Medicare Part D plans and PCa

Never gave Medicare Part D plans too much thought until this last year. Between my wife and I, it seems that some meds cost a lot more than they should and there is quite a variance between plans and cost.

Since the potential always exists for the need of more expensive cancer drugs for any of us, I was wondering how everyone is doing with the costs related to the newer medicines available? The Part B injections are not the issue but the drugs that one takes at home on some schedule and get covered under Part D.

My research based on my wife’s Ibrance yields an annual out of pocket of $11,000 pretty quickly. We have even getting it for free from Pfizer but that could end at any time. I assume the newer PCa drugs are similar. Comments?

Also, any experience with WellCare for Part D coverage?

My wife went on Medicare earlier this year, and after look over many many choices for Part D it seemed that Wellcare was the best deal for her particular meds (she has chronic migraines). We have been using it since March, there have been no issues so far. I plan to be going on Medicare in January, and will probably also be using Wellcare, but will have to see (A) if I will be continuing Orgovyx and (B) what different insurance will cover. So far I have been on ACA BCBS and they have covered it 100% w/no co-pay, but I see that the retail price is $2200 per month!

TomTempe said...
My wife and I have always been very healthy as far as needing medicine goes.
I didn't see paying for Schedule D. They do rip you off like 10% extra for each year you do don't sign up. (guessing from memory)

I'm still technically getting meds from the VA so that will qualify me as having a plan in case I have to opt in.
I'll take my chances on my wife, but she only takes a thyroid pill; $10 for 3 months supply.

Most people aren’t getting their meds from the VA.

If you have any cancer history you would be brain dead not having Plan D. Even a $8 a month D plan keeps you out of the penalty box of not buying Plan D if you need a better Plan D in the future.

Post Edited (Duck2) : 10/1/2021 9:37:08 PM (GMT-6)

Steve n Dallas said...
My Independent Agent contacts me each year (this week) and asks for my prescription information.

This past January he switched me from WellCare to Aetna Medicare Silverscript SmartRx . My monthly premium went from $13 to $7 and the monthly cost on my two prescriptions went from $15 to $-0- per month.

He had mentioned in the beginning that switching every so often is the name of the game. Each company offers lower prices to get your business.

Ever since my diagnosis and subsequent treatment I have reviewed all the Part D plans available in my state every year. Right now I'm doing well, but if things should change for me I assume ADT will be next in line for my treatment regimen. Therefore, each year I go through each plan and determine what my out-of-pocket costs will be should I have to start an ADT treatment plan. Admittedly, I'm making assumptions on what those drugs will be but I ask the Uro and RO during annual visits to narrow the field. I use that info to help choose which plan will be of greatest treatment and financial benefit for me during the next year.

Surprisingly, there is quite a difference in plan premiums and out-of-pocket costs if these drugs are needed.

"If you plan for it, you will likely not need it."

e.noont - Sounds like you do what I am starting to do. I am getting ready to put my research into a spreadsheet so it will be easier to see everything at one time and also have the GoodRx prices for a baseline comparison. As a retired engineer, this is like a sport to me that may serve little purpose in the end but have to run the numbers anyways or it may drive me crazy.

I was really surprise to see that in the Twin Cities, WellCare Value script has a $10.60/mo premium cost and total estimated yearly cost of $167 for the standard medications I take. Silverscript SmartRX has a $6.80/mo premium cost but has a total estimated yearly cost of $379. Both of these are much less than my BlueRX plan where the premiums have been going up a lot each year which drives the annual cost up quickly even though I pay little for the meds themselves.

The principal problem on the low end is the $480 deductible and how meds are treated in the first couple of tiers. The really cheap generics are either no cost or a few dollars per quarter but if one of them is not treated that way, the cost jumps up a lot as you actually pay for the drug cost. I have experienced that during the last couple of years when I pickup a certain antibiotic and the cost is $50 which is more than the total cost of the other drugs I take annually.

The numbers tend to even our more when I start adding various expensive meds and the Medicare comparision keeps changing the annual cost sort order for each more expensive drug I add. Usually the total cost is within $1,000 between most plans which is not that big of a spread on the high cost end.

It may be that I will just go with a cheap plan for today's meds and let the chips fall where they may if the crap hits the fan someday. Always can change again each Jan 1st once I know what the near future holds.

Still would like to hear from those that have WellCare (and Silverscript) about their experiences. I am going to chat with my pharmacist as well in the next week or two once I complete my study.

halbert - You should consider finding a Independent Agent like I did.... I was reading and researching and getting confused by the minute... I thought I wanted an Advantage Plan from all of the tv commercials I had been bombarded with.

My agent explained the pros and cons and I ended up with a Plan G and D policy.

One tid bit of good news.... If your birthday is May 25th, your Medicare will start on May 1st.

halbert - I don’t think you will find any advantage in trying to covert plans within Anthem/Express scripts unless they already have Medicare plans that you could access from your previous employer with a cost benefit. The rules are different, you need new cards, and so on. I don’t think Express scripts is/has a Part D plan either.

My wife retired from the school system and has access to a BCBS Advantage plan for 5 years that they negotiated as part of a group plan so the drug part is good. Otherwise it is an Advantage plan with its pluses and minuses. We skipped it as they would reimburse us for a Supplement plan up to their plan cost and my wife is a cancer survivor also.

