Medicare Part D 2021 price increases

[Dave J]

Dave J -- Is your wife on traditional Medicare with supplement (that is, not a Medicare Advantage plan?) If so, does she meet the home health criteria mentioned above?

She is on Traditional Medicare and supplement G. She has the shot in Doctor's office, they get it no problem for her, she does not meet home health care and has not had a fracture. She has had it 3 times , so far, since going on Medicare. Next time is in November. Her doctor is a busy OBGYN. They have paid every time with zero problems. I think the nurse calls a week or so ahead to make sure she is coming to appointment , likely to verify before ordering drug, but don't know that. There are other injectable drugs for same condition that have to be taken 1 time a day. My wife was on one of those 10 years or so ago. For two years she self administered. I'd guess they don't want to pay for a home health nurse to give those daily unless you are really unable to give it to yourself. a daily visit to home would be expensive.

If your Doctor is in a practice with enough patients to have a dedicated Medicare billing clerk, maybe they would be a good source of info on payments. I commend you for researching before hand. It is confusing. Good luck.

Dave

 

[Bamaman]

I've been spending the morning counting my inventory of pills and figuring out (after my December refills) what meds I will need in 2021. I won't have to buy any meds until July and Part D won't even pay anything next year because I won't meet their deductibles.

I would like to not even enroll in Part D, but I'm afraid of some unknown ailment cropping up that requires some ultra expensive medications.

I'm considering going with one of the cheapest Part D programs with $485 deductible, just in case I get sick and require new meds. In the meantime, I'm leaving the very expensive CVS and taking my business to Walmart or Publix and using GoodRX and coupons.

 

[harllee]

I've been spending the morning counting my inventory of pills and figuring out (after my December refills) what meds I will need in 2021. I won't have to buy any meds until July and Part D won't even pay anything next year because I won't meet their deductibles.

I would like to not even enroll in Part D, but I'm afraid of some unknown ailment cropping up that requires some ultra expensive medications.

I'm considering going with one of the cheapest Part D programs with $485 deductible, just in case I get sick and require new meds. In the meantime, I'm leaving the very expensive CVS and taking my business to Walmart or Publix and using GoodRX and coupons.

In my location there are some plans available with zero deductibles--of course the monthly payment is more but you might come out better with a zero deductible, sometimes my DH who takes several medications does better price wise with the zero deductible.

 

[Time2]

All my drugs are free at Publix in Florida. Or, $4 at Walmart. Still need a part D plan though.

How does that work? I have Humana/Walmart part D, My prescriptions are $3 or $12 for three months, If they are on the right tier.

 

[ShokWaveRider]

How does that work? I have Humana/Walmart part D, My prescriptions are $3 or $12 for three months, If they are on the right tier.

Local supermarket drug stores provide free prescription for certain common drugs and antibiotics, each has a list. I ask my doctor to use that list. Others are $0 deductible or copay on my Current Wellcare plan. Walmart has a $4 list.

I will be moving to SmartRX next year for half the monthly premium and the same coverage..... for me.

What I would like to know, with all these Medicare rules and restrictions for drugs, supplements and advantage plans. What do old folks do who do not have access to the Internet, do not have Smartphones and have no family to help them?

 

[audreyh1]

What I would like to know, with all these Medicare rules and restrictions for drugs, supplements and advantage plans. What do old folks do who do not have access to the Internet, do not have Smartphones and have no family to help them?

Exactly my concern when I get to that point. Even with internet and smartphones, I might not be able to use them well enough to manage my own care.

 

[Sue J]

Any Wellcare users have any comments on their mail order service?
Reliable/fast? Or?? I've only used Humana and been pleased w/ their <=
1 wk service but may have to switch due to cost increase.

DH and I both have had Wellcare Wellness Rx PDP. I use mail order (CVS CareMark) and DH prefers our local grocery pharmacy. Very good service through mail order and all of mine have been at $0 copay. DH has one that costs $5/mo $15/3 mo and unfortunately that one RX is being moved from Tier 2 to Tier 4 and will cost $120/3 mo. So he may move to another Part D where that Rx is $58/3 mo.

2020 is our first year on Medicare. While on ObamaCare since 2014 we always bought this Rx at a local pharmacy using GoodRx or RxSaver coupons. May just go back to doing that and buy a low cost Part D for him.

 

[harllee]

Local supermarket drug stores provide free prescription for certain common drugs and antibiotics, each has a list. I ask my doctor to use that list. Others are $0 deductible or copay on my Current Wellcare plan. Walmart has a $4 list.

I will be moving to SmartRX next year for half the monthly premium and the same coverage..... for me.

What I would like to know, with all these Medicare rules and restrictions for drugs, supplements and advantage plans. What do old folks do who do not have access to the Internet, do not have Smartphones and have no family to help them?

Our senior center has a person that will help people figure out their Part D free of charge. Use to be you could bring in a bag of your prescriptions and they would figure out the best Part D for you. Now they are doing by Zoom or over the phone. I do my 89 year old mom's Part D every year. She stays with a more expensive Blue Cross policy because it makes her more comfortable.

