Part D Plan and Seemingly Incorrect Drug Price

[Donno]

While perusing the Medicare web site today, looking at the drug plans for next year, I came across a very interesting drug price. I take a Biologic drug every 4 weeks and it costs a little over $6k a dose. Every drug plan had it priced at $6k except for Mutual of Omaha's drug plan mail order service which had it priced at $70. Their retail price was $6k+ but I was astonished to see the mail order price so low. I went to their website and it was the same.
So let's say this is a mistake and they don't catch it, do I get it for that price? What if they catch it after the plan year starts? This could potentially save me thousands of $$$ next year. If they did screw up, I suppose that they would just deny coverage for this drug to everyone. The drug name is Taltz.

 

[aja8888]

Could it be a generic version? (I don't know anything about the drug)

 

[Donno]

Could it be a generic version? (I don't know anything about the drug)

Nope, the drug has only been on the market for about 5 years and there is no generic. I suppose I'll wait a couple of months and see if the price changes, if it doesn't, I'm signing up and saving big bucks.

 

[Car-Guy]

Some of these crazy high price drugs are covered by various "charitable foundations" that will effectively pay for them. (All or part) "Maybe" MoO is quoting your cost after recognizing that one of these "foundations" will pay up for that particular drug?

 

[single2019]

Some of these crazy high price drugs are covered by various "charitable foundations" that will effectively pay for them. (All or part) "Maybe" MoO is quoting your cost after recognizing that one of these "foundations" will pay up for that particular drug?

That’s quite possible. This drug (Taltz) is available for $25/dose from the manufacture (for up to 3 years). Unfortunately the manufacturer subsidy is not available to patients on Medicare

 

[frank]

I think medicare.gov has a few bugs in it yet to be worked out. mine showed that all my pharmacies were out of network and prices were full prices for everything I use. I was hoping to see shingrix was now covered under part d with no copay, but am not seeing any discounts at all for any drugs, so we will have to wait to see if they straighten it out.

 

[Bamaman]

I've yet to figure out what's going on with Plan D. I'm thankful to have just 4 prescription meds.

My $2500 per quarter 8 insulin vials dropped down to $35 a month on Plan B because I was on an insulin pump. Now, they're going on Plan D for $35 a month due to politicians squeezing the arms of Big Pharma. Walmart sells insulin vials for $25 (instead of $315) without any prescription for the poor.

Many of us this time of the year are now in the Donut Hole, and paying more for some expensive meds. My wife and I both have $550 medicines we're paying more like $150 for. Thankfully it's not so long until year end.

 

[aja8888]

I'm lucky to be healthy at 79 years old. Only one drug (Flowmax) at $12 a year for the med and $22/month for the Part D plan. DW now, she's in the donut hole since August.

 

[harllee]

I would not trust anything on Medicare.gov at this point--it will not be ready to use until October 15. Personally I would also not trust anything about Mutual of Omaha, have had bad experiences with that company.

 

[frank]

anyone see anything about the shingles and other vaccinations being covered under medicare part d with no copay or cost to the recipient? I have been hearing this but it has not been widely advertised and when I pull up medicare.gov and do the 2023 plan it shows it at the same price as 2022.

 

[Sue J]

Check the Mutual of Omaha plan's drug formulary for that Part D drug plan for 2023. It should show you what tier that particular drug is in and how is covered. Formularies can change every year and every insurance company has their own.

 

[MissMolly]

anyone see anything about the shingles and other vaccinations being covered under medicare part d with no copay or cost to the recipient? I have been hearing this but it has not been widely advertised and when I pull up medicare.gov and do the 2023 plan it shows it at the same price as 2022.

Yes, all vaccines will be covered with no copay in 2023 including Shingles vaccine

https://www.valuepenguin.com/does-medicare-cover-shingles-vaccine#:~:text=Beginning%20Jan.,costs%20for%20a%20shingles%20vaccine.

 

[Donno]

Check the Mutual of Omaha plan's drug formulary for that Part D drug plan for 2023. It should show you what tier that particular drug is in and how is covered. Formularies can change every year and every insurance company has their own.

MoO's website lists Taltz as a specialty tier 5 drug. The only difference is that the retail pharmacies show a list price of around $7,000+/- depending on the pharmacy, and the mail order pharmacy shows the list price of around $70. I'm sure it's a mistake that they'll fix at some point, but right now the price is off by a factor of 100.

 

[aja8888]

This is from the Lilly website:

For most patients with Medicare Part D coverage, out-of-pocket costs can vary throughout the year depending on which phase of the Part D benefit you are currently in. Overall, about 56% of Taltz prescriptions cost between $0 and $50 per month, and the remaining prescriptions cost an average of $651 per month.

