My three-month sprint to full Medicare coverage

[target2019]

Guys, I'm 61, so a few years away from medicare, but close enough to start paying attention. I apologize in advance if this has already been addressed elsewhere, but reading through this thread, the question of using discount apps comes to mind. We currently have private insurance, but find using an app, like goodrx, is much cheaper than using our prescription insurance. Even though the prescription payments don't go toward our deductible, we get all of our prescriptions through goodrx at a substantial savings. We currently don't have any prescriptions near the magnitude of what's been mentioned here, but was wondering if this route had been tried for these high price drugs and what the results were?

Our group insurance was always superior. Spouse worked in hospital for 35 years, and it was one of the great benefits of the job (no deductibles). I do know that places I worked through the years couldn't provide anything like what we had. Mail-order Rx was always $5 for 90 days, and that's for generics. Whenever I checked for Rx and others, it was never lower, and a bit higher. It also requires going to the pharmacy monthly (at least for us). But I know it works for many.

Here is a coupon from Rx for ShopRite.
Balversa
56 tablets 4mg
$22,935

 

[target2019]

I see the first page of GoodRx prices include one-time offers. So you have to click on each one to see what the cost will be after that.

For levothyroxine 30 tablets 50mcg it looks like something less than $10 monthly.

My Rx is in the system at Aetna now, and they shipped 90 for $5 flat fee.

CostPlusDrugs has that for $6.60 for 90 tablets. I think they charge for shipping too.

More choices than in the past.

 

[target2019]

Following up on earlier panic, I have over 9 months of Medicare (A, B, D + G) under my belt. There's extra monthly reading when various reports get sent. It's all working smoothly now, and I'm much clearer about paying deductible amounts, up to the limit. That all seems to work well as the provider, insurance and Medicare process charges.

Since J&J sent me 4 months supply at the end of 2022, I had a decent buffer to get me through a few months of 2023.

To close the knowledge gap on the projected cost, yesterday we called Aetna and Medicare, and finally sat down to understand the yearly cost.

There was an ah-hah moment as we looked through a 20-page printout from Medicare, and a 6-pager from Aetna.

The key chart lays out 4 stages of coverage.
1 - Yearly Deductible
2 - Initial Coverage
3 - Coverage Gap
4 - Catastrophic Coverage

Each Rx is assigned to a Coverage Tier. The total cost of your medications goes through a yearly process. For some reason I could not fully understand how my Tier 5 therapy would go through this process. Maybe it was the fog of treatment I am under.

It's not worth a re-hash of the specifics, but in a complete calendar year, the cost per month would be something like $3,300 (maybe $4,800), but that will average out to approximately $1,000 per month when I move out of #3 Coverage Gap ($7,000 yearly) into #4.

 

[MBSC]

The key chart lays out 4 stages of coverage.
1 - Yearly Deductible
2 - Initial Coverage
3 - Coverage Gap
4 - Catastrophic Coverage

Each Rx is assigned to a Coverage Tier. The total cost of your medications goes through a yearly process...

It's not worth a re-hash of the specifics, but in a complete calendar year, the cost per month would be something like $3,300 (maybe $4,800), but that will average out to approximately $1,000 per month when I move out of #3 Coverage Gap ($7,000 yearly) into #4.

The Part D 'catastrophic coverage' stage goes away in 2024. Plans will have a Maximum out-of-Pocket (MOOP) of $8,000. The MOOP drops to $2000 in 2025 and is updated for inflation in subsequent years.

More info on the changes: https://www.kff.org/medicare/issue-...reduction-act-and-how-enrollees-will-benefit/

In 2024, the catastrophic threshold will be set at $8,000. This amount includes what Part D enrollees spend out of pocket plus the value of the manufacturer price discount on brands in the coverage gap phase. At this amount, Part D enrollees who take only brand-name drugs in 2024 will have spent about $3,300 out of their own pockets and will then face no additional costs for their medications.

 

[zl55lz]

The Part D 'catastrophic coverage' stage goes away in 2024. Plans will have a Maximum out-of-Pocket (MOOP) of $8,000. The MOOP drops to $2000 in 2025 and is updated for inflation in subsequent years.

This is very important info, especially for those on specialty meds. The $2000 (initially) per year out of pocket max does start in 2025, and the additional good news is that apparently that yearly amount can be divided by the 12 months of the year so approximately a max of $167 per month out of pocket for Rx.

For those of you on FEHB, this limit is also important since there are FEHB Medicare Advantage plans which will apparently give this benefit too since they contain Part D for Rx.

In addition, for those on FEHB, the FEHB plans have been notified they can also offer stand alone Part D plans to go with their regular FEHB plans which could allow the excellent combo of both the regular FEHB plan and Part D.

 

[target2019]

The Part D 'catastrophic coverage' stage goes away in 2024. Plans will have a Maximum out-of-Pocket (MOOP) of $8,000. The MOOP drops to $2000 in 2025 and is updated for inflation in subsequent years.

Thanks for the link and explanation. It is greatly appreciated.

