Part D Frustrations

[DaveLeeNC]

For 2025 I probably need to change my Part D provider (currently the AARP/UHC Rx Saver Plan) which used to be pretty nominal on a monthly basis but has been going up annually and is heading even further north next year. At this point in my life I am only taking a Statin, (generic) Zetia, Meloxicam, and Clopidogrel (through mid March 2025). All of these are available pretty cheap without Part D. But I need protection if/when my Rx needs become more complicated.

The new $2K OOP limit is nice but it only applies to drugs covered by your plan (which leaves a pretty big hole in your risk management strategy). I have no idea what risk I am taking if I go with the Wellcare $0 premium plan vs. another higher end (costing probably over $100/month) plan that (I assume) has a more extensive fomulary. And I don't know how to figure that out.

Comments or thoughts on this - thanks. Going through and comparing two formularies just doesn't seem doable to me.

dave

 

[VanWinkle]

Enter your prescriptions in your Medicare.gov account and it will allow you to compare costs on any D plan based on premium and prescription costs. It will also show if any of your scripts are not covered in the formulary. The Wellcare would allow you to keep D coverage at no premium expense.

 

[REWahoo]

Enter your prescriptions in your Medicare.gov account and it will allow you to compare costs on any D plan based on premium and prescription costs. It will also show if any of your scripts are not covered in the formulary. The Wellcare would allow you to keep D coverage at no premium expense.

^ This.

The new $2K OOP limit is nice but it only applies to drugs covered by your plan (which leaves a pretty big hole in your risk management strategy). I have no idea what risk I am taking if I go with the Wellcare $0 premium plan vs. another higher end (costing probably over $100/month) plan that (I assume) has a more extensive fomulary. And I don't know how to figure that out.

Realize whatever risk you are taking will only be until January of 2026. If you end up in 2025 needing a drug not covered by the Wellcare plan you can switch to a plan that does cover the drug at year end.

 

[youbet]

The new $2K OOP limit is nice but it only applies to drugs covered by your plan (which leaves a pretty big hole in your risk management strategy).

I agree. I haven't seen any tool or publication which compares/evaluates formularies and I really wish there was one. The Medicare.gov tool only checks for coverage of drugs you're currently taking. There is no evaluation of the overall strength of the formulary.

Of course, I'm not even sure there are significant differences from one formulary to another.

 

[Irishgirlyc58]

MBSC posted this in another thread about part D plans:

Q1Medicare.com Your Source for Medicare Part D Plan Information

Q1Medicare.com Your Source for Medicare Part D Plan Information

q1medicare.com

You can look up how many drugs are in the plans available in your area-

 

[Sunset]

MBSC posted this in another thread about part D plans:

Q1Medicare.com Your Source for Medicare Part D Plan Information

Q1Medicare.com Your Source for Medicare Part D Plan Information

q1medicare.com

You can look up how many drugs are in the plans available in your area-

Thanks...

Exactly what I wished for:
"However, I do wish we could see the formulary's and know the total number of drugs covered in each tier plus compared to the actual total number of all drugs available. Just so I know the odds I'm buying."

 

[Irishgirlyc58]

Thanks...

Exactly what I wished for:
"However, I do wish we could see the formulary's and know the total number of drugs covered in each tier plus compared to the actual total number of all drugs available. Just so I know the odds I'm buying."

Agreed! You would think that it wouldn’t be that difficult to provide with all the automation abilities these days.
I wonder if AI could do that?

 

[Koolau]

I'm guessing most of the plans will cover at least one of the drugs in the class. So, for instance, my plan dropped Jardiance but added Farxiga. They're essentially equivalent in profile. YMMV

 

[target2019]

For 2025 I probably need to change my Part D provider (currently the AARP/UHC Rx Saver Plan) which used to be pretty nominal on a monthly basis but has been going up annually and is heading even further north next year. At this point in my life I am only taking a Statin, (generic) Zetia, Meloxicam, and Clopidogrel (through mid March 2025). All of these are available pretty cheap without Part D. But I need protection if/when my Rx needs become more complicated.

The new $2K OOP limit is nice but it only applies to drugs covered by your plan (which leaves a pretty big hole in your risk management strategy). I have no idea what risk I am taking if I go with the Wellcare $0 premium plan vs. another higher end (costing probably over $100/month) plan that (I assume) has a more extensive fomulary. And I don't know how to figure that out.

Comments or thoughts on this - thanks. Going through and comparing two formularies just doesn't seem doable to me.

dave

I think you may already have the answer to your risk question for the next, un-named drug you will take. You might ask the doctor who is prescribing your un-covered drugs now. "What is the next line of treatment?"

When I asked that question, I was told the next drug would be infused in the clinic, so that falls under Part B, not Plan D.

