your MA/MAPD plan, go back to original Medicare, and add a Medicare supplement plan. Medical underwriting applies in most situations. Medicare also allows you to sign up for a PDP so you do not lose prescription coverage.
The Lasso MSA plan is discontinued for 2024 and is no longer is available.
Changing from one Medicare Supplement Plan to Another
First, it’s important to note that you can change your Medicare supplement plan ANY month of the year. This change is NOT restricted to the fall AEP, however, you must medically quality with the new company you are applying to. This change is usually done to get lower rates.
There is an exception. Washington has continuous open enrollment. Oregon and Idaho have the birthday rule which allows you an open enrollment period following your birthday. In these cases, there is NO medical underwriting.
Many of you have successfully used our website, PDPHelper.com to submit a list of your prescriptions to us. Doing so helps us to shop for you the most competitive PDP or MAPD.
PDPHelper.com: Submit a list of your prescriptions to us using this website.
Conclusion
As stated above, we strongly encourage you to use our PDPHelper.com website as a way of submitting of list of your current prescriptions. We thank you for your patronage and wish you the best for the upcoming 2024 season. End.
Hi and welcome, I’m Lance D. Reedy, CSA, an independent agent and owner of Northwest Senior Insurance. I specialize in working with Medicare beneficiaries.
The following are some tips to help us do an accurate search on your behalf for the next year’s Prescription Drug Plans (PDP). Our goal is to find the PDP that will be most suitable for you. 
by Lance D Reedy
The Annual Election Period (AEP) for 2024 Plans