PDPs with the largest formularies

[Limozine]

Twice recently I've had clients ask me questions like, "I have no idea what drugs I might be prescribed in 2025, but just in case, which plan has the greatest chance of covering these unknown drugs?"

Is there any way to intelligently answer such a question? Is it even possible to recommend a "best all around" plan in such cases?

 

[Millwood]

No because they can change the formulary all year long.

 

[axeman462]

Twice recently I've had clients ask me questions like, "I have no idea what drugs I might be prescribed in 2025, but just in case, which plan has the greatest chance of covering these unknown drugs?"

Is there any way to intelligently answer such a question? Is it even possible to recommend a "best all around" plan in such cases?

this is a legitimate question from the customer's perspective, and can be a little tough to answer.
But what I found, in my experience, over the years is that the customer is usually not actually looking for the "best" PDP with the most comprehensive formulary, but usually looking to see if you are going to stick around year and year, and give them continued guidance.

I usually say something to the effect of "we can't see the future etc.. we can only make projections on what your needs currently are, and what your family history say etc.. but when it comes down to it, we can really only take things from year to year. and I will be here every AEP to reassess your needs from one year to the next."
Its that last part is what I find most people find comfort in.

 

[somarco]

Can the 2025 drug plan formularies change during the annual Open Enrollment Period?

Yes. For example, the November formulary data included twelve (12) new brand-name drugs: Acthar®, DUVYZAT®, IQIRVO®, LIVDELZI®, MRESVIA®, NEMLUVIO®, OHTUVAYRE®, TORPENZ®, TRIDACAINE®, TYENNE®, Vaxchora Cholera Vaccine®, and VIGAFYDE® – and nine (9) new generic drugs: ADALIMUMAB-RYVK [Yuflyma®], AZURETTE [Volnea®], CARBINOXAMINE [RyVent®], GAVILYTE-N [TriLyte®], HYDROCORTISONE [Scalacort®], IVABRADINE HCL [Corlanor®], L-GLUTAMINE [Endari®], LIRAGLUTIDE 3-PAK [VICTOZA®], and TIOPRONIN [Thiola EC®]. Note that these new medications may only be available on a limited number of drug plans.

Check your plan's formulary for changes in drug coverage and drug utilization management restrictions including, Prior Authorization (P), Quantity Limits (Q), or Step-Therapy (S). If your drug has restrictions, you will need to work with your prescribing doctor to meet these requirements or ask your 2025 plan for a formulary exception.

You can see the 2025 utilization management restrictions for your medications in our Formulary Browser and Q1Rx Drug Finder which have been updated with the latest (November) formulary data available.

Important: Negotiated retail drug prices can also change during the annual Open Enrollment Period. Retail drug prices may determine what you pay for formulary drugs (coinsurance) and when you will enter Catastrophic Coverage. You can call a Medicare representative (1-800-Medicare) or check the Medicare.gov plan finder for the most-current retail drug prices.

Q1Medicare FAQ

 

[straightnochaser]

Formularies can be updated from March 1st... trying to predict the future in insurance is not easy and not something I typically like to do.

 

[ValeRosso]

Formularies can be updated from March 1st... trying to predict the future in insurance is not easy and not something I typically like to do.

I thought it could be updated anytime during the year

 

[straightnochaser]

I thought it could be updated anytime during the year

Insurers can't change the formulary until 60 days into a Plan Year.

 

[Dave G]

My reply to this type question may include:

- Most Part D plans have about 3,000 or more Medicare approved drugs on formulary. Every drug plan must include all cancer drugs, all mental health drugs and at least 2 drugs of every therapeutic class. So in theory, there is a drug on formulary your doctor can prescribe for your condition.

- Any newly prescribed drugs during the year are subject to the plan formulary and Tier placement. If you need a drug not on formulary, no need to panic. There is a standard, streamlined process to request a formulary exception to add the drug to your plan. To be approved, the drug must be medically necessary, no other drug on formulary effective for your condition and prescribed for an FDA-approved purpose (no "off label" use).

Great Independent Source for what drugs are on what plans:
www.Q1Medicare.com

Hope this helps. Happy AEP!

 

[annon123]

Great Independent Source for what drugs are on what plans:
www.Q1Medicare.com

Hope this helps. Happy AEP!

That is a handy source. Thanks. I noticed (and created my own spreadsheet for my state after being asked that) that there is a fairly large difference, even if the differences between companies for how many drugs are in the formulary isn't all that big, there is a noticeable between how many drugs are in which tier between some of the companies which may or may not matter for a client (for the unknown future). And, of course, as others have noted, this can change over time, along with the "retail" price of a drug.

And with (at least in my state) almost all of the companies have gone away from straight dollar amount of the copay in the higher tiers to a percentage, whichof course, can change the drug price over the calendar year. I make sure clients are aware of this so they don't come back to me complaining that the price of their drug went up midyear; that wasn't what I had quoted them now... etc.

 

[rmhaire]

Its that last part is what I find most people find comfort in.

Either that or that damn unicorn.