How is the $2000 MOOP calculated?

[just-a-client]

So what determines if a mapd rx part is enchanced or standard? Is enchanced if you have $ copays and standard if you have % copays ? The enchanced example your using is a $255 deductible plan?

Chiming in here, as a non-agent.

A plan can do things like that, and be an alternative plan,but not necessarily enhanced alternative.

These plan designs can include things like if a plan charges less than full deductible, has non-standard cost-sharing, has coverage in the gap, uses preferred pharmacies with a tiered stucture, has a broader formulary. The "enhanced alternative" plan increases the plans actuarial value above the Defined Standard benefit. The other alternative plans are actuarially equivalent.

This page explains all the different alternative plans. Quite a few! And it gets damned complicated. The page also explains how some plans are fully LIS and others are not. (So, Wellcare Classic has worse benefits like a full deductible and a higher premium than Value Script, so you'd wonder why anyone would pick it, but it's designed for dual eligibles and has $0 premium with LIS, along with reduced cost sharing if LIS-eligible.)

There are fewer LIS plans than there used to be, I guess because more plans are using enhanced alternative designs.

Perhaps with all alternative plans, the progress towards Max OOP max is the way Jim explained it above, even if the plan isn't "enhanced."

[EXTERNAL LINK] - What are the Medicare Part D abbreviations: EA BA DS AE in the plan benefit type?

 

[selfgen]

Who's not getting paid, dude this is a bigger deal on mapd than pdp, and if your thinking your Wellcare members will stick with them hold on the anoc just hit and I got 3 calls today from pissed off people, guess what meds not covered on the slimmed down formulary let the fun begin

They received their ANOC already???? Wow.
And what drug are you referring to that isn't on the formulary?

I'm more curious to find out if people taking 4 or 5 $1000+ drugs will even be able to a formulary that covers them all. Bet that gets fun.

At the Aetna rollout that I attended, one of the slides during the presentation stated that the Silverscript Choice PDP had "over 1400" drugs on the formulary!! Most drug plans have between 3,000 and 4,000 drugs that they covered. I was sure this had to be a mistake! I questioned the "expert" that was giving the presentation. She couldn't confirm if that number was correct or not. I still don't know as of yet. 1,400 is very, very low .

 

[AgentGeneral]

All these changes are not a big problem. Sky isn't falling. And unless youre in a state that whacked plans, it's fine. Just prepare. Formularies and med.gov super helpful. For the agents in states where plans were whacked, I feel bad for you bc that is a true pain in the arse, but these Rx changes aren't rocket science.

I see zero problem here.

Afterall, we are just the messengers and helpers, we didnt make the rules.

I stand where I thought I would months ago. BCBSM is more solid here in Michigan now, and they were solid before these changes. And for most, that's where theyll stay, unless theyre DSNP or Vets. For the Michigan agents, BCBSM pulled ahead into the lead passing Priority (not U65), with 35% of all enrollments done by agents. Yes, I'm aware these things change every year. I'm newer to medicare, but have done health for 20yrs. Always changes. All good. This change is fine as well. Except Wellcare, f them.

 

[Millwood]

All these changes are not a big problem. Sky isn't falling. And unless youre in a state that whacked plans, it's fine. Just prepare. Formularies and med.gov super helpful. For the agents in states where plans were whacked, I feel bad for you bc that is a true pain in the arse, but these Rx changes aren't rocket science.

I see zero problem here.

Afterall, we are just the messengers and helpers, we didnt make the rules.

I stand where I thought I would months ago. BCBSM is more solid here in Michigan now, and they were solid before these changes. And for most, that's where theyll stay, unless theyre DSNP or Vets. For the Michigan agents, BCBSM pulled ahead into the lead passing Priority (not U65), with 35% of all enrollments done by agents. Yes, I'm aware these things change every year. I'm newer to medicare, but have done health for 20yrs. Always changes. All good. This change is fine as well. Except Wellcare, f them.

Just sat in on a webnar from Cason Group out of S Carolina. They had a pharmacist and owner of a large independent pharmacy. Very insightful.
Doesn't look like any independent pharmacies will be preferred except for some regional Blues.

He quoted a survey that said 90% of independent pharmacies will not take part D
in 2025. It's a survey so who knows. Sounds like us agents not writing any PDP.

He said 40% of independent pharmacies will be out of business in next 2 years.

He said the reason a ton of independent pharmacies dropped Aetna SilverScript Sept. 30th this year was new drug FMO for lack of a better term. He gave an actual example. Ozempic costs his pharmacy $1,000 they are paid $800.

If a drug plan is enhanced the actual cost minus the copay (ie $47 tier 3) is what goes to satisfy the $2000.

AND the smoothing process OMG stay away, run . You will not be a hero you Do Not want any Part of it.........

 

[selfgen]

What is "smoothing"?

How do I know if a PDP plan is "enhanced" and what does that mean?

 

[goillini52]

You said the key words " many scenarios " . There's no way to manually fig out .I've read were a fixed cost copay like $47 . If the % like 25% is let's say $150 . You get the credit from the higher $150 vs your $47 or $103 toward you moop . I think it's Critical to sell mapd's and pdp's with fixed tier 3-5 copays . I'm not going to go down rabbit holes to try to explain this . Im tell all " if you have expensive drugs you'll have to to a $495 deductible . But once you hit that most drugs will be about the same cost as before . But the good news is you can never pay more than $2k in a yr and a great % of people pay less than that . So all those expensive drugs you have you can never pay more than $2k total . If you go to the pharmacy and they want $400 let's say for a drug . You can call the company and set a payment plan up .

I thought I read that if they want the payment plan, they have to do it when they sign up.

 

[Chazm]

What is "smoothing"?

How do I know if a PDP plan is "enhanced" and what does that mean?

Enhanced plans typically don't have a deductible and have a flat copay for tier 3. Not %

 

[DonP]

I thought I read that if they want the payment plan, they have to do it when they sign up.

No they can do any time.

 

[LostDollar]

He quoted a survey that said 90% of independent pharmacies will not take part D
in 2025. It's a survey so who knows. Sounds like us agents not writing any PDP.

Caveat, not an agent

For 2025, if zero premium PDP's are available, it seems to me like clients would be well served to sign up for one of those as a Part D penalty avoidance measure, even if it doesn't gain much benefit at the independent pharmacy.

 

[LostDollar]

He said 40% of independent pharmacies will be out of business in next 2 years.

Caveat, not an agent.

After scanning through a BCBSKS pharmacy list,

I wonder if there may not be a difference in the quantity of pharmacies that go out of business between pharmacies in small rural towns and independent pharmacies in larger urban areas with access to one or more of the large food or pharmacy chains.