Pluperfect
Recycles dryer sheets
- Joined
- Dec 12, 2018
- Messages
- 210
A friend has been prescribed Cequa, which are expensive eye drops in one-use vials--once they're opened, you can't close them. Cequa comes in a box of 60 and people use two vials per day, so 60 vials is a 30-day supply. However, it's possible to "double up" by using one vial per day, but you have to do something with the opened vial that will keep it from becoming contaminated, and my friend is open to the idea but generally averse because he's very scared of getting an eye infection from a contaminated vial.
I'm trying to figure out how much this drug will cost him, to see if it's worth it to try to use only one vial per day instead of two. The problem is that Cequa is not on any Part D plan's formulary in his area, but he got an exception from Wellcare so it will be covered as a Tier 5 drug, with 25% coinsurance. His Wellcare plan has a $590 deductible and a $0 premium.
The problem I'm having is that since Cequa is not on Wellcare's formulary, the Part D calculators at Medicare.gov and other places say "not covered" and simply list the retail price ($705) as what he'll pay, and of course it says he won't satisfy his $590 deductible. I can't figure out how to force it to do calculations as if the drug is covered, and I'm particularly interested in getting the TrOOP calculated.
My friend called Wellcare and the rep said the prescription is about $550 at places like Walgreens, so I did my own calculations based on that. (And I have no idea why Medicare.gov gives a different price.)
In the first month, he pays $550, leaving $40 of the $590 deductible remaining.
In the second month, he pays the $40 remaining of his deductible, and then 25% coinsurance on the remaining cost of the Cequa ($550 minus $40 = $510), which is $127.50.
In remaining months, he pays $167.50 ($550 x 25% coinsurance).
The grand total is $2,092.50, which is just over the $2,000 MOOP. But I don't know if this is the same as TrOOP because it doesn't take into account any manufacturer gap discount, but I can't figure out what the manufacturer gap discount is.
I found a previous post by @MBSC showing a TrOOP calculation, but it was for a drug with a $47 copay and it was using that number along with 25% of the drug's cost and taking the larger of the two to accumulate toward TrOOP. I can do those calculations rotely, without understanding how this fits in with a manufacturer gap discount, but in my case the coinsurance is the same as the 25% @MBSC used, so will there be no difference between MOOP and TrOOP? There's a difference between MOOP and TrOOP only if the enrollee's responsibility is either coinsurance that is something other than 25% or a copay?
If that's the case, then using the Cequa as directed (two vials per day) will cost him $2,000, and using one vial per day will cost him $1,267.50, which is a pretty significant difference. I want to be sure I'm working with the right numbers (like if the TrOOP is more like $1,500, it would be much easier to swallow paying about $200/year to not have any risk of infection from using already opened vials).
I'm trying to figure out how much this drug will cost him, to see if it's worth it to try to use only one vial per day instead of two. The problem is that Cequa is not on any Part D plan's formulary in his area, but he got an exception from Wellcare so it will be covered as a Tier 5 drug, with 25% coinsurance. His Wellcare plan has a $590 deductible and a $0 premium.
The problem I'm having is that since Cequa is not on Wellcare's formulary, the Part D calculators at Medicare.gov and other places say "not covered" and simply list the retail price ($705) as what he'll pay, and of course it says he won't satisfy his $590 deductible. I can't figure out how to force it to do calculations as if the drug is covered, and I'm particularly interested in getting the TrOOP calculated.
My friend called Wellcare and the rep said the prescription is about $550 at places like Walgreens, so I did my own calculations based on that. (And I have no idea why Medicare.gov gives a different price.)
In the first month, he pays $550, leaving $40 of the $590 deductible remaining.
In the second month, he pays the $40 remaining of his deductible, and then 25% coinsurance on the remaining cost of the Cequa ($550 minus $40 = $510), which is $127.50.
In remaining months, he pays $167.50 ($550 x 25% coinsurance).
The grand total is $2,092.50, which is just over the $2,000 MOOP. But I don't know if this is the same as TrOOP because it doesn't take into account any manufacturer gap discount, but I can't figure out what the manufacturer gap discount is.
I found a previous post by @MBSC showing a TrOOP calculation, but it was for a drug with a $47 copay and it was using that number along with 25% of the drug's cost and taking the larger of the two to accumulate toward TrOOP. I can do those calculations rotely, without understanding how this fits in with a manufacturer gap discount, but in my case the coinsurance is the same as the 25% @MBSC used, so will there be no difference between MOOP and TrOOP? There's a difference between MOOP and TrOOP only if the enrollee's responsibility is either coinsurance that is something other than 25% or a copay?
If that's the case, then using the Cequa as directed (two vials per day) will cost him $2,000, and using one vial per day will cost him $1,267.50, which is a pretty significant difference. I want to be sure I'm working with the right numbers (like if the TrOOP is more like $1,500, it would be much easier to swallow paying about $200/year to not have any risk of infection from using already opened vials).