 

[Sue J]

In case this hasn't been posted yet, here is the 2021 Aetna SilverScript SmartRx formulary. This is the new low cost one for around $7.30/mo in most areas. The actual formulary starts on page 10 of the .pdf . The index starts on page 72.

https://www.aetnamedicare.com/documents/individual/2021/formularies/FORM_2021_SMARTRX_EN.pdf

 

[harllee]

In case this hasn't been posted yet, here is the 2021 Aetna SilverScript SmartRx formulary. This is the new low cost one for around $7.30/mo in most areas. The actual formulary starts on page 10 of the .pdf

https://www.aetnamedicare.com/documents/individual/2021/formularies/FORM_2021_SMARTRX_EN.pdf

Be sure and look at the pharmacies you can use for this SilverScript plan--where I live you are limited to CVS.

 

[audreyh1]

Be sure and look at the pharmacies you can use for this SilverScript plan--where I live you are limited to CVS.

Thanks for the link and I did a search for for pharmacies based on our zip code. In our area preferred pharmacies are CVS, HEB grocery stores, and Costco. So for us that’s a pretty comprehensive selection. For one-offs (like antibiotics) we already use HEB. For ongoing pricier prescriptions we have used Costco.

 

[MBSC]

This seems pretty definitive that osteoporosis drugs are treated differently than other injectable drugs.....

The Prolia website linked to in post #89 says it is available to all Part B benes.

You are using the "and" clause in the Medicare quote to combine two different scenarios. The "and" clause is meant to separate the home health benefit from the drug benefit. I have edited the quote for clarity.

1. (Your Scenario): Medicare Part B (Medical Insurance) helps pay for an injectable drug for osteoporosis. You pay 20% of the Medicare-approved amount for the cost of the drug, and the Part B deductible applies.

2. If you can't get to the doctor's office for the injection, Medicare Part B (Medical Insurance) helps pay for visits by a home health nurse to inject the drug if you meet these conditions:

-You’re a woman.
-You meet the criteria for Medicare home health services.
-You have a bone fracture.
-You’re unable to give yourself the drug. You pay nothing for the home health nurse visit to inject the drug.

The "and" clause in the actual Medicare quote separates two distinct coverage issues, home health coverage and drug coverage. The nurse's visit is not a restriction but an additional benefit on top of the basic injectable coverage.

The doctor's billing manager can tell you how they bill to be in compliance with Scenario #1.

 

[MBSC]

Be sure and look at the pharmacies you can use for this SilverScript plan--where I live you are limited to CVS.

Your post indicates you live in Chapel Hill, NC. The Medicare Plan Finder indicates 3 Harris Teeter grocery store pharmacies within a 5 mile radius, all preferred in-network.

 

[Happyras]

I'm considering going with one of the cheapest Part D programs with $485 deductible, just in case I get sick and require new meds. In the meantime, I'm leaving the very expensive CVS and taking my business to Walmart or Publix and using GoodRX and coupons.

I am amazed at how little I pay using GoodRX. Ezetimibe is a tier 3 subject to deductible and costs me $150/90 day with Wellcare, but GoodRx its $12.

I spent the morning trying to avoid Plan D. It costs me $70 pp IRMAA in addition to the premium and pays nothing for our drugs, we use GoodRx. I am trying to find a cheap "creditable" drug plan and not pay anything to Medicare, and avoid the LEP penalty. The risk is the long term LEP penalty. However, I did rough calculation if I avoided Plan D for 60 months and did not have a creditable plan and premiums rose 6%/year, and then started Plan D with the 60% penalty, I would still save at least 10,000 in premiums over 30 years, more if 20 years, but I don't plan on dying at 80...

Anyone else tried to work around this scam to pay ACA costs. The whole IRMAA is totally targeted at retired folks who actually earned money to retire forcing them to pay for others.....this is in addition to the 3.8% NIIT tax we get to pay to also cover ACA costs.

 

[harllee]

Your post indicates you live in Chapel Hill, NC. The Medicare Plan Finder indicates 3 Harris Teeter grocery store pharmacies within a 5 mile radius, all preferred in-network.

Thanks--I see HT on the Medicare finder now-- for some reason they did not show up before--but I only want to go to pharmacies with drive throughs or that deliver (do not want to go inside a pharmacy in 2021 if I can avoid it) and none of the local HTs have a drive through. Anyway I want to stay with my local independent pharmacy (they deliver to my house) and they are out of network for this plan so I have decided to pay a few more bucks and go with a different plan that covers the pharmacy I want to use.

 

[Katsmeow]

The Prolia website linked to in post #89 says it is available to all Part B benes.

Well I looking at what Medicare says I was thinking that what Prolia was saying is that it is available to all Part B beneficiaries...but was neglecting to say that only a small fraction of them would actually be eligible. That is, to say it is available to all Part B beneficiaries but neglecting to add "if you are entitled to home health benefits." But, admittedly I was swayed to that because I found website after website that said you could get it under Part B if you qualified for home health. But...maybe they made the same error I made.

