PDP Premiums

[GoPokes]

(Not an agent)

Know you are now very, very busy, but I am curious after my first planfinder run.

I will be interested to see what you have to say about BC PDP's this year after you have had a chance to look for awhile.

Do Independent Agents get commissions for sale of BC PDP's?

Thank you.

BC is different in a lot of states. To make it more confusing, you have BCBS and Anthem, which are different, but look the same.

To answer your question, in KS, for 2025 BC PDP, yes, they are commissionable. The essentials plan is looking competitive. What are your thoughts LD?

 

[LostDollar]

BC is different in a lot of states. To make it more confusing, you have BCBS and Anthem, which are different, but look the same.

To answer your question, in KS, for 2025 BC PDP, yes, they are commissionable. The essentials plan is looking competitive. What are your thoughts LD?

I like it. I think it is a very nice option for the T1, T2, and T3 meds I have in my drug list.

I have a Dillons not too far from my home, much easier to drive to than WalMart or Walgreens. Cigna and Dillons seem to have had a parting of the ways. That and $0 vs $3 leaves me with WC or BC rather than Cigna.

BC pricing is acceptable to me.

You guys talk about pricing on CMS not being reliable, that it can change. If I understand correctly, some of the agents say one should look at the tier pricing tables.
WC goes $0, $5, 25%, 41%, 25%
BC goes $0, $2, 20%, 48%, 27%

WC puts 3 items on my list in T4. BC puts 2 of those in T3 and 1 in T2.

1 item on my list, a med some dental professionals will use for sedation dentistry, is not covered by any of those 3 plans. Everything else on my list is T1-T3. BC and Cigna assign the same tiers to everything on my list, except for one item which is T2 on BC and T1 on cigna.

And BC drops the deductible to $425.

I had just figured I would need to be continuing with WellCare, but it looks to me like the BC plan is a solid option.

I hope you can see that plan as beneficial for at least some of your clients.

regards
LD

 

[vic120]

everything is a mess, In NY Nassau county lest expensive is WellCare at $36

so many meds used to not cost much now is like a 50% cost share after a 600 deductible

Yea some areas wellcare is $0 but if anyone is taking any higher tier drugs and not over 2000 is getting got

and then I keep running into where a high plan for $115 or so but the out of pocket is showing like $900 and then $0 for the rest of the year

how does this make sense

ca I tell people to go this way with any confidence

 

[GoPokes]

I like it. I think it is a very nice option for the T1, T2, and T3 meds I have in my drug list.

I have a Dillons not too far from my home, much easier to drive to than WalMart or Walgreens. Cigna and Dillons seem to have had a parting of the ways. That and $0 vs $3 leaves me with WC or BC rather than Cigna.

BC pricing is acceptable to me.

You guys talk about pricing on CMS not being reliable, that it can change. If I understand correctly, some of the agents say one should look at the tier pricing tables.
WC goes $0, $5, 25%, 41%, 25%
BC goes $0, $2, 20%, 48%, 27%

WC puts 3 items on my list in T4. BC puts 2 of those in T3 and 1 in T2.

1 item on my list, a med some dental professionals will use for sedation dentistry, is not covered by any of those 3 plans. Everything else on my list is T1-T3. BC and Cigna assign the same tiers to everything on my list, except for one item which is T2 on BC and T1 on cigna.

And BC drops the deductible to $425.

I had just figured I would need to be continuing with WellCare, but it looks to me like the BC plan is a solid option.

I hope you can see that plan as beneficial for at least some of your clients.

regards
LD

Yes CMS medicare dot gov, is not entirely consistent, it may show one thing now, and something else later. There is no accountability (on CMS) when it happens. You are wise to look at the tiers and the formulary.

I too see the BC as very competitive to WC, which is appealing to me. I have about 300 WC members in KS, so I am excited to have a place to move them that is good for the consumer, and for myself. Im still a little bitter about WC.

Have you tried to get a formulary exception for your sedation med? Some companies are a little more friendly with exceptions than others, but it's worth a shot. You might ask your pharmacist about it. You can also ask for a tier exception too, if needed.

Since BC has that $425 deductible, I believe that makes their plan an enhanced plan, better than the CMS benchmark, as opposed to WC, which also gives them a competitive advantage.

Now, BC says they have a bunch of "mom and pop" pharmacies in their preferred network, but all the "mom and pop" independent owned pharmacists I have talked to said that is not exactly true. So, I would like to see BC put up or shut up, and provide some transparency as to who these "mom and pop" pharmacies are... the competition isnt doing any better, but if BC is gonna market under that premise, then I think they should in fact do what they say they are doing.

 

[LostDollar]

Since BC has that $425 deductible, I believe that makes their plan an enhanced plan, better than the CMS benchmark, as opposed to WC, which also gives them a competitive advantage.

if I am following the landscape file correctly, it shows $0 WC, $0 BC, and $3 Cigna all as enhanced alternative plans.

How that plays out in specific competitive benefits I don't know.

 

[LostDollar]

Have you tried to get a formulary exception for your sedation med? Some companies are a little more friendly with exceptions than others, but it's worth a shot. You might ask your pharmacist about it. You can also ask for a tier exception too, if needed.

