Part D Plan Finder Confusion

refiman1

Expert
22
Question: Assisting two clients moving from MAPD to Med Sup. One client on Novolin 70/30. Both were approved and was assisting them in enrolling through the Part d plan finder. After entering that drug, showed his estimated OOP at 3.5 k annually with the lowest cost Part D plan per the finder.

Currently pays around 850 annually with his MAPD plan.

The pharmacy he uses was also selected. Called pharmacy and stated I had no coverage. Cash price $170.00 month. Part D plan finder states with Rx plan 290/ month.

I then searched his current MAPD plan in the plan finder, which also stated his estimated OOP for prescription for 2016 was about 3,500, roughly the same.

Then had client call to ensure pricing for 2016, thinking this could be a bombshell in the making. They confirmed pricing for 2016 was 30.00 more annually than 2015. 45 month co-pay as it was a tier 3 preferred pharm drug at that pharmacy. His plan details 45.00 co-pay a month per vial but he actually pays 45.00/month for 7 vials....every month...and never has hit donut hole.

Got spooked by the whole matter and cancelled his policy. Was not going to put this guy in the trick bag on his insulin. But am quite confused.

Final thing, even called the proposed part d plan, explained what the pharmacy told me and all those jokers at the carrier can do is read what the Medicare plan finder estimates to them, though it was that informational breakdown that led me to call them in the first place.

Summary: Both his MAPD plan and proposed Part D plan on Medicare .gov show his drug costing him around 3500 OOP annually. Actual OOP, using Wal-Mart pharmacy, about 25% of that cost.

Can't confirm if that pricing would also be applicable under a Part D standalone, though the tier and co-pay show to be exactly the same.

Any veteran Part d guys/gals wanna take a stab at explaining why this is and where I can get more accurate trustworthy info than Medicare plan finder?

Profound thanks in advance for your collective insight.:biggrin::D
 
I find that people are very confused about when and how they have hit the donut hole and what that actually means.

I had one tell me he had never hit the donut hole on his Farxiga and 10 other prescriptions. (yeah right). He was young, maybe 66 so had not been on Medicare long.

Turns out not, not only had his doctor given him a bunch for free, he had been using a prescriptions assistance program discount card of sorts. So he was smack in the donut hole starting in the summer, but that card from the manufacturer was keeping his OOP down. He said that all of a sudden he went to the pharmacy and the prices had gone way up so he refused to get it filled and went to his doctor where he had been given free meds and the card. I explained that was, in fact, the point where he entered the donut hole.

Any chance that is the case with this gentleman? Many of my Medicare folks don't understand that they have hit the donut hole if they are in one of these programs because OOP is not affected much.

Also, if he is on generic a lot, some pharmacists will run the real cheap stuff on a cash-basis so it doesn't affect the donut hole. Like, if it is a tier 2 drug where their copay is $12, but the drug is $8.80 on the plan or $8 cash, the pharmacist won't run it on their card and just charges them the $8. Or lisinopril or something that is a $3 copay or $1.81 cash, etc. Saves the beneficiary money, and prolongs getting into the donut hole that much longer.

Sometimes it is cheaper for them on the generics when they are in the donut hole due to the way the part-d plans monkey with pricing.
 
Also, if he is on generic a lot, some pharmacists will run the real cheap stuff on a cash-basis so it doesn't affect the donut hole. Like, if it is a tier 2 drug where their copay is $12, but the drug is $8.80 on the plan or $8 cash, the pharmacist won't run it on their card and just charges them the $8. Or lisinopril or something that is a $3 copay or $1.81 cash, etc. Saves the beneficiary money, and prolongs getting into the donut hole that much longer.

Sometimes it is cheaper for them on the generics when they are in the donut hole due to the way the part-d plans monkey with pricing.

Yeah, those pesky generics keep putting people into the gap.

Rick
 
went to the pharmacy and the prices had gone way up so he refused to get it filled

Great client/patient.

If he can't afford, that is one thing. Sounds like he just refused to pay it and had nothing to do with affordability.

I used to have clients like that. Can afford premium/drugs but just won't pay because they think it is too much.

I fire them.
 
Yeah, those pesky generics keep putting people into the gap.

Rick

Point taken, but those generics can add up if they are on enough of them.

