Will a $0 deductible Rx Plan count $590 toward the $2,000 limit?

[wehotex]

I’m doing the comparisons between the various MAPD SOBs that are trickling in. One of the carrier reps posed this question to me about the lack of deductible applying to the $2,000. Is there any documentation that shows how/what the carriers will use to compute the $2,000 limit?

 

[Special Agent]

I’m doing the comparisons between the various MAPD SOBs that are trickling in. One of the carrier reps posed this question to me about the lack of deductible applying to the $2,000. Is there any documentation that shows how/what the carriers will use to compute the $2,000 limit?

yes but if someone is taking expensive brand name drugs and it is a fact that they will hit the 2000 troop they will most likely be better off with a higher premium standalone part d plan with no deductible and fixed tier 3 copayments like the UHC preferred plan because the insurance company is contributing to the troop starting the first month.I have seen examples where someone on Ozempic will pay 47.00 until July having met the 2000 tropp but only coming out of pocket 329.00.I looked at the pdf 2025 formulary for the UHC preferred plan and from first glance most of the drugs that where tier 3 in 2024 are still tier 3 in 2025.ie Eliques,ozempic

 

[wehotex]

yes but if someone is taking expensive brand name drugs and it is a fact that they will hit the 2000 troop they will most likely be better off with a higher premium standalone part d plan with no deductible and fixed tier 3 copayments like the UHC preferred plan because the insurance company is contributing to the troop starting the first month.I have seen examples where someone on Ozempic will pay 47.00 until July having met the 2000 tropp but only coming out of pocket 329.00.I looked at the pdf 2025 formulary for the UHC preferred plan and from first glance most of the drugs that where tier 3 in 2024 are still tier 3 in 2025.ie Eliques,ozempic

Which quoting engine are you using?

$590 + $329 would only equal $919. Which other figures help to reach towards the $2,000? Is the 10% manufacturers’ discount being applied to the $2,000?
$590 + $329 + $700 (estimate price of Ozempic $1,000/mo (10%). = $1,619

 

[Special Agent]

Which quoting engine are you using?

$590 + $329 would only equal $919. Which other figures help to reach towards the $2,000? Is the 10% manufacturers’ discount being applied to the $2,000?
$590 + $329 + $700 (estimate price of Ozempic $1,000/mo (10%). = $1,619

it is the difference between standard plan 25% and copay so in the case of a drug like ozempic that cost about 1000.00 they are getting 250.00 per month towards their troop even though they are only paying 47.00 per month

 

[Yagents]

yes but if someone is taking expensive brand name drugs and it is a fact that they will hit the 2000 troop they will most likely be better off with a higher premium standalone part d plan with no deductible and fixed tier 3 copayments like the UHC preferred plan because the insurance company is contributing to the troop starting the first month.I have seen examples where someone on Ozempic will pay 47.00 until July having met the 2000 tropp but only coming out of pocket 329.00.I looked at the pdf 2025 formulary for the UHC preferred plan and from first glance most of the drugs that where tier 3 in 2024 are still tier 3 in 2025.ie Eliques,ozempic

Care to factor in the premium of $100 month?

 

[Special Agent]

Care to factor in the premium of $100 month?

Well obviously that is a factor but a 100 premium plan that has an all in cost of less than 2000( in the ozempic example all in cost is 1329) is better than a 0 premium plan that has a 2000 all in cost- if my math is mathing correctly.

 

[MedicareWAA]

what worries me about the new Part D benefit is that agents need to be quite skilled to find the most suitable plan for a client. It’s simple when the person is very healthy. If they take an expensive drug, or in such health that an expensive drug will possibly be added soon, the math can get quite complicated.

You have to consider the actual out of pocket costs, which will be frequently based on two hypothetical scenarios (standard and enhanced designs) plus each plan’s actual negotiated rates. I’m not even sure most agents understand that’s how it works next year … that you can reach $2,000 without paying $2,000, and that everything varies by specific PBP.

This is especially true with MAPD because you then must balance the Part D math against all the other plan benefits.

I am worried because lots and lots and lots of agents don’t have the skill or interest necessary to do this properly. I’m not too confident that the online platforms (SunFire, MedicareCENTER) will be smart enough to do the math properly. I hope I’m wrong. In fairness, MedicareCenter is pretty good at showing the plan-specific negotiated cost of each drug. That’s essential with coinsurance, and the standard benefit comparison is always based on 25% coinsurance.

 

[wehotex]

Well obviously that is a factor but a 100 premium plan that has an all in cost of less than 2000( in the ozempic example all in cost is 1329) is better than a 0 premium plan that has a 2000 all in cost- if my math is mathing correctly.

To his point, $50 (12) = $600 premium/yr + $590 deduct + $1,410 (25% of Ozempic cost) = $2,600

$100 (12) = 1,200/yr + $1,400 = $2,600

Isn’t it the same?

 

[MedicareWAA]

To his point, $50 (12) = $600 premium/yr + $590 deduct + $1,410 (25% of Ozempic cost) = $2,600

$100 (12) = 1,200/yr + $1,400 = $2,600

Isn’t it the same?

I’ll assume Ozempic is $1,300 plan rate

Standard benefit design with $0 plan premium is $590 deductible + $1,410 = $2,000 true out of pocket cost.

Enhanced design in a PDP with $100 premium, no deductible, $45 copay means the member reaches the $2,000 OOP by actually only spending only (approx) $188 out of pocket. By the end of month 4, they’ve reached the max. Now add the $1,200 premium and the enhanced plan saves the enrollee a few hundred bucks.

The big discrepancy is when you have MAPD with that same enhanced benefit design. In many markets, there’s at least one of them that lets you hit the $2k max by only spending about $200 out of pocket.

In other words, in this very realistic scenario, the member basically pays nothing for their ozempic. Nor do they pay a plan premium.

This is an example of when an advantage plan will be so compelling as compared to a supplement and any standalone drug plan.

It’s worth noting that this is how the current administration decided to administer the program. The law doesn’t say it has to be this way … the whole comparing standard vs enhanced and having the bigger number accumulate toward the max.

 

[Special Agent]

I’ll assume Ozempic is $1,300 plan rate

Standard benefit design with $0 plan premium is $590 deductible + $1,410 = $2,000 true out of pocket cost.

Enhanced design in a PDP with $100 premium, no deductible, $45 copay means the member reaches the $2,000 OOP by actually only spending only (approx) $188 out of pocket. By the end of month 4, they’ve reached the max. Now add the $1,200 premium and the enhanced plan saves the enrollee a few hundred bucks.

The big discrepancy is when you have MAPD with that same enhanced benefit design. In many markets, there’s at least one of them that lets you hit the $2k max by only spending about $200 out of pocket.

In other words, in this very realistic scenario, the member basically pays nothing for their ozempic. Nor do they pay a plan premium.

This is an example of when an advantage plan will be so compelling as compared to a supplement and any standalone drug plan.

It’s worth noting that this is how the current administration decided to administer the program. The law doesn’t say it has to be this way … the whole comparing standard vs enhanced and having the bigger number accumulate toward the max.

If you assume Ozempic at 1300 then for enhanced plan with no deductible ...

first month consumer gets 590.00 + 25% of remaining amount of 1300 drug cost which is 710 x .25% = 177.50 for a total of 767.5 credit towards troop in january then each month after the get 325.00 towards troop

In this scenario if they have 47.00 tier 3 copay then thy reach troop in 5th month after paying only 235.00 oop