Looking at an expected giant drug cost for 2024 for my wife, and running the Medicare compare site it seems that the zero cost Wellcare plan has a lower total cost than any other of the 27 plans offered in my area. This seems to be because the catastrophe level is exceeded, and so total cost for Wellcare is lower due to the zero premium. That defies common sense. What am I missing?
Plan D no monthly payment too good to... - Advanced Prostate...
Plan D no monthly payment too good to be true?
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cigafred
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Wellcare gets really bad reviews in past years.
It's not too good to be true! Hubby had it last year, all was good and will have it again 2024. It is a Zero premium and as you said after his first Nubeqa is filled, will be Zero the remaining of 2024 (should be close to $800 per month). Since he's had it all this year, his renewal shows what the premium and Nubeqa cost for 2024 will be. So good for it, it's NOT too good to be true and we've had no problems with Wellcare! 😄
Double check that your specialty pharmacy is in network for 2024 if you use one, they seem to have removed most of them.
Very good to know. First I have heard about this twist. Thanks.
In my area they are going to cost me $0.50/month. I have a friend who had them last year with no issues. I've signed up it will save me about $1,500 next year.
It’s $0.40 in our area (west coast)!
We had Wellcare this year and it was fine. But for 2024 they have removed our specialty pharmacy from the network. AFAIK you have to use a specialty pharmacy to get certain drugs (Orgovyx, Erleada, all the other expensive cancer drugs). So be very sure there's a specialty pharmacy in network before you sign up if you use one. It looks like we will have to sign up for a more expensive plan for this reason.
BTW, Wellcare still lists our specialty pharmacy as in network on their website for 2024, but there's a big asterisk "subject to change". So I think we have to go with what's showing on Medicare.gov
I did not even notice "specialty pharmacy" on Medcare.gov. I will get on it now. Thanks.
Thanks for really useful information, very helpful.
I have been with two different plans while on Nubeqa. MVP two years then, now 2023, Unitedhelthcare through AARP.Both plans I smashed through the catastrophic level the first month. Different copay by far however that I didn't look at. United ws much higher for Nubeqa, much.
But I am also it's a 503(c) that covers Nubeqa and other Cancer related treatments fully so other than on paper I am ahead on other costs. Went from MVP @ $45/month to $0 per month plus OTC $$.
Point is look at everything before changing plans
I’m on Nubeqa and get it for free from Bayer since my annual household income is less than $91,000. Very grateful for that. For my other prescriptions, I have a pretty inexpensive plan through Aetna, but I end up using Good RX when I pay for the drugs — I’ve found that 99% of the time it’s much cheaper than using the prescription drug insurance.
I was surprised ,too, when I checked at Medicare.gov. That new law seems to be really having a good effect.
You can always change drug plans again next year if you are not satisfied.
The new law would be the Medicare Part D reform that was included in the Inflation Reduction Act. cms.gov/inflation-reduction...
I also using the Wellcare plan for 2024. I checked with Medicare they agreed, it gives me the best overall plan,
This all sounds good to me but what is the yearly deductible for the D plan? That’s usually the catcher.
The standard deductible for 2024 is $545. But it's lower on some plans, usually on plans that have a higher monthly premium. You just have to go on medicare.gov and look at the total yearly cost for the meds you take on the various plans.
I have plan F at $186.00 per month and no deductible. No deductible for hospital stay. Just got out of Hospital with a sepsis hip joint. Everything will be covered and nothing out of pocket. By my recollection if I were to have D $1600 deductible for hospital. Im I missing something?
Plan F sounds like a Medicare supplement plan, not a Plan D drug plan
That’s where I’m making the mistake.
This alphabet thing is confusing sometimes.
I have Medicare, a Medicare Supplemental Plan F, and a Medicare Part D Drug Plan. I think most of the discussion here is about Part D Drug plans.
I have plan f as well. I am trying to switch to g this year. Don’t know if I can. F and g are the same except f covers Medicare b deductible but costs about $50 more per month. When I first got it it was a wash but not available any longer for new people coming into Medicare so premiums continue to rise due to lower numbers in the plan.
Part D is a separate plan you have to have to cover drugs on medicare. It's in addition to your supplemental plan (which for you is plan F).
Hospital stays are covered under Part A. Your supplemental plan F covers the part of the hospital stay that wasn't covered by medicare Part A.