If they are on 10 generic prescriptions a month in addition to the name brand stuff (which the drug plan is making them pay a $3 copay each for and saying the drug price is $10 each), then 6 months of those generics at part d prices equal $600 towards the donut hole. In reality, a lot of them are $3-4 cash prescriptions.

They can put it all on the part d card and pay $30 a month plus $45 for the name brand one and then have to pay $150 for their name brand drug (plus the $58 for their generics) starting in September. Or they can go the cash route for the generics and maybe they don't have to hit the donut hole until Nov, where the name brand goes to $150 and their generics stay at $30-40.
 
Maybe I was unclear. The carrier confirmed he has to only pay 45.00 a month for 7 vials. There is no generic and I saw the boxes with trade names. Also, doesn't receive freebies from Doc.

That is why I am so confused. Special pricing that Wal-Mart only has, he did mention his OOP would be much more anywhere else?

I would think that if that were the case, Aetna Rx would be relatively the same, as their Tier 3 coverage is identical as to what is outlined in his current MADP plan.

:skeptical::skeptical::skeptical::skeptical:
 
Question: Assisting two clients moving from MAPD to Med Sup. One client on Novolin 70/30. Both were approved and was assisting them in enrolling through the Part d plan finder. After entering that drug, showed his estimated OOP at 3.5 k annually with the lowest cost Part D plan per the finder.

Currently pays around 850 annually with his MAPD plan.

The pharmacy he uses was also selected. Called pharmacy and stated I had no coverage. Cash price $170.00 month. Part D plan finder states with Rx plan 290/ month.

I then searched his current MAPD plan in the plan finder, which also stated his estimated OOP for prescription for 2016 was about 3,500, roughly the same.

Then had client call to ensure pricing for 2016, thinking this could be a bombshell in the making. They confirmed pricing for 2016 was 30.00 more annually than 2015. 45 month co-pay as it was a tier 3 preferred pharm drug at that pharmacy. His plan details 45.00 co-pay a month per vial but he actually pays 45.00/month for 7 vials....every month...and never has hit donut hole.

Got spooked by the whole matter and cancelled his policy. Was not going to put this guy in the trick bag on his insulin. But am quite confused.

Final thing, even called the proposed part d plan, explained what the pharmacy told me and all those jokers at the carrier can do is read what the Medicare plan finder estimates to them, though it was that informational breakdown that led me to call them in the first place.

Summary: Both his MAPD plan and proposed Part D plan on Medicare .gov show his drug costing him around 3500 OOP annually. Actual OOP, using Wal-Mart pharmacy, about 25% of that cost.

Can't confirm if that pricing would also be applicable under a Part D standalone, though the tier and co-pay show to be exactly the same.

Any veteran Part d guys/gals wanna take a stab at explaining why this is and where I can get more accurate trustworthy info than Medicare plan finder?

Profound thanks in advance for your collective insight.:biggrin::D




are you sure he wasnt talking with medicare because carrier reps wouldn't be using medicare.gov they use their specific sites.

BTW this woudn't be a UHC case because they dropped novolin on all their part d coverage and subsituted novalog
 
He gets nothing from his doctor and Wal mart pharmacy confirmed the price. at the pricing they provided, he would never hit the donut hole, on just this medication. But Plan finder says otherwise. I was only writing him AARP med sup, which pays bupkus. Feel lie I am putting too much time into a one-off case but it would have been nice if somebody had a rational explanation for it since Medicare and the carriers dont.

Appreciate the help.

----------

No generic for this med. Brand name only.
 
He gets nothing from his doctor and Wal mart pharmacy confirmed the price. at the pricing they provided, he would never hit the donut hole, on just this medication. But Plan finder says otherwise. I was only writing him AARP med sup, which pays bupkus. Feel lie I am putting too much time into a one-off case but it would have been nice if somebody had a rational explanation for it since Medicare and the carriers dont.

Appreciate the help.

----------

No generic for this med. Brand name only.




wow you do the cost of 7 vials monthly of any type of novolin is over 800.00 monthly and that is added the 45.00 copay ? so just for the one drug he is using up his intial coverage in 4 months
 
WalMart states that he can get all 7 for 170 a month. Verified it myself. Only been paying 45.00/moth co-pay through his MAPD.

Now you understand my confusion.
 
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