Medicare Part D plans and PCa

Well, I am a few more weeks into my Part D drug plan study and have a few observations for what it is worth.

Talked with the pharmacist and she said they deal with all the companies on my list and could not say that one was any better than the others from their standpoint. She really did know much about Part D plans or differences between plans. They are all computer systems to her and they all get the job done. Apparently the difference is when things don’t get approved and the patient and doctor have to do all the work to get approved, not the pharmacist. Not much help.

Assuming a pharmacy is a “preferred provider”, the biggest cost difference between plans other than premium cost is the way the plans treat the Tier 3 (Preferred brand-name and some higher-cost generic drugs) and Tier 4 (Nonpreferred brand-name drugs and some nonpreferred, highest-cost generic drugs). These differences can be hundreds of dollars per year, especially if the drug is taken monthly.

However, getting written scripts from the doctor (or taking the bottle with refills listed) and checking out cash pricing with GoodRX and other pharmacy cash pricing, we can keep these costs in line with the better coverage plans without paying the higher premiums. I have tested this out in the last couple of weeks with a drug for my wife and a new one for me. In both case, talking with the pharmacist and using GoodRX as a guide, we were able to get the Tier 3 drugs for a good price and much cheaper than some of the cheap Part D plans like WellCare and Silverscript . Doing this provides the best of both worlds at the lowest cost. You have to be an active participant in this exercise and not just let the doctors and pharmacies operate on auto pilot.

The cheap Part D plans have no or very low cost or deductible on the Tier 1 & 2 generic drugs like atorvastatin, lisinopril, and losartan so that part is attractive and not the source of extra expense. Once you get to the Tier 5 drugs, your are screwed and do not have to worry much about the cost of the other drugs.

For my wife and I, WellCare Value script is looking pretty good at $10/mo with cash pricing being the way to go for the more higher tier drugs. Sometimes we may have to go to Costco or WalMart for certain drugs but our pharmacy has been able to stay close to the GoodRX pricing without using the coupons. My wife always liked shopping for a deal so this part is right up her alley.

The craziest thing I came across was that the University of MN pharmacy was not a preferred provider with the Blue Cross Medicare Part D drug plan. You can’t make this stuff up, the medication/drug system in the US is beyond belief at times and the consumer has to be careful or waste a lot of money in the process thinking someone is looking out for their best interests.

Mumbo, good work on your research. I have used Silverscript for 6 years, first when it was CVS and now Aetna since their purchase last year. Overall, I have been pleased, I am in the process of re-shopping as I recommend everyone do so.

The reason why Advantage plans drug coverage look like Part D is that they have to. Advantage Plans must cover at least what traditional Medicare covers. Thus the similarity. Remember Part D and Advantage Plans only came about in the last 25 years. In 1992 when Supplement Plans were first offered, about a third covered prescription drugs but we’re never allowed by Congress as Senator Kennedy and others wanted to deny the commercial insurers participation. Advantage Plans came in 1997 and put payor responsibility on the commercial insurers. Finally in the early 2000’s they relented due to the growing demand by seniors for drug coverage and Part D was approved using commercial insurers as the primary payor.

The, disturbing to me, trend is for CMS to classify certain doctor administered injections/infusions as Part D rather than B. This directly conflicts with Medicare definitions but is being done. Many of the newer expensive monoclonal antibody drugs and other immunotherapies have been so classified shifting payor responsibility to the commercial insurer and patient rather the the government. This will greatly increase patient cost as many have already experienced.

As people research Medicare options, remember that moving to, and or changing a Supplement Plan can be done at any time of the year, not just during the limited enrollment periods. I changed our G Supplement to an N Supplement last May and have been very pleased as it reduced our premiums by about 65% and should have lower future increases than G. We have only had one $20 co-pay so we are very much ahead with the change.

Thanks for the Wellmark info. Mumbo.