So, more reading and listening about treatment will indicate what Rx's might be in your future.

If you're talking about totally unknown risk of drug treatment for a new disease, that is the crap-shoot of our system.

 

[DaveLeeNC]

Enter your prescriptions in your Medicare.gov account and it will allow you to compare costs on any D plan based on premium and prescription costs. It will also show if any of your scripts are not covered in the formulary. The Wellcare would allow you to keep D coverage at no premium expense.

The tool is useful, but as I stated it doesn't address the question. There really isn't much difference WRT the cost of the drugs that I am now taking. It is the risk of what I might be taking in the future that is harder to assess.

dave

 

[DaveLeeNC]

So, more reading and listening about treatment will indicate what Rx's might be in your future.

If you're talking about totally unknown risk of drug treatment for a new disease, that is the crap-shoot of our system.

That approach was most interesting. My only drug treatable condition (that I am aware of) is cardiovascular disease where I have one stent and a couple of known (and untreated) smaller blockages. I am now on a statin and (generic) zetia plus generic Plavix. So I just added a high cost blood thinner in place of Plavix (Brilinta) and the next step in cholesterol control which is the very expensive part D drugs Repatha or Praluent. Pretty much all the plans ended up at the same year end total cost but with one interesting difference. All the plans that I tried except the Wellcare zero premium plan covered Repatha but not Praluent. Wellcare covered Praluent but not Repatha. I don't know what to think about that.

dave

 

[MBSC]

I do wish we could see the formulary's and know the total number of drugs covered in each tier plus compared to the actual total number of all drugs available. Just so I know the odds I'm buying.

Browse 2025 Part D plans: Browse Any 2025 Medicare Part D or Medicare Advantage Plan Formulary

Wellcare Value Script (3272 covered drugs):
Tier 1: 353 drugs
Tier 2: 636
Tier 3: 335
Tier 4: 1282
Tier 5: 666

AARP Preferred PDP (3611 covered drugs):
This is the largest formulary among the national stand-alone PDPs. For comparison, some 2024 MAPD plans had 4371.

Tier 1: 267
Tier 2: 649
Tier 3: 971
Tier 4: 1071
Tier 5: 653

There is an option to hide tiers. If you hide tiers 1,2,4,5 it displays the drugs in tier 3 for the PDP you selected.

 

[mf15]

On the top left of the page you can brows any plan formulary. Here is wellcare zero cost plan. Great site.

Browse the 2025 PA Plan Formulary (Drug List)

Browse the 2025 PA Plan Formulary (Drug List)

q1medicare.com

 

[DaveLeeNC]

Browse 2025 Part D plans: Browse Any 2025 Medicare Part D or Medicare Advantage Plan Formulary

Wellcare Value Script (3272 covered drugs):
Tier 1: 353 drugs
Tier 2: 636
Tier 3: 335
Tier 4: 1282
Tier 5: 666

AARP Preferred PDP (3611 covered drugs):
This is the largest formulary among the national stand-alone PDPs. For comparison, some 2024 MAPD plans had 4371.

Tier 1: 267
Tier 2: 649
Tier 3: 971
Tier 4: 1071
Tier 5: 653

There is an option to hide tiers. If you hide tiers 1,2,4,5 it displays the drugs in tier 3 for the PDP you selected.

That is useful. But it is a little hard to make a judgment as the Tier assignments vary by insurer. Regardless it is a useful (in general terms) way to dissect the formularies.

dave

 

[Sunset]

The answer is having your doctor tell you what year will require what new drug, then match that to the plans.

Personally, I can't predict the future, and based on my health can't even fathom future drugs as there are often options within treatments for a condition.

So, I took WellCare, knowing it's worked well for me so far at $0 cost, and in the future, I may have to pay a lot until I can switch to a new plan for a new drug.

I did help a 90+ yr old relative pick a new plan D, it was WellCare, and he will save over $1,000 this year from that choice.

 

[audreyh1]

I don't see how you could select a provider for 2025 by guessing which new drugs you might possibly need before 2026. Other than a conversation with your doctor perhaps. And formularies change over time too. No guarantees about the following year.

(Co-posted with Sunset)

 

[sengsational]

Dave, You might get some mileage out of this recent thread on the same topic: Shopping Medicare Part-D with the GoodRx Wild-Card

I have no idea what risk I am taking if I go with the Wellcare $0 premium plan vs. another higher end (costing probably over $100/month) plan that (I assume) has a more extensive fomulary. And I don't know how to figure that out.

You would almost certainly be assuming incorrectly. The idea that a plan would be better for you because it costs more isn't justified.

All the plans that I tried except the Wellcare zero premium plan covered Repatha but not Praluent. Wellcare covered Praluent but not Repatha. I don't know what to think about that.

