2025 Rx $2,000 "light bulb" moment

[sshafran]

I've had at least 8 clients with "light bulb" moments this year in talking about the new $2k max (often, $750-1750 out of pocket).

Those hitting catastrophic will ask something like, what if I get prescribed more?

Well, nothing if it's on their list. You hit the max.

I can almost see them salivating over more medication.

I've literally had a few say something along the lines of "this is awesome, I'm going to start (or start back on) ____."



This won't backfire.

 

[InsuranceGuy29]

I've had at least 8 clients with "light bulb" moments this year in talking about the new $2k max (often, $750-1750 out of pocket).

Those hitting catastrophic will ask something like, what if I get prescribed more?

Well, nothing if it's on their list. You hit the max.

I can almost see them salivating over more medication.

I've literally had a few say something along the lines of "this is awesome, I'm going to start (or start back on) ____."



This won't backfire.

In my opinion, it's terrible. The goal of healthcare is to be healthy and OFF of prescriptions. The goal isn't to get excited that they're gonna be cheaper and get MORE.

All this legislation did is subconsciously encourage seniors to "ask their doctor" about more of the meds (many of which are toxic) they see in the brainwashing commercials.

Big Pharma is responsible for something like 70% of all TV station revenue. There were other ways to help seniors that need (<----very key word) to be on many high-priced meds, due to it being ABSOLUTELY medically necessary.

And then people wonder why preauthorizations exist. Because so many people are on meds that they absolutely do NOT need to REALLY be on.

The doctor just has backdoor deals in place with the pharmaceutical reps that are routinely in their offices/the pharmaceutical companies.

Without some preauthorizations, healthcare would cost us all 5x more of what it is already. It would be completely unaffordable for absolutely everyone.

I have run into SO many people in the past year that are on Ozempic. Before this year, I never even heard of it. Why? Because they are pushing this drug on commercials LIKE CRAZY.

Why? Because they own the patent and it's expensive as f*ck. You certainly don't see them pushing generics that will do virtually the same thing.

And then people call me and wonder why the copay is $150/month. Ma'am...Sir....because it's a $1,300/month drug with no generics for its particular brand. That's why.

Then I, the agent, and the insurance company, have to take the brunt of the anger. Ask your doctor, who is getting paid off, to find something cheaper.

You have to keep these doctors at least somewhat in check and let them know that you're paying attention to their prescribing habits, otherwise our costs will go sky high.

That's why they don't like Medicare Advantage so much, because they now get graded on how HEALTHY they are actually keeping people. Not how many services or prescriptions they're ordering for them.

It threatens their backdoor secretive payoff structure from Big Pharma. They're actually held accountable.

 

[Fisher]

All this legislation did is subconsciously encourage seniors to "ask their doctor" about more of the meds (many of which are toxic) they see in the brainwashing commercials.

I will not disagree on this point. Not much different than Obamacare disincentivizing peeps to try to better themselves financially. And the common denominator is...?

 

[InsuranceGuy29]

I will not disagree on this point. Not much different than Obamacare disincentivizing peeps to try to better themselves financially. And the common denominator is...?

Yup...Obamacare is a draining of the Middle Class that's disguised as "insurance." Oh sure, the insurance is there, but it just isn't good for most, and its main purpose is to cripple everyday working people, and disincentivize them from making more money. The more money you make, the more money you pay for insurance, and the worse your insurance plan gets. Make it make sense. All by design.....needs to change immensely.

 

[Millwood]

I've had at least 8 clients with "light bulb" moments this year in talking about the new $2k max (often, $750-1750 out of pocket).

Those hitting catastrophic will ask something like, what if I get prescribed more?

Well, nothing if it's on their list. You hit the max.

I can almost see them salivating over more medication.

I've literally had a few say something along the lines of "this is awesome, I'm going to start (or start back on) ____."



This won't backfire.

I'm pretty sure Medicare will be paying more for drugs than providers. It will bankrupt Medicare...........
Something will have to change.

 

[hockeyday]

I'm pretty sure Medicare will be paying more for drugs than providers. It will bankrupt Medicare...........
Something will have to change.

After2k it's mostly on the insurance company

 

[somarco]

Let's see if I understand this . . .

If a patient hits their OOP cap . . . Rx, Health care (Medigap or MAPD) . . . they suddenly wants MORE drugs and MORE health care because it is "free"?

The treatment or medication no longer has to be medically necessary?

In all the years I have worked in this industry, including about a dozen years before managed care, I don't recall ever seeing rampant abuse like this.

But I do run across situations where a provider, usually in the mental health field, bills a carrier for non-existent bodies in group therapy sessions.

 

[Millwood]

After2k it's mostly on the insurance company

Well the money only comes from 2 sources.
Medicare and the beneficiary. $100 month beneficiary premium only equals $1200 for the year. You tell me where the rest comes from? I think you made my point for me.

 

[goillini52]

I will not disagree on this point. Not much different than Obamacare disincentivizing peeps to try to better themselves financially. And the common denominator is...?

 

[sshafran]

Let's see if I understand this . . .

If a patient hits their OOP cap . . . Rx, Health care (Medigap or MAPD) . . . they suddenly wants MORE drugs and MORE health care because it is "free"?

The treatment or medication no longer has to be medically necessary?

In all the years I have worked in this industry, including about a dozen years before managed care, I don't recall ever seeing rampant abuse like this.

But I do run across situations where a provider, usually in the mental health field, bills a carrier for non-existent bodies in group therapy sessions.

"I stopped taking Farxiga and changed to to _____ in May when I hit the donut hole. I'll take Farxiga all year next year."

Seems most common with diabetic meds.

Another example - I had a lady who gets some type of assistance on one of her brands from Eli Lilly. But she can't get help on her other brand. She's hitting $2k easily. Sees no reason to apply with Eli Lilly again since it'll be "free" with insurance.

A pharmacy associated with a local group has a really generous program for high cost meds: $1/day, but with some restrictions (it's a drive for a lot of my local clients).

No need for that - insurance pays for it now.

But I think the biggest culprit will be: Changing from generic back to brand, and opting for the higher cost diabetic meds. Or not trying to go from Buproprion XL to regular. Etc etc.

The incentive to "lower" for those with high cost Rxs is no longer an issue. Once they hit a much lower threshold, it's all free.

Maybe the remedy will have to be more step therapy and PA.