Matthew Jakubowski: I Noticed Last Year You Fell

Hyosung Pang, time travel, 2020. Source:

Hi, may I please speak with <Mr./ Mrs.> <first name> <last name>? Hello, <Mr./Mrs.> <last name>. My name is <dialer first name>. I am a <job role> from <Reliance Total Care/Alliance Partners> and I’m calling with some helpful information about your <Series 1/Gold tier/Series 2/Silver tier> prescription drug coverage. How is your day going?

Before we continue our call, for security purposes, may I please have your date of birth? Thank you. Please note this conversation is being recorded so we can improve our quality and training. I want to begin by saying thank you for being a valued subscriber to our health insurance plan.

Looking at our records of your prescription drug history, I noticed last year you fell into the donut hole, which is also called the coverage gap. The coverage gap begins after the costs you pay and the costs we pay reach a specific limit.

So, we’re reaching out to talk about options that could help you avoid falling into the coverage gap again. Does that sound like something you’d like to discuss? Great!

Let me share some information on that. The phase known as the coverage gap begins when all the money you’ve paid for prescription drugs combined with the share we’ve paid hits that coverage limit I mentioned. The government determines the amount of this limit for all of our <Series 1/Gold star/Series 2/Silver star> health insurance plans. The formula they use changes slightly every year according to several factors.

This year, the limit is $16,481. As you know, when that coverage gap phase begins, the amount you pay for your prescriptions changes.

It breaks down like this: in the gap, you’re responsible for 25% of the cost of your drugs, whether they’re brand-name or generics. Then either your health plan, the drug manufacturer, or the government covers the rest of the costs.

It helps to talk about a specific example. The records I’m looking at show that last month you filled a prescription for <drug name> at <pharmacy location> and paid a <$0/$9/$10/$20/$40/$47/$60/$94/$141/$300> copay. The true cost of this drug is <$872/$1,791/$2,013/$4,131>. So in the coverage gap phase you would pay 25% of the remainder of that amount and we would cover the rest. It’s the same for either a brand-name drug or a generic, but brand drugs usually cost more.

I see you get your medicines at a local pharmacy. Were you aware you can change to a retail pharmacy or order your drugs by mail and save money? The copay you pay may also be lower. Plus, buying your <Series 1/Series 4> generic medications via these other methods allows you to obtain a 90-day supply for only a 60-day copay. Using the mail order option, getting a <Series 1/2/4> medication also lets you get a 90-day supply for the price of a 60-day copay.

Now, I see you take a <Series X> medication. Are you interested in trying one of these other options instead of shopping at your local pharmacy? Great!

I also noticed your doctor has prescribed you insulin, but the type you take isn’t part of our more affordable drug program, which only <Series 5/Series 8> plan members can get. If you change brands, you can obtain a 30-day supply for a <$531/$681> copay. This low copay is available before and after the gap in coverage phases. If you go online to http://www.formularyseries/ you can check if your insulin is currently available at this rate. Just look for the <Green ST5/8> icon.

Naturally, please check with your doctor about making this kind of change. You can discuss the list of select insulins at your next appointment. Do you need help finding the list of insulins available that you can select with your plan? OK, if you change your mind later just let us know.

Do you know about the local and national programs available to help people pay for their medications? It depends on your income level and any other insurance you might have. But I would be happy to show you how to contact one of these programs if you’re interested.

I’m very happy we got to talk today. If you ever need health advice, you have a personal health advocate available at no cost to you 24 hours a day, seven days a week, who can track your concerns and be your partner on your health journey.

Also, our system may randomly select you to offer your thoughts and opinions about your health plan. I hope you’ll take that valuable opportunity if you are selected. It’s immensely valuable for us to know what our members are thinking and experiencing. So please do spend all the time you need to capture your thoughts and experiences accurately.

Your time is very valuable to us and <Reliance Total Care/Alliance Partners> is grateful for each chance we are given to learn about members like you. Your well-being matters most and making sure everyone has a long, healthy life is our goal, no matter their ZIP code, income status, or the color of their skin. We know our world isn’t like that now, but we are determined to do all we can to make it the world we live in one day.

I really enjoyed talking with you today. Have a great week.