I guess we will all learn more about the $2000 part D Medicare cap and it’s fine print over time. I’m starting a new med later this month. Retail price is $3500 or so/month but fortunately it’s on the formulary and my copay is supposed to be <$1000/month but with the drug card from the pharmaceutical company (not asset nor income based but only available to folks meeting criteria), no copay!
We don’t have a part D because we use the drug plan that’s with H’s group plan that he had when we retired and we can keep as long as either of us is alive. The plan has been pretty good and I just checked and found my copay for my over 9 drugs over past 12 months was <$1000.
Our broker tells us that unless you know the name of the drug you maybe-might be prescribed, there is no way to know what might be best. From the government Medicare site: The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer. If a particular drug isn’t listed, your doctor can request an exception in order to get them to cover that drug (I’ve seen reports of that working and not working, so YMMV). The discount programs like GoodRx and SingleCare might have good prices. There may be programs your doctor knows about, as well. You can change your plan for the following year - at least they gave us that possibility.
I tried plugging in some drugs to various plans to see if they’d be covered. The $0 Wellcare plan didn’t seem any worse than some higher price plans. If you already are taking high priced drugs, you may actually find that a higher price plan costs you less than the $2,000 cap due to the very convoluted way the cap is calculated.
In other words, it’s pretty much a shot in the dark unless you already know what drugs you might be prescribed in the coming year.
Moreover, you need to know the timing of when it will be prescribed. Getting an expensive script in February is much different on your pocket book than say, next December. And finally, formularies change frequently.
And since these are known unknowns, you go with the best information available. And review Part D plans during open enrollment every year.
We’ve had Wellcare past couple of years and it’s been fine. But due to the new regs, Wellcare’s pricing has skyrocketed in my zip code, so we’re changing (to Cigna).
Broker’s are fine, but have you run the numbers yourself?
Yea,my husband ran the numbers for his current meds (generics) - WellCare wins. We do worry about switchover logistics and dealing with a new system since Humana setup is working well. The hard thing to model is risk on tbd future pricey med.
But logistics are simple. It took me <2 minutes to complete the app on the Medicare website – or your broker can do it – and then when you get your new card, just present it to your local pharmacy on the first visit after Jan 1. Pharmacies know the drill, so it just takes them a few minutes to update their system.
H did have an issue with his switch last year, but I suspect it was because he was still in the 3-month window during which switching of plans can happen when you first enroll in Medicare. We probably didn’t need to straighten it out, but he had an expensive vaccine (free with Medicare, but $750 without insurance) that I didn’t want to somehow get a bill for if one of the companies decided to come after us for payment. It took me awhile to get everything fixed, but I was able to get it straightened out. I was glad that the same company was the best choice for me for both years, since I start in December. Definitely no issues switching normally.
As with others in California, I am switching from Wellcare to Cigna - not because of the premiums but because my four specific meds will be about $500 less. I just did my last refills under my current plan for two of them. The other two need new prescriptions - I do better requesting via myChart than through the provider. I asked my doctor to just do one 90 day renewal for those two. I’ll send my new Part D card info to the office at the end of December and then when I need to refill, I’ll ask via myChart for new prescriptions for all four.
Then go through the decision process again next year since my non generic is one of the negotiated price drugs and who knows what that will mean for cost. And of course everything could go totally haywire depending on today.
I spent 2 hours on the phone with my insurance broker last week. A lot was explaining the $2000 limit. I have MA and want to switch plans.
The $2000 is what she calls ‘Medicare math’. Medicare will now allow a $590 deductible for prescriptions. Tier I drugs are still no copay, Tier II are a little more (don’t remember the percentage), and tier III can charge a 24% copay. Tier 4 and 5 are huge amounts percentages.
But the MA companies don’t HAVE to charge the max. I have Aetna which will be charging the $590 and then the 24%. Say you have Ozempic which is tier III. If it is $1000/mo, Aetna will charge $590 for the first month (and maybe 24% of the $410 remaining I don’t know how that works), and then the next month $240 until the patient reaches $2000 in copays. For United Health, they are sticking with the $420 deductible, but medicare will give credit for the $590. They are also sticking with the current copay of $47, but medicare will give credit for the $240 (24%), so you’ll hit your $2000 deductible without actually paying $2000 OOP. My math may not be correct, but I think you’d pay $420 plus $47 x 5.9 months, or about $700, while the other would pay $590 and $240 x 5.8 months = $1982 (so will have to pay a few $$ less than $240 in month 6)
All insurance companies are required to let you pay the $2000 max on a monthly payment plan so you don’t get hit with $2000 in Jan.
And that’s what I got from my 2 hour conversation.
Interesting, I went from Aetna to WellCare in Georgia - now I have $0 premiums and the cost of my annual meds are 1/2 what I was paying for premiums at Aetna - even with a premium and lower payment for drugs, I never hit the $2000.