It is open enrollment time for medicare. Things that seem too good to be true?

[Philly13]

I have been very busy working and have not had the time I would like to participate in the group, or even keep up with the information.

I feel a heads up might be useful, as we are in the middle of open enrollment, and it is a good time to take inventory of coverage. I am on Medicare and have found the Medicare.Gov site helpful and relatively easy to use.

My PDP was switched to WellCare when Aetna bought CVS. It motivated me to do some research. I created an account on Medicare.gov. The Medicare sight will list all options available within a zipcode. I uploaded my current meds and then it prices each option evaluating costs including premiums and deductible.

I take Abiraterone acetate (generic zytiga) and all but 2 plans put me in catastrophic coverage in January. The 2 that didn't purportedly keep me out of the coverage gap all year in 2020 and out of pocket caps in the $2,000 range. If true, that is roughly $8,000 out of pocket saving.

I have been trying to check if it is real. To date, I am not totally comfortable with the answers from the pharmacy and the insurance company. I will continue to work to find someone who can focus on 2020 and not give me canned answers from 2019.

At any rate, it is probably a good idea to evaluate coverage during the enrollment periods to see if better options are available.

I am not mentioning the insurance company yet. I want to make sure the government website and the insurance company has not made an error before sharing.

Best

Philly

[pleinairpainter]

Just sent you a private message via this forum.

[HopingForTheBest1]

I used to sell Medicare policies. As an independent agent, where I offered multiple companies, I would always use the Medicare.gov website for and with my clients. As you know, this site has a wealth of info and it gives you the ability to compare. CMS , the govt agency responsible for Medicare, makes sure the info is up to date and accurate.

It is always important during the annual open enrollment period to check out your prescription drug coverage to make sure you have the most comprehensive and cost effective plan specifically for the meds you take. You enter all of your meds on the site, and it will give you your options. More often than not you could save money by comparing.

[Cynthgob in reply to HopingForTheBest1]

The new catastrophic limit was increased to 6300$!!! But aren’t all Medicare D policies covered by catastrophic coverage? It’s a lot but at least you know you are capped at $6300. Thoughts??

[Survivor1965 in reply to Cynthgob]

Didn’t know they raised the deductible from $5050 to $6300. The problem I have with part D is the 5% co-pay with no out of pocket limit. That 5% adds up quick like to the tune of $500-$1000 a month for Xtandi/Lupron/Xgeva etc.

I am staying on my COBRA because it’s still cheaper than Medicare.

[herb1 in reply to Survivor1965]

Survivor: Be careful. I stayed on cobra for a short time when I retired, at about age 64. But because I did not initiate A and/or B when I was 65 I have been penalized (at least 10%) every month since--I am now 83! Go, talk to SS and try to get the facts

[Survivor1965 in reply to herb1]

Thanks for the reply. My understanding is the penalty is 10% a year, so in my case it would be about $15 a year. But that is a drop in the bucket compared to the many many thousands I would pay for the part D co-pay.

[herb1 in reply to Survivor1965]

For me it was 10%(OR MORE) PER MONTH! FOREVER!

[carbide]

I also try to get the best deal (part D coverage). We all try.

Sadly Big Pharma & Insurance has pricing FIXED. Americans pay the highest price for drugs. Often 10X's Higher than other countries with & without universal health care.

USA Congress has been Purchased by

Lobbyists!

List price on Zytiga, $15k/mo.

A Month! Then Insurance & Pharmacy

plays their foney discount game.

Like buying Water from bad guys in the desert!

[monte1111 in reply to carbide]

How much does congress pay for medical? Don't think they had to do Obama Care. Someone correct me, but it is probably zero $$$$.

[carbide in reply to monte1111]

Congress members probably would pay nothing. And,

Congress (both parties) accept big money from Big Pharma Lobbyists.

A bit late to move to Canada for me.

Vote for equal health care, Medicare with the drugs for all citizens.

Just my opinion.

[WayneSC]

I would encourage each of you to look at the GoodRX app for potential additional savings beyond what your drug plan may offer. It has provided substantial savings for me and our dog.

There is no charge to use the service and you can use the app without divulging your name.

There is a low likelihood there will be savings on highly specialized drugs.

[Buddy1950]

I so appreciate this discussion right now as I'm trying to figure out what might be best for my husband. Which drugs are prescription (part D)? I know the enoxaprin was covered if a nurse gave it under medicare, but if he gave it himself, it was not and prescription. Hard to predict which drugs might be ahead in the next year and it could be a costly mistake to pick the wrong company. Looks frightening to get prescribed Zytiga! Lupron is not prescription, and under the medicare/supplement plan? Sorry to be so inept at this.

