Medicare Drug Plans

[lawman]

Help me understand..I have Wellcare Value Script drug plan..It is free..I pay zero..My Dr. wants to prescribe an expensive drug for me..If I understand correctly once out of pocket expense hits $2100.00 a year the rest of the year is free for that prescription. Is that correct? Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

 

[RetiredHappy]

Help me understand..I have Wellcare Value Script drug plan..It is free..I pay zero..My Dr. wants to prescribe an expensive drug for me..If I understand correctly once out of pocket expense hits $2100.00 a year the rest of the year is free for that prescription. Is that correct? Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

It depends on whether the drug is in the Medicare formulary or not. Many biologics like Skyrizi and Humira are not in the Medicare formulary, which means that you pay full freight and there is no limit on out of pocket costs.

You can go back to Medicare.gov and price out the drug against your Wellcare plan to see how much it actually costs you for this year.

 

[lawman]

It depends on whether the drug is in the Medicare formulary or not. Many biologics like Skyrizi and Humira are not in the Medicare formulary, which means that you pay full freight and there is no limit on out of pocket costs.

You can go back to Medicare.gov and price out the drug against your Wellcare plan to see how much it actually costs you for this year.

Not sure I'm following you...The drug is listed in the formulary..I called Wellcare and using their numbers I will hit $2100.00 after about 7 months..$2100.00 equals out to $175.00 month average...

 

[Donno]

Not sure I'm following you...The drug is listed in the formulary..I called Wellcare and using their numbers I will hit $2100.00 after about 7 months..$2100.00 equals out to $175.00 month average...

I take a biologic drug and hit the $2100 out-of-pocket limit with the first refill in January. For the rest of the year every prescription I get filled is $0 with my Wellcare ValueScript plan.

 

[RetiredHappy]

Not sure I'm following you...The drug is listed in the formulary..I called Wellcare and using their numbers I will hit $2100.00 after about 7 months..$2100.00 equals out to $175.00 month average...

If it is formulary, then it is not an issue. There are drugs that are not on the formulary list and those have no limits on out of pocket costs.

 

[TrvlBug]

It depends on whether the drug is in the Medicare formulary or not. Many biologics like Skyrizi and Humira are not in the Medicare formulary, which means that you pay full freight and there is no limit on out of pocket costs.

You can go back to Medicare.gov and price out the drug against your Wellcare plan to see how much it actually costs you for this year.

This. DH is prescribed 2 expensive drugs, both of which were on Wellcare's formulary in 2025. One of them was not in 2026 and he had to move to another drug plan costing just over $100/month in order for the $2100/year max to take effect. Otherwise, we would be out of pocket ~$9K for the year. Then the doc took him off the drug that wasn't on Wellcare's formulary .

 

[Koolau]

Yeah, it's kinda nice when you no longer get charged several hundred for a drug that you had to pay for earlier in the year. But then you have to try to "forget" that you've already paid $2100 for your year's drugs so far.

I guess it could be a lot worse.

 

[VanWinkle]

I agree with OP, why pay a steep premium if a covered drug will top out at 2100 either way.

 

[CaptTom]

I guess it could be a lot worse.

True. But it is pretty bad...

Then the doc took him off the drug that wasn't on Wellcare's formulary

^^ For example.

Basically, Medicare tells you to list what drugs you're going to be prescribed over the next 12 months, and pick a plan accordingly.

This would be like the auto insurance company telling you to list all the accidents you plan to be in over the next year.

Sort of the opposite of the meaning of the word "insurance."

That, and I still don't really understand how Wellcare makes any money on the "$0 premium" plan.

 

[sengsational]

Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

There's very little chance that buying anything other than the cheapest plan makes sense in this situation, given your Rx is on the list.

And the lists are remarkably similar between plans offered by the same company, and even between companies.

One way the cheap plans differ is how difficult they make it to get approved. They call it "utilization management", which is the bureaucracy they specifically design to make people give up and self-pay. By law, each formulary must cover a drug for every "indication" which is why the formularies are so similar. But if you used drug A and it doesn't work, the process to get drug B approved will differ between plans and companies. But you're retired...what else do you have to do but hang on the phone for hours, get disconnected, call back, document everything, write letters to your state department of insurance, etc, etc?

 

[sengsational]

still don't really understand how Wellcare makes any money on the "$0 premium" plan.

The price they charge for a lot of Rx is higher than the market(ish) value. For instance, you might pay 2x or 5x to have the drug covered under Wellcare as opposed to GoodRx or Mark Cuban or some other non-insurance option.

 

[Ian S]

The price they charge for a lot of Rx is higher than the market(ish) value. For instance, you might pay 2x or 5x to have the drug covered under Wellcare as opposed to GoodRx or Mark Cuban or some other non-insurance option.

I'll be more specific here with my own example. The three drugs I'm on are very common and treat very common conditions so there have to be many people on these drugs. Yet each one is $0 a month and has been for a couple of years now. With $0 premium for the Wellcare plan how do they and CVS make money?!

 

[Sue J]

Help me understand..I have Wellcare Value Script drug plan..It is free..I pay zero..My Dr. wants to prescribe an expensive drug for me..If I understand correctly once out of pocket expense hits $2100.00 a year the rest of the year is free for that prescription. Is that correct? Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

Just in case... check your prescription with GoodRx, RxSaver or a few others to see if they offer any coupon codes. It's surprising how much Part D plans charge when going outside of your plan can save you a lot of money.