Not having that or any other subsidized plan available, you study the medical and drug plans for cost/coverage and pick whatever makes sense. In any case, you should sign up for Medicare at age 65 no matter what happens since it is no cost until you turn on Part B.

Hal, most employer sponsored retiree plans include prescription drug coverage negating the need for Plan D coverage. And by having it you are exempt from any Plan D surcharge should you need it in the future. Some on retiree plans also get a Plan D if their primary coverage has a dollar limit and they are on an expensive drug like Xtandi.

Wife and I have been lucky, she is a NYC Retired Teacher and we have had Traditional Medicare + an Emblem Health Plan F Senior Care Supplement. The supplement has always been paid for by the City for all retired city retirees and in addition they reimburse us for all Mediccare part B and IRMMA premiums. However starting in 2022, all employees are being switched to a group Medicare Advantage plan which is being run by Emprie BC/BS AND Emblem Health Jointly. We have a choice to stay on our current plan, but will have to pay $191 per person, $382 per couple per month to keep what we have.

I want no part of an insurance company getting between me and my doctors medical decisions, so i am going to pay out of pocket to keep what i have. There are multiple lawsuits against the city trying to stop this, but it remains to be seen whether they bear fruit.

The one thing we do pay for is Emblem Health/Express scripts Part D which costs us $150 pp, $300 per couple, not including any IRMAA adjustments. Drug coverage is NOT reimbursed by the city, unlike Medicare part B. From what I have read on this thread, sounds like i should look at other options for drug coverage. Which i will do.

GoBucks - Good example of how these drug plans make little sense. I also got AARP MedicareRX Walgreens as the low total price with Abiraterone by a long shot. It was a $1,800 total annual cost vs. my current BlueRx insurance at $10,894. A lot of the plans were in the $10K range. Maybe they were the only ones to obtain the cheap generic version from India?

I checked GoodRX coupons and the annual cost of Abiraterone runs from $260/month at Costco to $3,276 at Walgreens, figure that out.

You can pick other expensive drugs and get a different order of total cost. Your example was the largest I have seen when testing the policies for possible drug changes. It is one thing to look at drugs you are on currently, another to project possibilities with PCa.

With recent PSA tests suggesting I may be at the start of ADT resistance, I checked my Blue Cross Medicare Advantage formulary for co-pay requirements for Zytiga and Xtandi. These drugs are in Tier 4 - meaning I would have a 28 percent co-pay. I also see these have a published cost of 10 to 12 thousand dollars per month. I have no idea what people actually end up paying, but without some kind of cost relief from the drug manufacturer, the simple math comes out to a co-pay of over $3,000 per month. Does anyone really have to pay that? Or is this like college tuition, where hardly anyone other than the rich pays the full show price for tuition, room, and board?

In any case, I'm lucky in that I have the VA as a fall-back. As long as a VA oncologist agrees with my Dana-Farber oncologist when the time comes, I'll get these drugs for free from the VA. But not many people have that option. Because of my VA disability rating I have no co-pay through the VA. But even if I was in a lower rated VA priority group, my annual drug co-pay would be capped at $700. I find it bizarre that under one federal program - the VA - an eligible patient's out-of-pocket maximum is $700. But under another federal program -- Medicare -- there is no drug coverage at all, and even with a Part D or Medicare Advantage plan the patient is on the hook for potentially tens of thousands of dollars.

Thanks Mumbo,
These drug prices and convoluted insurance requirements are insane.

Sad to say we didn't go to Merlefest this year. They rescheduled it from April to September, allowing time for more people to get vaccinated. And they required proof of vaccination or a negative test to get onto the festival grounds. Our tickets from the cancelled 2020 festival were rolled over to this year so we could have gone. But looking at the percentages of people vaccinated in rural North Carolina vs here in Massachusetts, we chose not to spend four days at a crowded music festival. And even though festival-goers had to prove vaccination status, the vaccination rate among local residents and the reports of break-through cases even among the vaccinated was enough to keep us away.

I'm hoping things may be better come April 2022, but I expect instead of Merlefest we will now be looking for smaller more local venues going forward. Maybe COVID is nature's way of telling us that at 75 it might be time to rethink making 2,000 mile trailer towing trips.
Jim

I got my statement today from my BC/BS Medicare Advantage Plan for the 3-month Lupron shot I got in August. Theoretically, under the BC/BS formulary I have a 27% copay this year ($28% in 2022). The statement shows “amount charged” by Dana-Farber was $2184. Amount allowed by BC/BS was $507. And my co-pay is $101. So based on this, the copay is a function of the amount allowed, not the drug company’s asking price. But even then, the math doesn’t work out, though it is to my advantage. My co-pay comes out to only 20% not 27%.

Anyway, this suggests that copays for the truly onerously expensive drugs like enzalutamide, and apalutamide acetate is a percentage of the “amount allowed” not the drug manufacturer’s published price. Though even if a monthly asking price of $10,000 to $12,000 is heavily discounted by the insurer -- what is the "amount allowed" under whatever deal the insurer has with the drug manufacturer?
Jim