You are using the "and" clause in the Medicare quote to combine two different scenarios. The "and" clause is meant to separate the home health benefit from the drug benefit. I have edited the quote for clarity.
The "and" clause in the actual Medicare quote separates two distinct coverage issues, home health coverage and drug coverage. The nurse's visit is not a restriction but an additional benefit on top of the basic injectable coverage.

I am hoping that is correct. Yes, I was reading "and" to be conjunctive and that both were required to get the benefit. I think the way you edited it is infinitely more clear than what is on the Medicare web page! You should write for them....

The doctor's billing manager can tell you how they bill to be in compliance with Scenario #1.

And this is what I am going to do. I will do that before choosing my Part D plan. Thanks, much.

 

[frank]

what is boomer benefits and where does one contact them? I have heard of them but the only thing that I see around here is the ship program.

 

[REWahoo]

https://boomerbenefits.com/

Click on the above link to learn about what they offer.

 

[molly312]

On the topic of Prolia, it is my understanding that there is evidence that women/men who have/had breast cancer and have osteoporosis/osteopenia receive prolia injections covered by Part B. The reason is that it has been shown to help prevent bone metastisis in breast cancer patients at risk. That is a "qualifying" condition.

 

[Katsmeow]

On the topic of Prolia, it is my understanding that there is evidence that women/men who have/had breast cancer and have osteoporosis/osteopenia receive prolia injections covered by Part B. The reason is that it has been shown to help prevent bone metastisis in breast cancer patients at risk. That is a "qualifying" condition.

I think the medication qualifies for anyone with osteoporosis. I have not had breast cancer. In my case, it is better for me because I have unacceptable side effects from the drugs in the class that Fosamax and most osteoporosis drugs are in. The issue is whether it is covered only as part of the home health care benefit or whether it is covered for injections in the doctor's office. At first it looked to me like it required you to need the home health care. Then MBSC explained that the home health care benefit was in addition to the people receiving the injection in the doctor's office. So that would put it as something covered just by Part B if I get the injection at the doctor's office.

The general rule is that Part B covers injections if the drug is not usually self-administered. This is a subcutaneous injection. So I think the issue is whether Medicare thinks it should be self-administered. The Prolia website suggests that Part B does cover it (and not just for home health).

However, I did find this discussion at some insurance agents web site in 2018. This says the client's doctor said Part B covers it 800-MEDICARE said no unless getting under home health care.

https://insurance-forums.com/community/threads/reclast-prolia-change-in-part-b-coverage.92494/

There seemed to be discussion that previously it was covered by Part B but Medicare decided that it could be self administered so it was now Part D (unless home healthcare applies).

So that puts me thoroughly confused.

I do plan to call my Doctor's office. But I am concerned they will tell me it is covered by Part B and do the injection then it turns out not to be I have to pay them out of pocket for the full cost of the injection with no Part D help. Sigh....

 

[Dave J]

There seemed to be discussion that previously it was covered by Part B but Medicare decided that it could be self administered so it was now Part D (unless home healthcare applies).

So that puts me thoroughly confused.

I do plan to call my Doctor's office. But I am concerned they will tell me it is covered by Part B and do the injection then it turns out not to be I have to pay them out of pocket for the full cost of the injection with no Part D help. Sigh....

That is not our actual experience in 2019 and 2020. Prolia in Doctor's office was covered all three shots so far and we fully expect it to cover it next month for number 4. Our clinic used to do a prequalify and an actual cost quote for out of pocket cost pre-medicare on Prolia so we know what the cost was before hand. I assume they would do that on Medicare.

 

[Katsmeow]

That is not our actual experience in 2019 and 2020. Prolia in Doctor's office was covered all three shots so far and we fully expect it to cover it next month for number 4. Our clinic used to do a prequalify and an actual cost quote for out of pocket cost pre-medicare on Prolia so we know what the cost was before hand. I assume they would do that on Medicare.

Yes, I am going to call and find out how they handle it. This doctor's office is often not that great on some insurance stuff. DH just had lab work done and they managed to not give the lab any of his insurance info (the blood was drawn in their office so DH never dealt with the lab). So the lab billed him for the full cost of the lab work. he called and submitted the info but the doctor's office certainly fell down on that. I want to make sure they get this right. Your wife's information certainly does support the notion that this is covered for shots in the doctor's office. So, that makes me hopeful.

 

[harllee]

Need some help on the Medicare.gov Part D website for DH. He takes several prescription drugs and has entered them all on Medicare.gov and done a search for the best Part D plan for 2020. But many of the plans say "drug pricing information is not currently available". Is anyone else seeing this? Is the Medicare.gov site not up to date yet for 2020?

 

[ShokWaveRider]

I just signed up for the Aetna Medicare Part D Plan for $7.30.

 

[Car-Guy]

We were informed about a week ago that our Medicare part D pricing would remain the same in 2021 "BUT" to keep it we must convert to their Medicare Advantage program... (my previous employers retiree insurance program) Basically they want it all or nothing. And if you "opt out", all your dependents in the plan are also forced out and can never get back in.

There should be a law against "effectively" forcing you to their Medicare Advantage program.