Part D Frustrations

[sengsational]

@euro, yes, good point. I got a little fast and loose, there.

 

[target2019]

The lowest cost may turn out to cost more.

 

[Out of Steam]

Because I take a specialty drug and would like to keep getting the copayment assistance I have now (if possible), I believe that I need to opt out of Medicare Part D under FEP Blue Cross Basic for 2025.

I don't have all the facts yet. I have an inquiry into Blue Cross.

 

[PointBreeze]

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).

And although it’s been mentioned in the thread already, it bears repeating as it is walloping us next year: If the drug isn’t covered by your plan, then the $2000 cap doesn’t apply. DP’s $15 glaucoma drops, , is experiencing a nationwide shortage. The replacement her doc has her taking, Simbrinza, isn’t covered by WellCare, and would cost almost $3,000. There are other plans that cover it, but the premiums are very high. So our Part D costs next year are going to be much higher than this year. A nasty surprise.

 

[Irishgirlyc58]

And although it’s been mentioned in the thread already, it bears repeating as it is walloping us next year: If the drug isn’t covered by your plan, then the $2000 cap doesn’t apply. DP’s $15 glaucoma drops, , is experiencing a nationwide shortage. The replacement her doc has her taking, Simbrinza, isn’t covered by WellCare, and would cost almost $3,000. There are other plans that cover it, but the premiums are very high. So our Part D costs next year are going to be much higher than this year. A nasty surprise.

Wouldn’t it be cheaper to pay more for a plan that covers that medication?
I’ve been running some different scenarios to determine which plan I want and it’s interesting that if you have a very expensive drug look for coverage from an enhanced alternative plan. The calculation for the $2,000 cap isn’t straightforward and ends up being less out of the consumer’s pocket.

 

[CaptTom]

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

I keep coming back to this thought, too. It seems analogous to auto insurers asking you to list all the accidents you plan on having next year, before quoting a price on their policies.

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

That's comforting. At least it narrows the risk of suddenly being prescribed an expensive, but not covered, drug.

 

[LadyIJ]

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.

You can put in all kinds of drugs in the Medicare drug app just to experiment- like I put in amoxicillin and a COVID drug that my old plan didn’t cover - under “add drugs” just to try to see worse case scenarios. Then you can take them out.

 

[LadyIJ]

Wouldn’t it be cheaper to pay more for a plan that covers that medication?
I’ve been running some different scenarios to determine which plan I want and it’s interesting that if you have a very expensive drug look for coverage from an enhanced alternative plan. The calculation for the $2,000 cap isn’t straightforward and ends up being less out of the consumer’s pocket.

I think that’s what he’s implying he’ll do, but the premiums will be much higher than WellCare ($0).

 

[Lstansbury]

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.

The greatest risk is in the part B 20 percent copay for cancer drugs. Cancer dx comes out of the blue and the drugs are insanely expensive. Make sure you have that covered in your planning.

And it's actually two prescription drugs per category, otherwise, great information on these posts.

I am a licensed agent ( not in your state), so it's not a solicitation when I say you can DM me and I can help at least give you a little insight, no obligation, no sales.

 

[audreyh1]

The greatest risk is in the part B 20 percent copay for cancer drugs. Cancer dx comes out of the blue and the drugs are insanely expensive. Make sure you have that covered in your planning.

And it's actually two prescription drugs per category, otherwise, great information on these posts.

I am a licensed agent ( not in your state), so it's not a solicitation when I say you can DM me and I can help at least give you a little insight, no obligation, no sales.

The 20% copay for Part B cancer drugs is what Medigap coverage is for.

 

[Lstansbury]

And although it’s been mentioned in the thread already, it bears repeating as it is walloping us next year: If the drug isn’t covered by your plan, then the $2000 cap doesn’t apply. DP’s $15 glaucoma drops, , is experiencing a nationwide shortage. The replacement her doc has her taking, Simbrinza, isn’t covered by WellCare, and would cost almost $3,000. There are other plans that cover it, but the premiums are very high. So our Part D costs next year are going to be much higher than this year. A nasty surprise.

I'm an agent, we refer people to maple leaf RX in Canada, Simbrinza is available there, most expensive is around $100 per month. Not great, not $3k

 

[Lstansbury]

The 20% copay for Part B cancer drugs is what Medigap coverage is foyes, assimeomg OP

The 20% copay for Part B cancer drugs is what Medigap coverage is for.

Yes, indeed! Assuming OP has a gap plan.

 

[audreyh1]

I think most here on traditional Medicare do have Medigap plans.

 

[Lstansbury]

I think most here on traditional Medicare do have Medigap plans.

So glad to hear that. Approx 70 percent of the population does not

 

[CaptTom]

I'm an agent, we refer people to maple leaf RX in Canada, Simbrinza is available there, most expensive is around $100 per month. Not great, not $3k

I looked that up. Do you mean Maple Leaf Meds or Maple Leaf Rx?

