What am I missing? (Reaching catastrophic phase)

[InsuranceKnight]

Noticed several of my PDP reviews are reaching $0 well before the $2000 cap when looking at the monthly breakdown.
Below is one example.
Thoughts other than Medicare.gov is calculation wrong and producing wrong estimates?
What am I missing?

 

[Winger]

Uses Medicare standard model of part D to calculate costs to the $2000. $590 deductible and 25% of drug costs. Doesn’t matter what member is actually paying. I believe…

 

[InsuranceKnight]

Sorry. Not following. I don't see how they're reaching $2000 from the screenshot above. FYI, the screenshot above is AARP's $0 deductible plan.

 

[InsuranceKnight]

Here's another example with a deductible plan.

1. January: Takes all meds; Meets the deductible immediately w/ cost sharing = $711.80
2. Feb & Mar: $182 for the only medication w/ Mounjaro = $182.01
3. April: Takes all meds; $376.29, but Walmart shows $372.19 which I'm assuming it's entering catastrophic phase.
4. May-Dec: Showing catastrophic figures of $0 for remainder of the year.

Clearly those figures don't add up to $2,000.

Everything I read says the $2k cap is based on what the bene pays. Is it also factoring in what the drug manufacturer contributes?

 

[Midlevel]

Winger is correct. They take the higher of the standard 590.00 or the deductible their drug plan has. In this case if the plan has 0.00 deductible they still apply the 590.00 towards 2000.00 max. Then next month they take what is higher, the client’s copay or 25% of the total drug cost. I have 1 client taking 4 expensive drugs for a total of 41000.00/year. He is going to pay around 600.00 total on the BCBS MAPD due to 0.00 deductible and 47.00 copay on all 4 drugs.

You should have learned this in every carrier meeting you attended. It’s been known since beginning of September.

 

[InsuranceKnight]

Winger is correct. They take the higher of the standard 590.00 or the deductible their drug plan has. In this case if the plan has 0.00 deductible they still apply the 590.00 towards 2000.00 max. Then next month they take what is higher, the client’s copay or 25% of the total drug cost. I have 1 client taking 4 expensive drugs for a total of 41000.00/year. He is going to pay around 600.00 total on the BCBS MAPD due to 0.00 deductible and 47.00 copay on all 4 drugs.

You should have learned this in every carrier meeting you attended. It’s been known since beginning of September.

I haven't attended any carrier meetings as I don't sell MAPD or PDP. I'm trying to help our Medigap clients and I came across the above situations a few times. Medicare.gov sometimes produces odd results and was trying to ascertain if that was what was happening here.

 

[Midlevel]

I haven't attended any carrier meetings as I don't sell MAPD or PDP. I'm trying to help our Medigap clients and I came across the above situations a few times. Medicare.gov sometimes produces odd results and was trying to ascertain if that was what was happening here.

You should broaden your horizons and show clients all their options rather then just one. They would really be amazed how good they come out with no premium, no deductible and 47.00 copay. That being said the full cost of drugs is still way off depending on which plan you are looking at but they will still hit their max well before 2000.00 depending on the plan.

 

[annon123]

What they pay actually depends on if they have a basic or enhanced D. That affects true out of pocket expenses (TrOUP) i

A basic D is exactly what you think - what you pay is what counts.

With an Enhanced plan that is not how they do it. You may end up paying less than $2000. The TrOUP is different.

MAP's prescription works differently like this too.

This is NOT my video and don't know him but he does a very good job explaining the differences. Of course his basic explanations you won't need about D to begin with which is the first part of the video so start at about 7:30 in the video) but his examples will help show the differences.

He also has a link to the medicare file (so watch on youtube and not on here) that shows which plans are enhanced and which ones aren't if you don't know that already (video has youtube ads unfortunately).