Thx 👍
I have used Wellcare part D plan for the last 5 years and am totally pleased using CVS (a Wellcare preferred pharmacy) for the generic meds and since my cancer diagnosis/treatment mid 2022, the MDACC specialty pharmacy for Orgovyx and Erleada (until I got a Janssen grant for the the Erleada a few months ago). The first month of these obscenely priced drugs will fulfill all deductables and get through the "donut hole" leaving only a 5% copay at most for any covered drugs the rest of the year. If memory serves ... Wellcare started around $20/mo for me and in 2024 will be a bit over $5/month. Looking at the EOBs, medicare payment documentation, etc. - I'm thinking that Wellcare is getting some sort of small percentage for handling even the part D drug copays that Medicare pays which is the only way I can figure they can offer these paltry rates. My wife also switched to Wellcare part D last year and has also had a good experience with her medications for diabetes, etc.
Pretty sure the 5% copay is gone now.
I stand corrected. I just logged into my medicare.gov and looked again at the 2024 changes to my Wellcare plan. $6.30/month; $545 deductible; my current total drug cost + premium cost for 2024 estimated at $3411.29 including Erleada and Orgovyx. After the January copay of 3335.69 the following months indicate a $0 copay for all rx. I'll be stopping the ADT (after 24 months) in August of 2024 until my psa indicates otherwise.
I'm looking to enroll with Wellcare as my part D provider and like you I'm taking Erleada . And similar to you, my yearly cost worked out to $3338 with just one payment of $3343 in January and no further payments the rest of the year. What I dont understand is the fact that the maximum part D out of pocket for 2024 is $8000, Not complaining, but why aren't the yearly charges $8000 instead of $3343?
Also did you have any hassles getting Erleada free from Janssen while on medicare? Finally what happens if you've paid your total yearly payment upfront in January and you discontinue a drug during the year can you claim a refund? Thanks for your help.
Hi lefty26,
Plan D has 4 payers – the plan (Wellcare in this case), the patient, medicare, and the manufacturer.
(see table in reply below as to who pays what/when - couldn't make it work in text)
Orgovyx Drug Cost/month (as of 11/6/23) = $4530.62; Wellcare paid 2573.73; I paid $135.45
I filled Erleada in January 2023 (before my Janssen grant and before/after I exited the donut hole) Erleada Drug Cost / month = $ 23535.70; Wellcare paid 12395.68; I paid $3329.91
My MO and the pharmacy at MDACC suggested and submitted the Janssen grant after I filled out the majority of the form (the doctor has to fill out part of it). The Janssen guidelines are 1. you have commercial, employee-sponsored insurance, or government coverage such as Medicare. 2. You live in the U.S or territory; 3. You have been prescribed an eligible Janssen medication; 4. You meet the income requirements for the specific medication. (Erleada income limit is 87480/household of 1; 113320/household of 2; 210840/household of 5)
Initially I also had to prove I paid over 4% of my annual income in prescription copays which the orgovyx and erleada copays took care of in January 2023.
Additionally...
I applied and received a grant from the Healthwell foundation back in 2022 and another from the Pan Foundation which help with copays (though the Erleada can exhaust them really fast). Another one is the Patient Advocate Foundation Co-Pay Relief. These grants are usually only open for a few days (or maybe hours) so you need to get your ducks in a row and respond immediately when they are open. If you sign up, they will alert you via email (and maybe text) when they have money available for specific funds like prostate cancer drug copays.
You aren't paying a yearly payment upfront, just a month of these obscenely priced drugs.
Best of luck with all this...
How did you learn about the companies that can provide assistance. Do you happen to have any of the phone numbers. We have Pan Foundation, but when the renewal time came, they were already full and we’re on a waiting list. Thanks.
During my 2 months in a temporary apartment during my proton therapy I had a lot of time on my hands and spent a morning searching for grants (mainly for the Erleada at $27k+ per month). Three others that help with drug-specific copays are: The Healthwell foundation, Patient Advocate Foundation Co-pay Relief, and The Assistance Fund. The Pan Foundation has an alert called Fund Finder that can help to alert when these funds have money available. I applied to all even though money was not available and they will send an email when money is available and you can then finish your application. There may be a text option on some. You have to stay on top of it because the money is usually only available for a few hours at most. Once you are funded you have some precedence over new patients, but still have to respond within hours to extend or renew your grant. If you don't use your grant within 3 months, they automatically close your grant and return your grant money back into the pool for others so there is some "churn" making funding available when folks stop using these drugs for whatever reason. Good luck
Thank you! This is so helpful. My husband has about $550 left from his Pan Foundation Grant, but that’s not enough for it to cover the copay and Pan told him he couldn’t apply for new grant until current grant was $0, and the current grant applications filled up so fast so he had to find something else. It’s good to know after 3 months Pan will take the money back and then he’ll have a $0 balance. We’re going to use Mark Cuban’s CostPlus pharmacy for now. I’ll look into the other plans you mentioned. I really appreciate you getting back to me. I think I’ve been more stressed out about this than at any other time in this PC journey!