From a search: "Maple Leaf Meds is an online Canadian pharmacy, whereas Maple Leaf RX is a physical pharmacy location in the United States."

 

[Jerry1]

Because I take a specialty drug

And although it’s been mentioned in the thread already, it bears repeating as it is walloping us next year: If the drug isn’t covered by your plan, then the $2000 cap doesn’t apply.

I’m working on understanding my situation which involves a speciality drug. I’ve been told something very interesting and hope it pans out. I start Medicare on 12/1/24. I selected a Part D plan. I’m waiting on finalization of my enrollment so that I can apply for approval of the speciality drug I’m taking. I’ve been told that if the plan authorizes the drug that the process for allowing it requires that the plan essentially put that drug into a tier for that individual (me). The good news is that once it’s approved and in a tier, then the out of pocket cap applies. If this is the case, I will hit my max in the first month of the year and not have to pay anything further beyond my Part D premium. I’ll report back on my success, or lack there of.

 

[audreyh1]

So glad to hear that. Approx 70 percent of the population does not

We are a very financially aware group overall and planning for early retirement means examining a lot of future costs in detail. Many discussions on this forum about different costs during retirement.

 

[Lstansbury]

I looked that up. Do you mean Maple Leaf Meds or Maple Leaf Rx?

From a search: "Maple Leaf Meds is an online Canadian pharmacy, whereas Maple Leaf RX is a physical pharmacy location in the United States."

Not sure if my reply from mobile device made it, so I'm using web browser now. Maple Leaf Meds is the site. Thanks for the info about the Maple Leaf RX in the US.

 

[Lstansbury]

The number

We are a very financially aware group overall and planning for early retirement means examining a lot of future costs in detail. Many discussions on this forum about different costs during retirement.

I've always enjoyed and been grateful for this group's ability to dive deep into the details to protect their assets. It's been my go-to source for almost a decade. But I don't assume anything about an individual's health care insurance choices, no matter how much money they have. The number of incredibly high wealth individuals I have spoken with who have Advantage PPOs because of the $0 premiums -- well, it has been eye opening. Especially this year as people are shopping more than ever.

 

[audreyh1]

The number of incredibly high wealth individuals I have spoken with who have Advantage PPOs because of the $0 premiums -- well, it has been eye opening. Especially this year as people are shopping more than ever.

Wow!

 

[Lstansbury]

IKR?!!! A much older client UHW individual came to me this year to try to switch back to Gap plan. The client had gotten caught with some of the preauthorizations and coinsurances on a serious illness, and realized her premiums would be less than what she had paid OOP last two years. People just don't ever envision themselves getting sick. And they don't like having to deal with three or four different health plans (Part D, Part G, Dental).

As a former hospital administrator, health care contract negotiator, Medicare outreach education specialist and member of the American College of Health Care Executives? I will NEVER give up my original Medicare/medigap. Just seen too many decisions made on behalf of the dollar versus the patient. It's really tragic when it happens.

Just my POV, btw. Advantage plans are great for people who haven't had much access to insurance in the past. Especially the dental benefits. It's just so individiual.

 

[audreyh1]

We notice that those receiving retiree benefits from their former employer often have very good Medicare Advantage plans, PPOs, extensive networks. But these plans are not available to the general public.

 

[Irishgirlyc58]

I think that’s what he’s implying he’ll do, but the premiums will be much higher than WellCare ($0).

Ha! I should have realized that. I'm so used to talking with people IRL who have no idea about reviewing their part D plans every year.

 

[NatureBoy]

So glad to hear that. Approx 70 percent of the population does not

The big picture is that 70% are not going completely uncovered for the 20% of Part B expenses. It's more like ~ 10%. From the Kaiser Family Foundation:

"Nearly 90% of people in traditional Medicare had some form of additional coverage, such as Medigap (42%), employer or union-sponsored retiree health benefits (31%), or Medicaid (16%), but 11% (three million Medicare beneficiaries) had no additional coverage."

A Snapshot of Sources of Coverage Among Medicare Beneficiaries | KFF

This brief analyzes the different types of coverage that people with Medicare have and the demographic characteristics of Medicare beneficiaries with these different coverage types.

www.kff.org

 

[jebmke]

IKR?!!! A much older client UHW individual came to me this year to try to switch back to Gap plan. The client had gotten caught with some of the preauthorizations and coinsurances on a serious illness, and realized her premiums would be less than what she had paid OOP last two years. People just don't ever envision themselves getting sick. And they don't like having to deal with three or four different health plans (Part D, Part G, Dental).

I've been on Medicare for 7 years and other than Part D, I've never had to "deal with" an insurance company other than pay the premium. I don't have Dental Insurance. The times I have looked at it, the financial case wasn't there.