Sorry, but the World is Not coming to an End

hockeyday said:
It's going to come back to what tier does the current t6 meds fall too, paying 11 buck after deductible in 24 is not to bad, paying 25% after deductible is a fast track to 2k,
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I'm not an agent. Finally registered after reading this forum since early days leading up to ACA, and then ACA early days. But I've been on Medicare now for 7 years, reading this Senior forum. I'm inspired to chime in now.

Wellcare Value Script had that $11 tier for 2023 and 2024 for very expensive diabetes drugs. I thought about how the cost-sharing for those drugs would actually work out those years. After deductible, you'd pay $11 - but just for a few months. The total drug costs were so high that you'd then enter the coverage gap pretty quickly - and pay 25% till you reached the catastrophic phase and owed, as of 2024, nothing. But that meant spending around $3500 before reaching the catastrophic phase. (And in 2023, it meant paying 5% after that, forever.)

I realized pretty quickly that Wellcare would have to change this for 2025, because there is no way they could possibly allow an $11 co-pay for these expensive drugs for the entire year. And no one here would imagine that could be sustainable. So I figured those drugs would likely move into Tier 3 or Tier 4.

Wellcare, for California, is lowering Tier 4 from 50% to 35% (preferred pharmacy, but 36% at standard pharmacy). Tiers 3 and 5 remain 25%. If these Tier 6 drugs get put into Tier 3, it does mean they would cost 25% immediately rather than only after hitting the gap. But then, costs are capped at $2000 max oop, so I think it's probably a net gain. Probably a net gain even if the drugs are in Tier 4 too - you'd just hit $2000 max oop sooner in the year.

If I may, I have more to say about why I personally don't think the sky is falling - details about what Medicare reinsurance actually means, why I think CMS has changed it, and what I think it really means that their reinsurance contribution will be dropping. (I think it is less of an issue than people have been worried about.)

I'll post my thoughts about that eventually and look forward to feedback!

Thanks for letting a non-professional like me post.
 
Glad to see you writing here. What we know is that the beneficiary will be meeting the 2000 max much sooner than prior years because behind the scenes, the insurance companies will be calculating much differently and giving you credit for a high priced drug even though you may have only paid a copay for the drug. The higher of the two is what they use to calculate your 2000.00 max. Let’s say you paid 47.00 copay for eliquis on the plan you chose but the basic Medicare drug plan has a 590.00 deductible. Behind the scenes, the insurance company takes the greater of the two and will apply that price to your max out of pocket. That means they would apply 590.00 to your out of pocket and not 47.00 or the next month they apply 25% of the price while you only paid 47.00 because the base plan will have a 590.00 deductible and 25% coinsurance after. So one will be hitting that 2000 max even quicker than expected on some drug plans That’s the best part about the new 2025 plans. However, the plans come at a price. The companies can’t lose money on these plans. Once the calculated 2000 has been done behind the scenes, they now will be paying 60% and the manufacture will be covering the additional 40%. In the past it was the government/manufacturer that was covering the majority of the expense and not the insurance company. This along with the beneficiary meeting the 2000 max much quicker on some plans will cause the monthly rates to be higher. You are right to expect your out of pocket cost for the drug to be lower but also expect your monthly cost of the plan to be higher. The calculations the insurance company will be doing behind the scenes are complex to the point that even an insurance broker will have a hard time knowing when a senior will be hitting their 2k max for the year. Even the zero copay drugs will be calculated into the 2k max. Maybe the drug is 20.00 and you paid zero, they will be taking the higher of the two and apply to your 2k. We will have to see how this affects the price moving forward but we are anticipating premium increases across the board. Of course this is not in writing and not official. Everything can change. This was presented to me by UHC about a month ago. I can’t even confirm the accuracy being nothing is in writing. It is a calculation that every plan will be following. For the reason why this is part of the Inflation Reduction Act. The new plans will be helping control the Medicare trust fund from running out of money. More financial responsibility to the insurance companies and seniors.
 
As far as the negotiated drug pricing the government is trying to do to help with the cost. We really won’t see the effect of that for a few years. Once they can negotiate more drugs than just a handful, I’m sure we can expect the drug plans to go down in price but not in the immediate future. We also need to be concerned with GLP-1 drugs for treating diabetes and now weight loss. There is a high percentage of seniors that can be qualified for these expensive medications. With a 2000 max out of pocket, could encourage more seniors to try them
 
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