Part D. . . makes me crazy!

Well, it had to happen some time. I have had Blue Cross/Blue Shield, in addition to Medicare for 11 years now. Just this year, our Blue Cross plan changed its prescription drug coverage from the usual BCBS plan to a "Medicare Part D Equivalent" plan (wording is my own, they have a name for it, but I've forgotten the name). They claim that their new formulary now matches that of Medicare Part D.

This new plan is supposed to be the government's way of making prescription drugs "more affordable" for the plan participants. Well, sort of.

Some of my meds which used to carry $5 to $10 copays now only cost me $3 or $5, some even free. But ONE of them more than eats up any savings I might have gleaned from the mandatory plan change. That one is Tadalafil (generic Cialis), 5 mg., daily dose. I have been using this, off label, for 5 or 6 years to help with BPH.

I got a letter from the plan admin that the coverage for this med has changed. You bet it has! The plan no longer covers it AT ALL! Not the generic, not the branded product. Just NO! Their instructions are "Talk with your doctor to see what else you could possibly take." Really? First, it would probably take me a couple of months to get an appointment to discuss this. Second, what alternatives exist for off-label usage of meds?

To give you an example of the cost for this, my prescription is written for 90 tablets every three months. I used to pay a $10 copay for the three months' supply. Now, without insurance, it would be $967!

When I called the uro's office and spoke with the nurse, she said that she had fielded several calls about this exact issue. Her advice was to look up "GoodRx" and that a number of their patients had good results with them. I tried it, and my 90-day supply cost me $24. Not $10, but surely not $967.

So, a warning to others who may be using Cialis/Tadalafil and have BCBS. Be ready for the shock, and check out alternative ways to buy. For this one alone, I bypass my insurance entirely and use a third-party prescription benefit management company. The others still go through my insurance plan.

I hear you, Mumbo. The added wrinkle for me is that I really don't have a separate Part D plan. For many years our prescription meds coverage was simply a feature of our BCBS insurance plan. It was all-inclusive. This year it is still included within our plan premium, but they changed the prescription coverage to use the Part D formulary. We do not get a choice. It is the whole plan or none. The medical coverage is super good, so we need to stay with the plan. They claim that the new formulary will save money for the "average" patient, but for those having certain drug needs, the new plan is vastly more expensive.

The discontinuation of tadalafil was a surprise to me. Why drop this one? Sildenafil/Viagra is covered, but it does not have the same off-label use for BPH. They left my TRT coverage the same as before, and I expected more push-back on that one. The copay remained $10 for a 90-day supply of the gel that I use.

I did fill the tadalafil with GoodRx, and it was only $24 for 90 days. I can live with that, for sure, but it just now complicates the periodic refill process. Now, I use three different pharmacies, with different insurance/discount plans and at all different refill dates. Life used to be simple with one drugstore trip and one mail-order every three months. It is a good thing I am mostly retired and have the time to take care of this.

The government decided we could not get Cialis or other one's like Viagra but they can!
Usual bs
I use tadalifil for bph and use Good Rx

They didn't want people on Medicare or Medicaid getting a medication that aids in sexual encounters.
Glen

My wife and I transitioned to Medicare in the fall of 2023. We made the decision to go supplement rather than advantage. The tadalafil was no shock to me--it wasn't covered within the previous Express Scrips plan either. As other have pointed out, goodrx is great--but it's interesting that it depends on the pharmacy chain you use. CVS lists almost no savings with it, but Walgreen's was down in the $25 range for 3 month supply.

I also went to wellcare, and that $.50 monthly premium almost feels too go to be true. Bottom line, Medicare+supplements is overall saving me a LOT. No longer having $1500/$3000 annual deductibles for medical care is fundamentally a good thing.

All true and valid comments. Our medical insurance "supplement" is the standard BCBS plan that is offered to Federal employees. Up until the current revision, it was great. Between Medicare and BCBS, nearly all the medical costs were covered, with very manageable prescription costs - as long as you were willing to use generic meds and were able to use the mail-order pharmacy for a few of the pricey ones.

Now, some of my generics got even cheaper BUT I have to go outside the insurance plan, using GoodRx, for the tadalafil and my wife has to figure out how best to get her asthma inhaler. That one used to be very reasonable with "old" BCBS, but now the revised plan no longer covers the generic inhaler, and the branded one is expensive and has some limitations as to quantity/frequency of refills. Even GoodRx is more expensive for that one than the old plan was.

I guess somebody comes out ahead with the plan revisions, but it sure isn't me.

Mumbo said...
…As a side note, I got BCBC Part D drug plan also and it was really expensive for the same coverage as the cheap plans so I dropped it after two years. My WellCare plan is now $0.50/mo with no cost for BP, Lipid, etc meds. However, they are terrible with many other drugs so I go another way for those. Many men are only taking BP and Lipid meds so this plan is the cheapest by a mile…..

That where I am as well. I use GoodRx or CostPlusDrugs for things not in my plan. The one who really saves by doing this is my wife who takes some expensive eye drops. Every time she needs a refill she works the links and finds it for much less than if it was in our Part D.

We have the fifty-cent per month WellCare D plan. For long term management of my wife’s breast cancer her oncologist has put her on Ibrance. 21 daily pills each month. Retail price is $13 grand per month. As a tier 5 drug we were looking at a copay of $2,750 the first month. The pharmacy has two specialists devoted to finding money for patients and we qualified for two grants. The first was from Pfizer and they provided the first month free. The second pays our copay. Thus, no direct cost to us.

This is coupled with a monthly shot that gets reimbursed at about $3 grand each. Of course Part B and our supplement plan pays all but the $240 yearly deductible.

Cancer management can be very expensive.

Besides Good Rx, you might check out DiRx. Tadalafil is quite reasonable through them.

GoodRx for Tadalafil in my area is certainly reasonable. For a year's supply (if taken daily) at Costco:

5mg: $100
10mg: $164
20mg: $171

I only take 20mg "as needed" so one script goes a long way...

Jim