 

[target2019]

In September 2023 I needed to order my first Rx for Balversa (targeted therapy pill.) I've been doing well with the drug since mid-2021. Just adding more details here about cost of that drug.

Before spouse retired and group insurance went away, the cost was $5 per month. I can't explain that cost at all, but was greatful for it.

I transitioned to a Part D plan, SilverScript, midway through 2022. Since J&J hit me up with three additional monthly fills for $0, I was able to get through July 2023 with no cost for this Tier 5 drug.

The Rx order for September cost us $3300 (rounded down) for a month. I just reordered for October and the cost dipped below $1000. I will file for 2 more refills in 2023. At this time I expect to pay @1000 for each month. That comes from a printout earlier this year. Total cost for 2023 will be around $6300, for a partial year.

The Rx for 2024 is showing as $3300 for the entire year (Medicare site.) January is that cost, and remaining months are all -0-.

This is a positive turn in the road, for sure.

 

[target2019]

There is a level of $3300, and ii hit that in January..

Confirming that additional drug refills this year have -0- cost. Checked my credit cards to be sure.

I'm sitting in Radiology, drinking my Readi-Cat 2 drinks. CT-scan in an hour.

What could be finer?

 

[target2019]

Time to log significant changes.

13.6% increase for AARP (UHC) Medicare Supplement Plan G starts in June.

Now will be billed as two (2) automatic payments instead of one.

New Jersey, $197.35 monthly, which includes multi-insured and EFT discounts. $216.74 is the base cost.

 

[target2019]

Looking back at my Jan 2024 transactions for the Part D plan, I finally understand why I have not experienced the donut hole. At the beginning of the year this was applied to my total out-of-pocket (from other sources):

$4,673.42 (paid by Medicare Coverage Gap Discount Program)

So I only paid $3,326.58 out-of-pocket during the first 2-3 months. Thereafter all prescribed drugs were free.

Next year (2025) the out-of-pocket drops to $2,000.

 

[target2019]

A new twist for my Part D plan. SilverScript SmartSaver (PDP) which cost $12.40 per month in 2024, will rise to $47.40 per month in 2025. In 2024 the deductible was $280 (Tiers 2 - 5); in 2025 the deductible will be $590.

I believe this will play out for me as $568.80 (plan cost) + $590.00 (deductible) + $2000.00 (MOOP). With one month's Rx of the Tier 5 drug, hopefully I will meet all payment obligations in the first month.

And Aetna has a neat trick selling this, as it is not a plan change, but a combination of plans.

On January 1, 2025, SilverScript® Insurance Company (Aetna Medicare) will be combining
SilverScript SmartSaver (PDP) with one of our plans, SilverScript Choice (PDP).

I just completed my 4th year of the targeted therapy, and during that time we've moved through coverage by employer group insurance and now Part D. The monthly cost of other drugs pales in comparison to that one drug (Erdaftinib). So I ignore the other co-pays, as they are relatively small.

This post is simply another mark on my personal journey. I doubt it has any value to others with much different circumstances. But who know?

 

[RetMD21]

Drug coverage (or noncoverage) is not just unfortunate, but also mysterious. I don't think most of us fully understand it.

....

It takes Medicare longer than you would think to add new drugs to the approved list. Although you can't get the manufacturer "discount program" for drugs covered by Medicare I think you can before the coverage starts. The whole thing is a confusing mess.

I am glad that things worked out for OP.

 

[target2019]

This is how catastrophic coverage played out with the soon-to-be-defunct AARP SilverScript plan of 2024.

It's been more than 2-1/2 years since I started this thread. The number of mailings, EOBs, and messages through the medical portals keeps me busy.

 

[target2019]

Dexcom G7 Continuous Glucose Monitor (CGM)

Just had an expected call-back from a medical device supplier. Due to recent events (left kidney removed) causing already high blood glucose to go extreme while in the hospital, I added an Endicronoligist, and saw him on Monday. We discussed my full-blown diabetes (came home with 10 unit long-lasting pens), and talked about Ozempic. I also got tagged with a CGM (Dexcom G7) so we could learn more about the 24-hour goings on. Yes, I'm real technical about this.

The device itself is pretty amazing. I'm learning in almost-real-time what certain foods do to your blood glucose levels. The data goes to the provider too, as well as friends and family I signed up.

The prescription went to a supplier, and they notified me on Saturday that the Rx was going through Medicare and Supplement review. Today, Monday, and another very nice rep told me that the sensor is covered. So a 90-day supply is coming to me through UPS in 2 days.

 

[plsprius]

Dental and vision coverage are not part of Part B or a supplement Part G. Only Medicare Advantage plans include dental and vision.

If you haven't gotten the Shingrix vaccinations yet, get that done before Medicare. Many pre medicare plans cover those at 100% where medicare covers that in Part B after the deductible is met.

Just a reminder for all. Since 2023, Shingrix for shingles is now covered under Medicare Part D at no cost, so the Part B deductible doesn't apply. This is now true for the vaccines that are not covered on Part B.

Take home message--your common vaccines on Medicare should be covered at no cost.