Also check with Cost Plus Drugs. They add new drugs often and have very clear pricing.

If you don't mind sharing what the drug is and the dosage, maybe someone here already takes the same thing and knows where to find a better price.

 

[audreyh1]

That, and I still don't really understand how Wellcare makes any money on the "$0 premium" plan.

They receive Medicare funding for each enrollee.

 

[Koolau]

True. But it is pretty bad...

A couple things on the $2100 limit.

While I can see it being a "lot" for some people, for those on the Forum, it's more like an irritation for most of us.

$2100 CAN be a pittance compared to the potential drug costs for a few of us. I take two drugs whose list is close to $3K/three months. My MC supplement/Part D covers a fair amount but then OOP ends at $2100.

 

[hesperus]

Help me understand..I have Wellcare Value Script drug plan..It is free..I pay zero..My Dr. wants to prescribe an expensive drug for me..If I understand correctly once out of pocket expense hits $2100.00 a year the rest of the year is free for that prescription. Is that correct? Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

You are mostly understanding it right. Under the current Medicare Part D rules there is an annual out of pocket cap, so once your true out of pocket spending hits that limit the plan covers the rest of the year for covered drugs. The reason people still choose different plans is that the path to that cap can vary a lot. Formularies are different, some plans place drugs in lower tiers, negotiate better prices, or require smaller copays early in the year. If your medication is expensive you might hit the cap quickly, but if someone takes several mid priced drugs the structure of the plan can make a big difference before they ever reach that limit.

 

[lawman]

You are mostly understanding it right. Under the current Medicare Part D rules there is an annual out of pocket cap, so once your true out of pocket spending hits that limit the plan covers the rest of the year for covered drugs. The reason people still choose different plans is that the path to that cap can vary a lot. Formularies are different, some plans place drugs in lower tiers, negotiate better prices, or require smaller copays early in the year. If your medication is expensive you might hit the cap quickly, but if someone takes several mid priced drugs the structure of the plan can make a big difference before they ever reach that limit.

Makes sense..The drug I would be buying is around $1000.00 a month..

 

[mf15]

Tip if you use CVS and you go there with a GoodRX coupon, ask if they have a better CVS coupon,sometimes they do.
oldmike

 

[lawman]

When I go to my Medicare.com it shows my plan D ccorrectly as Wellcare Value Scripts ..However, it shows my drug cost to be over $3000.00 for the remainder of the year..If my maximum out of pocket is $2100.00 how can my remaining cost be over $3000.00?

 

[RetiredHappy]

When I go to my Medicare.com it shows my plan D ccorrectly as Wellcare Value Scripts ..However, it shows my drug cost to be over $3000.00 for the remainder of the year..If my maximum out of pocket is $2100.00 how can my remaining cost be over $3000.00?

Is it formulary with the Wellcare Value Scripts that you have?

 

[lawman]

Is it formulary with the Wellcare Value Scripts that you have?

Not sure I understand..All my drugs are listed in the formulary..One is a Tier 4 drug..

 

[Cerys]

Help me understand..I have Wellcare Value Script drug plan..It is free..I pay zero..My Dr. wants to prescribe an expensive drug for me..If I understand correctly once out of pocket expense hits $2100.00 a year the rest of the year is free for that prescription. Is that correct? Why would anyone pay for an expensive drug plan if their out of pocket expense is still going to hit $2100.00

When you apply to get a drug plan every year at open enrollment, you give your prescriptions to the system so they can find you the best drug plan.

If you lie and say zero drugs, you will still get a drug plan and you may not have to pay anything for it. But if you turn around and use it for several you take -- and enrollment allows them to go into your records -- that's fraud, they will disenroll you, so no coverage at all, which means you will have a permanent non-enrollment penalty for the rest of your life for part d.

So last year it was $2000, because I was taking two tier 3 drugs, I hit it in June. I paid $125 a month for drug coverage.

This year because one of my tier 3 drugs is generic, and totally not the one I thought it was gonna be , I am now paying twenty dollars a month , but the co-pay on my other tier three drug is six hundred dollars. On a higher paying plan that would probably be 150 bucks.

 

[lawman]

" But if you turn around and use it for several you take -- and enrollment allows them to go into your records -- that's fraud, "

Do you think I'm risking prison time?

 

[Romer]

Not sure I understand..All my drugs are listed in the formulary..One is a Tier 4 drug..

There are many options for the Part D prescription plan. Many plans have different formoularies or covered presecriptions. Some have only generic, some have only brand, some are not included in one plan and are included in others

Having just selected our plan (turning 65) we ran my wifes List of prescriptions against the multiple choices.

They were all included in the Wellcare plan at a $0 premium making the total cost $2,089

However, not all were included in the AARP Plan making the total cost for that plan $12,570

I am guessing that the AARP plan covers drugs that wellcare does not. Fortunately, for our needs, the Wellcare plan covers it

You can use this link to compare plans in your area Find a Medicare plan

you enter in all your medications and pharmacies and it will give you a report of all available plans with premiums and total cost for what is in and out of the plan. You can look at each plan to see what the cost drivers are if not included

It sounds like you already know your prescriptions are included, so you should be good if you checked that

 

[isisdave]

When I go to my Medicare.com it shows my plan D ccorrectly as Wellcare Value Scripts ..However, it shows my drug cost to be over $3000.00 for the remainder of the year..If my maximum out of pocket is $2100.00 how can my remaining cost be over $3000.00?

Isn't it drug AND PREMIUM total? I think that's the default source.