2025 Rx $2,000 "light bulb" moment

[sshafran]

It's more common than many people realize.

We have friends who were just saying that they had a surgery mid-year and hit max. So, now they're trying to think of anything that could or should be done so they can get it in before the end of the year for "free."

Not only that, I know they'll choose urgent care over PCP for convenience - it's no longer a cost difference, so why not when you can walk in for free?

 

[somarco]

Well the money only comes from 2 sources.
Medicare and the beneficiary

Plus the money from DC . . . AKA the taxpayer . . .

 

[Chazm]

Last week I had a client that takes Trelegy and I think the other drug was Eliquis, or something else that is expensive. They get Trelegy for free with a mfg discount in 2024, so I took that drug out of my search.

Without Trelegy, they will spend $1100 next year on meds. With Trelegy in my search, they will spend $800. Guess which way they are going?

Another person I talked to last week said their drug will no longer will be free from the mfg. The mfg sent them a letter stating that with the new drug cap rule in 2025, they will no longer cover their drug for free.

Drug plans are going to spend a lot more next year. I should say the higher premium plans will. I think WellCare will make out OK

 

[somarco]

The IRA cap on meds has certainly impacted plans for 2025. It would have been much worse if DC hadn't funneled a ton of money in playoffs to the drug carriers in hope of minimizing the premium increases.

Even still, there is fallout and even more to come in 2026.

In 2024 we have 20 PDP offerings in Georgia . . . for 2025 only 14.

In 2025 I am seeing fewer high priced meds on the formulary and considerably higher copays for t1 - t3 generics.

Fewer preferred pharmacies. Aetna does not have any.

WELLCARE does not have brand name insulin, at least none that I have found.

Higher premiums, and more OOP except for the few who hit the $2k cap.

Almost all of my clients use discount cards instead of the drug plan.

High priced meds like Eliquis (brand and generic) are usually less expensive from Canada with some saving $500+ vs running the drug through their plan.

 

[somarco]

The goal of healthcare is to be healthy and OFF of prescriptions.

Tell that to patients with heart and cancer meds.

"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.

FARXIGA is for folks with cardiac failure and often CKD as well. There are few substitutes but Invokana and Jardiance are two that MAY be less expensive.

For all the belly aching about limiting the OOP for Rx and health care there are folks out there who might stop taking meds or receiving treatment if not for the OOP cap.

 

[Chazm]

The IRA cap on meds has certainly impacted plans for 2025. It would have been much worse if DC hadn't funneled a ton of money in playoffs to the drug carriers in hope of minimizing the premium increases.

Even still, there is fallout and even more to come in 2026.

In 2024 we have 20 PDP offerings in Georgia . . . for 2025 only 14.

In 2025 I am seeing fewer high priced meds on the formulary and considerably higher copays for t1 - t3 generics.

Fewer preferred pharmacies. Aetna does not have any.

WELLCARE does not have brand name insulin, at least none that I have found.

Higher premiums, and more OOP except for the few who hit the $2k cap.

Almost all of my clients use discount cards instead of the drug plan.

High priced meds like Eliquis (brand and generic) are usually less expensive from Canada with some saving $500+ vs running the drug through their plan.

Not what I’m seeing. I’m having my clients that use Canada save money on their MAPD or PDP now.
My friend takes Eliquis and Farxiga. Uses Canadian drugs. Guess where he’s gonna save over 1k next year?

Eliquis from Canada is about $80/month or $960 a year. With a part d or PDP it’s under that amount. If they continue to get it from Canada and then find out they need another expensive drug later on, they are going to be mighty pissed off that they didn’t take a drug plan that covers it.

 

[hockeyday]

Not what I’m seeing. I’m having my clients that use Canada save money on their MAPD or PDP now.
My friend takes Eliquis and Farxiga. Uses Canadian drugs. Guess where he’s gonna save over 1k next year?

Eliquis from Canada is about $80/month or $960 a year. With a part d or PDP it’s under that amount. If they continue to get it from Canada and then find out they need another expensive drug later on, they are going to be mighty pissed off that they didn’t take a drug plan that covers it.

That's what I'm seeing too

 

[somarco]

Not what I’m seeing. I’m having my clients that use Canada save money on their MAPD or PDP now.
My friend takes Eliquis and Farxiga. Uses Canadian drugs. Guess where he’s gonna save over 1k next year?

Other than your client saves $1,000 and mine saves $500, where is the disagreement?

 

[Chazm]

Other than your client saves $1,000 and mine saves $500, where is the disagreement?

If they add more brand drugs. With a cap I don’t see why they wouldnt take a drug plan

 

[somarco]

If they add more brand drugs. With a cap I don’t see why they wouldnt take a drug plan

Depends on how the numbers shake out . . . plus some folks don't like mail order, including from Canada.

There is very little I do that is purely a dollars in dollars out transaction.

Just a different way of solving the problem while letting the client choose the "package" they want.