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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.
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