Even if the $550 won't cover the full copay, it could be applied to partially pay for the copay and you pick up the rest. I had that happen in January of 2023 (getting through that donut hole...) and the MDACC pharmacy used what was left with my grant and I paid the difference of about $1100.
A miracle happened and today in the mail he got 3 bottles of 120 250mg abiraterone and all it cost him was $186.00 which he paid from his HSA account. Plus order is for 3 refills of 3 months (9 months). We have no idea how this happened. After being given so much misinformation and finally deciding to go with Mark Cuban (CostPlus), we learned the prescription was never sent to CostPlus (even though my husband sent a message to his doctor to send it to CostPlus). He got a call yesterday from Scripps Specialty Pharmacy and they had the prescription and would fill it and would use the $500+ leftover money from Pan Foundation. My husband said go ahead and fill it. Then he gets a call back from Scripps saying CVS specialty pharmacy had gotten the order and now the Pan balance was $0. My husband told Scripps he had told CVS he wasn’t going to use them and not to fill prescription, so the person at Scripps called CVS back, and they reversed the use of the Pan money, so Scripps was able to fill the order and use the Pan money. And if all of this sounds confusing, we had 10 days of total confusion with this whole process!!! We are celebrating tonight with pizza, wine (for me), and cupcakes!
Thank you so much for all your suggestions.
I'm glad it worked out for you!
Were you able to verify that MDACC specialty pharmacy is still in network for 2024?
When I try to add pharmacies in the 77030 zip code, MDACC does not show up. I'm assuming that is perhaps because MDACC only treats cancer and therefore would not normally stock your typical generic non cancer related prescriptions. They are definitely a specialty pharmacy and perhaps only a specialty pharmacy. When they send the Orgovyx, it is enclosed in a plastic bag, zipped into an insulted bag with ice packs and shipped overnight in a fedex clinical box with a morning delivery, not the sort of process you get from most pharmacies (including TC Scripts that Janssen uses.) From the medicare.gov spreadsheet of drugs/pharmacies/pricing, it looks like Orgovyz and Erleada can be obtained from any of the 4 I added, which are CVS, Walgreens, Walmart, and Mail Order. I called CVS early on and they could provide it, but only by having it brought in from a (or perhaps their only) specialty pharmacy. Looking at the spreadsheet, the annual estimated cost is within a few cents for all but walgreens, which is only about $30 more.
The really tricky thing about Plan D - the drug company can change drugs to a different tier, or raise the rate (supposedly based on their cost for the drug) any time they want. What you see on the Medicare website in regards to coverage is "Subject to change" when the rubber hits the road.
Their cost of the drug - at one point I was considering two different plans from the same insurance company. They both used the same intermediate vendor for the drugs, but the claimed costs were drastically different. It took a lot of research to figure out why - but basically they were claiming their drug cost on the more costly plan was roughly 2x that of the identical drug on the less costly plan so paying a percentage of the cost widely differed between the two plans. Same company, I'd assume same drug provider. How does that work? Dunno - but there it was. Sleezy? Another word for insurance companies? The latest gambit by the plans I reviewed was moving drugs to a new tier - even common drugs like statins suddenly end up in tier-3. How'd that happen?
Another consideration is existing “Prior Authorizations”. Many expensive drugs require these from your insurance to dramatically lower the cost. For example, when this first came to my attention Walgreens wanted to charge me approx. $2,200 for Repatha, a drug newly prescribed by my cardiologist. They said they would go back to my doc for a prior authorization. That required my doc to answer a long questionnaire. He finally did that for me and it brought the cost down to $511. Just recently my MO obtained POs for both Orgovyx and Abiraterone.
IM CONCERNED IF I CHANGE Rx PLANS I’LL NEED NEW POs….
I have used Wellcare for 4 years now. No problems.
We use Wellcare without problems. Obtain needed drugs at Walgreens. (CVS is another option.) Of course the drugs do add up.....
I'm gonna buy Park Place and then beware if you happen to land on it........
Good Luck, Good Health and Good Humor.
j-o-h-n Friday 11/17/2023 4:32 PM EST
While it may seem counterintuitive, a zero-cost Medicare Advantage plan, like the Wellcare plan you're considering, can actually be beneficial if your wife's expected drug costs are high. This is because the plan's lower overall cost is achieved by reaching the "catastrophe level" of coverage sooner, meaning your wife's out-of-pocket costs are capped after a certain amount is spent. In this scenario, the zero premium outweighs the potential for higher initial co-pays, making the Wellcare plan a viable option despite its unusual structure.
Isn't that what my original posting said? In any case, the switching period is over for this year.
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