[Cantabrigian51 in reply to Buddy1950]

Warning: I am not an expert, but I think I can answer some of your questions. Medicare part D plans are insurance plans which the government certifies. They don't all cover all drugs. You should check using medicare.gov/plan-compare/#... on the formulary (approved drug list) for each plan. This official medicare site will tell you how much your out of pocket cost will be, by month, for the list of drugs you submit. As mcp1941 says, there is no limit to out of pocket expenses. I found a list of the most expensive Part D drugs and most expensive drug was $14,000/yr out of pocket. Each of the plans will be different for a different set of drugs.

I also don't know if my oncologist will change my drugs next year, but I made up several possible lists and tried each one to find the cheapest plan for the given set of drugs. My oncologist was able to tell me the most likely next drug, so you might ask for advice.

Finally, as others have said, there is help available for patients who are in lower income brackets. Medicare limit for extra help is $28,720 for a married couple.

In Massachusetts - "applicants who are a minimum of 65 years old and receive Medicare are permitted an annual income of up to 500% of the federal poverty limit. As of 2019, single applicants can have an annual income up to $62,450 and married applicants up to $84,550. Note that this is the maximum income limit and benefits increase for persons of lower annual incomes. For applicants who are at least 65 years old and do not receive Medicare, there is no income limit."

Good luck. I agree that it should be easier to figure this out and the costs are out of control

Aside: Lupron is paid for by medicare because it is an injection given in a doctor's office. Medicare has arcane rules about what is and is not paid for.

[Buddy1950 in reply to Cantabrigian51]

I can't thank you enough. I have looked at medicare compare... and surprised as zytiga can be $150 a month at the local grocery pharm, 10,000 at walmart, 9000 local pharmacy ... and at Mayo $138,900 from cigna ... other palns more. Thank you so much, very nice of you to write all of this. Just in time as Friday is the Mayo appt and at least know to ask what might be ahead. --- Susan

[Philly13 in reply to Buddy1950]

Holy Moly Mayo. $138,900. WOW. I hope that has a Gift With Purchase included..

[dentaltwin]

My info is a couple of years old, but when I looked I saw that pretty much all the high-priced cancer drugs were non-formulary. This means practically that for these drugs, in all the plans I looked at, you were into catestrophic in the first one or two months. If you actually have a plan with a real cap on OOP expenses, for sure consider it. Also, it helps if you have a real local pharmacy with a pharmacist who will go to bat for you. I avoid the CVS/Walgreens and their god-forsaken PBMs.

I have Silver Scripts; at present I only take a few cheap generic drugs. My plan has paid my pharmacist not a penny. I don't know how he survives.

[Philly13 in reply to dentaltwin]

My research, so far, indicates you are not correct for 2020 for the ridiculously expensive pharmaceuticals many of our fellow Pca warriors take. plans are regional. Information for me in Pennsylvania is likely different than other parts of the country. I think the deadline for enrollment in new plans is December 7. I urge everyone on reading to invest time on Medicare.gov. Try to anticipate what the next year might bring. Cigna lists dozens of pharmacies but only 2 will keep me out of the freaking coverage gap.

My local pharmacy where my Dad was friendly with the owner’s Dad does me no good. I have been using them since 1967. It was painful to leave them. A long time employee told me he has to use one of the chains also.

Side note, I hate the term survivor. Quirky thing, but I am a warrior fighting actively. Survivor is passive. Not the way I want to think.

[dentaltwin in reply to Philly13]

It's quite possible there are regional differences. However (and this may differ by region as well) different insurers have somewhat different formularies, and the tier level of meds in one plan may be different for others.

[mcp1941]

My OOP expenses on Part d will be over $10,000 this year. There is no such thing as a cap on OOP expenses as far as I can find out. I am being treated for PCa and Multiple Myeloma.

Mike P.

[Hidden]

Please share when you can Philly.

[j-o-h-n]

Thanks Philly....... just think how much we save on condoms..........

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/06/2019 7:32 PM EST

[Philly13 in reply to j-o-h-n]

Hahaha. And more haha. Habits are hard to break so I still buy them though the size has changed to a difficult to locate microscopically small.

[j-o-h-n in reply to Philly13]

I now use saran wrap instead..

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/06/2019 9:45 PM EST

[monte1111]

And taking Dolly to dinner.........

[j-o-h-n in reply to monte1111]

I just make it up to her with flowers... she just loves them.....covers up her smell of vinyl...

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 11/06/2019 9:49 PM EST

[TFBUNDY]

Oh the joy to be born British.... Unarmed police, unarmed criminals, and FREE health care...