We had this same cost issue with a breathing drug my wife needs and one year it repriced it at some ungodly amount (like $3,000/month). We were able to switch her Part D plan to one where that drug is around $600/month.

This stuff is nuts and these drug plans can change the costs of drugs anytime and at will.

Every year we go through this for her dozen or so drugs and I generally wait until early December to finalize the choice of Plan.

 

[Pluperfect]

Yes, all vaccines will be covered with no copay in 2023 including Shingles vaccine

https://www.valuepenguin.com/does-medicare-cover-shingles-vaccine#:~:text=Beginning%20Jan.,costs%20for%20a%20shingles%20vaccine.

With all due respect, that's not a great source. It's an article about how much Shingrix costs in 2022 with a yellow box near the top about how it will be free starting in 2023, but no indication of the source of that information, and no other mention of it. I read the whole thing before realizing it wasn't going to talk about 2023.

But further sleuthing reveals that it's the Inflation Reduction Act that is responsible for this change, and it applies to adult vaccines recommended by the Advisory Committee on Immunization practices (ACIP), which includes the shingles vaccine. They are included with prescription drug coverage, with no copay and no deductible.

See questions 2 and 7 here:
https://www.cms.gov/files/document/10522-external-faqs-about-inflation-reduction-act.pdf

 

[Donno]

This is from the Lilly website:



We had this same cost issue with a breathing drug my wife needs and one year it repriced it at some ungodly amount (like $3,000/month). We were able to switch her Part D plan to one where that drug is around $600/month.

This stuff is nuts and these drug plans can change the costs of drugs anytime and at will.

Every year we go through this for her dozen or so drugs and I generally wait until early December to finalize the choice of Plan.

According to Medicare.gov, my first month of Taltz will be a little over $2000, the second month about $1000 and the remaining months about $330. I roll through the coverage phases in 2 months, so I get to catastrophic coverage in February. Under my ACA plan I was covered by their $5/mo copay card which was nice.
After this coming year the catastrophic co-pay gets eliminated which will lower my annual costs by about $3300 and the following year I will fall under the $2000 out of pocket max. I can deal with 2024 and 2025 and beyond costs, but this next year is going to be a tough pill to swallow as I'm looking at about a $7000 out of pocket cost for medications.

 

[MBSC]

anyone see anything about the shingles and other vaccinations being covered under medicare part d with no copay or cost to the recipient? I have been hearing this but it has not been widely advertised and when I pull up medicare.gov and do the 2023 plan it shows it at the same price as 2022.

Click on the red "Alert - Inflation Reduction Act" at the top of the Medicare.gov homepage and scroll down past insulin to vaccines.

2023 Part D plans were submitted prior to the insulin/vaccine changes included in the Inflation Reduction Act so the Plan Finder contains outdated cost sharing. The correct copay will be applied at the point of purchase. Since the Shingrix copay is $0, do not include it in your list of drugs to find the lowest cost plan when Open Enrollment starts 10/15.

CMS created the PDF attached at the bottom for those who help Part D insulin users choose plans.

CMS Memo:

SUBJECT: Contract Year 2023 Program Guidance Related to Inflation Reduction Act Changes to Part D Coverage of Vaccines and Insulin

Medicare Plan Finder
The CY 2023 Medicare Plan Finder (MPF) will reflect Part D sponsors’ insulin and vaccine benefits and cost sharing as they were submitted in their 2023 bid and formulary submissions. For October 1, 2022, CMS is updating MPF to include new insulin and vaccine drug footnotes and other help features to explain the benefit changes resulting from the IRA.

Special Enrollment Period
Since MPF will reflect Part D sponsors’ insulin benefits and cost sharing as they were submitted in their CY 2023 bids, CMS is granting a Special Enrollment Period (SEP) for Exceptional Circumstances to allow beneficiaries to add, drop, or change their Part D coverage if they find a better option after the 2022 Annual Enrollment Period (AEP) and through the end of 2023.

This SEP will be available for all beneficiaries who use a covered insulin product and begins on December 8th, 2022 and ends on December 31, 2023. Beneficiaries may use this SEP one time during this period. To utilize this SEP, beneficiaries must call 1-800-MEDICARE so a customer service representative can process the enrollment change. Consistent with current policy, when Part D enrollees change plans mid-year, their True Out-of-Pocket (TrOOP) costs carry over from one plan to the next.

Source (9/26/22 memo): https://www.cms.gov/httpseditcmsgov...memos-archive/hpms-memos-wk-5-september-26-30