Regarding the N copays. Many of your visits will not attract a copay if your doc properly codes them. They basically apply to a new situation. Continuing or follow up visits don’t apply. For instance when I had COVID I had four visits, but only one copay for the initial visit. If you save 70 per month you would need to have 42 yearly initial visits with a copay to offset the premium savings. Not likely. Since I made the change about six months ago I have had about eight doc visits and only one copay was charged.

In seeing what some pay for either Lupron and/or Orgovyx, I'm sorry guys.

BC/BS thru my university has covered all the costs for ADT both Lupron and Orgovyx.
I'm a few years from 65, so lucky I guess. Not looking forward to it all, maybe I'll just get snipped.

Just found out that my 2022 Silverscript monthly premium will be going up from $7.30 to $7.70

And the monthly cost for my two prescripts will be going up from $0.00 to $2.00 .

I think everyone wants a piece of the new and improved SSI increase amount.

Great Plan D information Mumbo. Can I hire you to do my search? I’m feeling lazy after an extended trip out west with few responsibilities.

Again regarding Supplement Plan N, the Medicare Part B deductible is the same. Then Plan G pays 100% of the Part B 80% co-pay. With Plan N you also pay a $20 physician copay when initiating a new reason for a physician visit. Any other Part B treatment is the same with G and N. My experience since switching has included 4 visits for COVID and I paid one $20 copay, one urologist visit with PSA test and I paid no copay, one ophthalmologist visit with no copay, and one optometrist visit for my bi-annual eye exam and I paid a $20 copay. This week I again visit my ophthalmologist and I expect no co-pay and next month I will have my quarterly urologist and PSA draw, so no co-pay as these are continuing care and maintenance of an existing condition. My wife has had one $20 copay. So in the six months since the change we have experienced 3 copays ($60 cost) on about 9 visits and saved about $540 in premium. Pretty good trade off.

Regarding coding, just stay on top of it and watch your EOB statements. You can get them quickly on line. If you see a problem, call the provider and manage it to correct the code. It is better for them to code in your favor as they get their money sooner and don’t have to suffer the cost of billing and collecting from you.

The advice I received and confirmed which led me to switch. is that the best reason to use N rather than G or F is to avoid the expected greater premium increases. This will easily be in the thousands of dollars over the next 5-20 years.

The copays in employer sponsored plans are different than those in Supplement N. Often the employer sponsored plans will have a higher copay for a specialist versus a PCP or PA. Supplement N is a flat $20 for some, but not all, visits. The copays and deductibles in an Advantage Plan must be no worse than in traditional Medicare without a supplement. Generally, they are better, or no one would buy such a plan.

To change supplement plans I suggest you start by calling your current insurer. They have all your history as they have been paying the claims. They will use that information and add current information like weight and smoking status to determine your eligibility. In my case it was done during a phone call and the determination was made. Took about 20 minutes.

If you compare plans and find that another insurer would have a better rate, then you will have to go through their underwriting and they will access your health and treatment history to determine your eligibility. While you are applying do not give up your current coverage. This process should be expected to take a few days to a couple of weeks.

Remember, supplement plan coverage are the same regardless of the insurer, but the premiums charged and service levels may be different. Premium increase histories can be different as well, so look at all of these before changing plans.

Cancer history is not necessarily a problem when you show the evidence of cure or durable remission. Our history was no problem. Clearly a current situation indicating a possible worsening condition will be a problem as is current treatment for advanced stage cancer. Most insurers want to see a period of five years from dx and two or more years since treatment and they will want a steady history of bio markers like PSA.

What does your Congress representative and two senators say about your travails? They are your government.

OK, so I just got my annual enrollment stuff from my former employer and their retiree medical plan. It looks like in 2 years when I transition to Medicare that if I'm in a state where they operate, I will be switched automatically to an AON health plan. I went to their website to see what is up with them and I can't even look them over without actually being old enough to join.

Does anyone know anything about them?