Providers submit formularies for approval. If there is more than one drug choice for an approved treatment, they can include one or more of the options. The plan would be rejected if it contains zero options.

Besides having a do-over option every year, you also can appeal and have a non-formulary drug covered if you and your doctor agree that the drug is your best option, and it's an approved treatment. There maybe other drugs you need to try first, but even non-formulary drugs are not completely off the table. Not necessarily quick and easy, but possible.

 

[sengsational]

I don't see how you could select a provider for 2025 by guessing which new drugs you might possibly need before 2026.

There might be a scenario where one would price-out a drug you currently don't take. What if you have a condition that's mild, but has a measurable risk of getting bad. Under the mild condition, the drug isn't justified, but if the condition gets bad, then the doctor would put you on it. The standard shopping method on Medicare.gov might lead you to one plan over the other. Or if the drug was an expensive one, then it would come down to the premium cost and being on the formulary.

 

[audreyh1]

There might be a scenario where one would price-out a drug you currently don't take. What if you have a condition that's mild, but has a measurable risk of getting bad. Under the mild condition, the drug isn't justified, but if the condition gets bad, then the doctor would put you on it. The standard shopping method on Medicare.gov might lead you to one plan over the other. Or if the drug was an expensive one, then it would come down to the premium cost and being on the formulary.

Right, talking to your doctor can help identify a possibility or two.

 

[DaveLeeNC]

@sengsational thanks for the input. I assume that to summarize what you are saying ... "the risk of encountering significant expense in a given year because your required drug (or accepted equivalent) is not in the forumulary of your Part D insurer (regardless of which plan you pick) is minimal".

Does that pretty much catch your perpsective here? I would like to believe that is true. I just don't know how to know.

dave

 

[ShokWaveRider]

I looked up some of the expensive drugs like Eliquis and they are covered by our $0 WellCare plan. They are not cheap but at least in 2025 they will be cheaper. There is a Max OOP of $2,000 so regardless of the price, one's costs are capped. Having heart issues, Eliquis is most likely the one I would need, hopefully not but one never knows. It is a lot cheaper in Canada and I would probably use an On-Line Canadian Pharmacy if I ever needed any of them.

 

[MichaelB]

The way I understand it, CMS defines a series of health categories or conditions and requires insurers to include in the formulary at least one prescription drug for each category. My experience with physicians is they work with patients to find treatment options that are covered by insurance. So, it’s unlikely I will need a drug that isn't on a formulary and also doesn’t have an equivalent drug on the formulary.

And, as REWahoo pointed out earlier, even if my physician prefers another drug, the Plan D policy can be changed at year end.

I think it’s not likely to find an expensive drug covered by insurance with a low premium. If an expensive drug is included in the Plan D policy the premium will be high.

Unless one has a good idea of what medical condition one will have and which new prescription drugs one will need next year, the best Plan D option is the one that has the lowest total cost (premiums + out of pocket) based on current prescription drug use. The Medicare Plan D finder does a good job helping find that.

 

[euro]

I don't think, generally, the risk posed by the possibility that you may need a drug that isn't in a particular formulary is all that high. As has been pointed out, you are really "only" locked into your plan for 12 months, so, unless you are talking a million dollar gene therapy drug, you may be able to self-cover in a pinch. Moreover, my understanding is that for such special situations, you can file for a one-time "formulary exemption" and those will be granted in many (if not most) cases. Thus, further reducing the risk.

 

[sengsational]

@sengsational thanks for the input. I assume that to summarize what you are saying ... "the risk of encountering significant expense in a given year because your required drug (or accepted equivalent) is not in the forumulary of your Part D insurer (regardless of which plan you pick) is minimal".

Does that pretty much catch your perpsective here? I would like to believe that is true. I just don't know how to know.

You do what everyone is saying: type your current Rx into the part-D pricing tool and pick the lowest total cost. The most that can cost is $2,000. Now, if you get surprised by needing another Rx during the year, that's a risk. But what are the chances of getting that news? What are the chances the drug will be an expensive one? And not be on the formulary and all the alternatives are not appropriate for you? Maybe you'd have the new drug prescribed one year from now and only need to figure out how to manage one month. Or you could get unlucky and learn in January that you need another drug, it's a tier 5 (expensive) drug, it's not on the formulary, no alternatives exist, and the part D provider won't let you appeal. I think the chances of that are not zero, but very low.

 

[euro]

You do what everyone is saying: type your current Rx into the part-D pricing tool and pick the lowest total cost. The most that can cost is $2,000.

Just a point of clarification: The $2000 cap is for drug cost plus deductibles. It doesn't include the premium, so you could see plans that say they cover all the listed drugs, but the "total annual estimated cost" could still somewhat exceed $2000 (unless it happens to be a zero premium plan).