This gets into an area where DS4 starts talking about me as a PIA client.

Instead of running a bunch of alternative scenarios on planfinder, this year what I did was to put my drug list into my CMS file.

For those sedation drugs, I went through my prescription fills and found three different ones that had been prescribed. I put them into my medication list at 1 (each) for 12 months. That shows me how the plans cover them. This one particular med is $8 for one pill, which I can do, but that also gives me an information base where I can ask a dentist what sedation meds he will use, and if he says that one, I can ask if he would find one of the other ones acceptable and prescribe it instead.

I did the same thing with narcotic pain meds. I learned an interesting thing when I had a hip replaced a year or two ago.

Historically when I had a dental procedure or small outpatient surgery I was prescribed a small quantity of oxycodone/acetaminaphen combination pills. My hip surgeon did not like those combo meds. I learned there was such a thing as plain Oxycodone.

He prescribed Oxycodone and Tramadol, with specific instructions for each and I was then free to intersperse Tylenol and Ibuprofen as I saw fit. I tolerated those better and I think that approach allowed me to use less Oxycodone and made getting off both the narcotics easier.

The next time I need a treatment that requires a small amount of narcotic pain killers, I am going to ask the provider if they can prescribe me a small quantity of low dosage Tramadol.

At any rate, on that CMS med list, I did the same thing, I listed a small quantity of Oxycodone and Tramadol, not enough to seriously skew the annual price, but it shows me the price and tier coverage for the meds.

With that approach to information gathering on my part, seeking a formulary exception for triazolam would be a total waste of everybody's time.

Oxybutynin is my personal cost challenge this year. The pricing difference between WC and BC at Dillons is very dramatic.

(I had been considering the possibility of trying Myrbetriq but I think I am priced out of the market on that one.)

 

[LostDollar]

Now, BC says they have a bunch of "mom and pop" pharmacies in their preferred network, but all the "mom and pop" independent owned pharmacists I have talked to said that is not exactly true. So, I would like to see BC put up or shut up, and provide some transparency as to who these "mom and pop" pharmacies are... the competition isnt doing any better, but if BC is gonna market under that premise, then I think they should in fact do what they say they are doing.

(My post below is based on being a PDP buyer, not an MAPD buyer. Don't know how, or if, the MAPD would make things different.)

When you posted before, I looked up BC pharmacy list, didn't have time to get back to this then, so it is not fresh in my mind now.

What I think I saw was if you go out to small towns around bigger cities like Garden City, Colby, Hays, Salina, Topeka, etc; you would see pharmacies listed as in network, but not starred as preferred. I did not try to do any price comparisons to see how that difference looked.

The essence of what you are getting may be something like:

BC, well they are in our network so they are preferred (more preferred than a pharmacy out of network would be.).

Pharmacist: well, we are not preferred (because we don't get the really good price structure Dillon's and WalMart do).

The more rural folks with the small town pharmacies may need to be seriously fitting drug discount cards into their Medication buying plans (if they are doing PDP's).

And I am not sure you would find much difference between any of the plans as far as how in-network and preferred categorizations would show up.

 

[just-a-client]

Standard in-network (non-preferred) prices for Tier 3 and 4 are often the same and even at times better than in preferred pharmacies. It's the providing of extra-cheap low tiers that is mostly the deal offered by preferred pharmacies. Those drugs are loss leaders to get people in the door to buy more profitable OTC products, groceries, and Halloween masks.

Plus, once you get a preferred pharmacy listed at the doctor, they're going to send all your prescriptions there. People assume that they are going to get the best price at the preferred pharmacy for any drug but it's just not necessarily true. A person needs to shop around the tier 3 and 4 drugs or use their PBM website drug pricing tool which will show the correct current prices at all of one's local pharmacies. (Caremark has a good one, Express Scripts has a superb one.)

If you do find a better price it can be a pain in the neck to get back to one's provider and ask them to resubmit the prescription to the pharmacy of your choice.

Pharmacies that sign up to be preferred know all this and have decided the cost/benefit is worth it.

Medicare.gov plan finder will demonstrate this. You just have to include some non-preferred network pharmacies in the setup. Their tier 1 and 2 drugs will be way too expensive, ignore those and just check 3 and 4.

 

[somarco]

I run all the client drugs through my plan finder, looking for the lowest total cost.

If some meds are NC by all plans I peel those off and look for PAP's, grants, discounts (generic), Canada.

If the NC meds are covered by other, higher priced plans, I compare the high priced plans vs the lower priced plans and make a recommendation.

If the $2k OOP cap is in play, I often go for the lowest premium plan and, if necessary, peel off the NC meds.

 

[LostDollar]

If you do find a better price it can be a pain in the neck to get back to one's provider and ask them to resubmit the prescription to the pharmacy of your choice.

I had something earlier this year, maybe oxybutynin, but not sure, that had a better price at Walgreens than at Dillon's (My KS version of Kroger). When I talked about needing to call my family doc to get a new prescription called to them, the pharmacist told me they (Walgreens) could just call Dillons and have them transfer the prescription.

so the pharmacies seem to have a system to work with for at least a small quantity of transfers due to pricing issues.