Part D TrOOP for drug not on formulary (but exception granted)

Pluperfect

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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).
 
GoodRx shows that drug as you described for between $500-$750 in my area. Single Care has similar pricing.
 
Interesting quandary. Maybe those that know more about how pricing law works on Part D could verify this idea, but could you find a drug that IS covered under Tier 5 that has a similar price, and let the calculator on Medicare work it's magic?

To be clear, this other drug is not a medical replacement for the eye drops; the only similarity would be the tier and price.
 
It looks like you can get it for $89 per month, so $1,068 per year, without any dose splitting.
If you go to the PhilRx site that's linked in what you quoted, you'll find that people on Medicare can get it for $89/month only if their prescription drug plan refuses to grant an exception, and you have to provide proof of the denial.
Medicare patients may be eligible for manufacturer cash discount pricing in case their plan does not cover CEQUA as a benefit and there is a confirmed PA denial.
As I noted, Wellcare granted the exception.
 
...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 [$137.50] ($550 x 25% coinsurance).

The grand total is $2,092.50, which is just over the $2,000 MOOP.... 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?
You are correct. In this case, the TrOOP and MOOP will be $590 then 25% of the actual price with a $2000 cap.
 
You are correct. In this case, the TrOOP and MOOP will be $590 then 25% of the actual price with a $2000 cap.
So when it's not on the formulary, not in the Medicare calculator, who is setting the "actual price?" and where does one find these "actual prices" if you haven't gone through the exception process yet? Not picking on you MBSC, thanks for your observation, but I'm frustrated with what I perceive as a morass in the case of the OP's dilemma.
... you'll find that people on Medicare can get it for $89/month only if their prescription drug plan refuses to grant an exception...
Those dang pharma companies and their slight of hand :mad:
 
I take Restasis a similar eye drop that comes in vials that is also expensive (but they have just come out with a Restasis generic that is a little cheaper). I have talked to my doctor and researched how to stretch out the vial. The instructions say one drop per eye twice a day. My doctor says I can us the vial multiple times if I keep in clean once opened. I put it in a baggie after opened. The internet says to refrigerate also. I am able to get 2-3 days of use per vial. I am been doing this for several months with no problem.
 
could you find a drug that IS covered under Tier 5 that has a similar price, and let the calculator on Medicare work it's magic?
I had thought of the same thing but didn't know where to start. But after you came up with the same idea, I did some poking around and it's just impossible. I did find Wellcare's formulary and found some Tier 5 drugs and tested about five of them (it's a laborious process) but most (all?) were $2,000/month, so finding a ~$500 one will be sheer luck, and I'm generally not a lucky person. So I've given up on that.

So when it's not on the formulary, not in the Medicare calculator, who is setting the "actual price?" and where does one find these "actual prices" if you haven't gone through the exception process yet?
About that "actual price"...my friend talked to a Wellcare representative for about an hour, and got pricing at a few pharmacies. She told him Walgreens is $551.53. (CVS was $549.53 and HEB was $536.63, so at least there's some consistency that gives me comfort.)

But I just went to the Wellcare website and used their plan finder and entered Cequa as the only drug, and on all three Wellcare plans it was listed as "not covered" and "you pay $675.56."

On the Medicare.gov plan finder, it says the retail price at Walgreens (and 4 other pharmacies) is $704.49. So I figured the $551.53 price he was told was Wellcare's negotiated price, but then what is the $675.56 that's on Wellcare's own website, and is neither the "retail price" listed on the Medicare site nor the price the representative told him it would be?

He's going to get the prescription filled at Walgreens. (He needs this first box whether he doubles up or not.) I did a write-up of the calculations for applying the deductible, and it's based on the $551.53 price he was told. He's going to take that with him when he picks up the prescription and compare it to what he's being charged and report back.

I kind of don't want to know.

ETA: I was looking over my notes and was reminded that on Cequa's own website, it says "While the list price of CEQUA is $527.28..."
cequa.com/cost

So we have Cequa saying it's $527.28, Medicare saying it's $704.49, Wellcare's website saying it's $675.56, and Wellcare's representative saying it's $551.53.

This is why when people chant "Medicare for all!" I want to throw up. At least we'd be inflicting this **** on non-elderly people for a change.
 
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You are correct. In this case, the TrOOP and MOOP will be $590 then 25% of the actual price with a $2000 cap.
Thank you for the confirmation. That's what it was looking like, and it would be just my luck to have the two numbers be the same when I'm trying to figure out how the gap discount works.

In remaining months, he pays $167.50 [$137.50] ($550 x 25% coinsurance).
And thank you for that correction. I have no excuse for a typo when doing arithmetic, but you should see the pile of papers I have where I was calculating all this for different scenarios (different pharmacies/prices, whether using a box once a month or once every two months).

But mainly, it means you carefully read my post. I feel like I've won the internet today. And here I just said I wasn't lucky.
 
Somehow it's not surprising to me that it costs you more if insurance makes an exception and approves the drug
 
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