I received the following email message today, so it seems any efforts by special interests to prevent the cap from being enacted have been diffused. This will mean thousands of dollars in annual savings for those on Tier 3 and 4 drugs. I'm still on three Tier 1 generics, but I never thought I'd live to see such a yearly cap for drug costs.
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Medicare dot gov logo
Starting in 2025: Yearly out-of-pocket costs capped at $2,000 for prescription drugs covered by Medicare
Mark your calendars — Medicare Open Enrollment starts October 15! Did you know new benefits are coming to Medicare drug coverage next year?
Starting in 2025, all Medicare plans will include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan. So, it's more important than ever to make sure your drugs are covered.
Also starting next year, you can choose to participate in a program that spreads your out-of-pocket drug costs across the calendar year, instead of paying all at once at the pharmacy. It's called the Medicare Prescription Payment Plan — and you can opt in with your plan throughout the 2025 plan year. Contact your plan for more details.
Preview Coverage Options
Remember, Medicare plans can change from one year to the next, and so can your health needs. Preview and compare all your health and drug options and see if you can save!
Sincerely,
The Medicare Team
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Significant help for some of us to keep staying S&W,
cujoe
Written by
cujoe
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I'm not sure why this cap on drugs is so exciting to people. It baffles me. It comes at the expense of others. To keep the part D premiums from increasing, the government is pumping in an additional 5 billion dollars. What happens next year when there are not election consequences? Reimbursements to doctors have been cut and more doctors are dropping medicare coverage and/or cutting the number of medicare patients. More patients seeking fewer medicare enrolled doctors doesn't sound good to me. I'm still 7+ years from medicare, I doubt all this happy dance about a 2k cap on drugs will still be going on.
Tell that to someone on a fixed income who is paying north of $15K on top of insurance premiums for drugs essential to their survival. Medical care in this country is a train-wreck for sure, but the insurance and pharma companies like it that way.
Well..if one is only concerned with retiree fixed income patients and ignores the millions of others who are not part D eligible, one might want to consider where the cost will be transferred to cover this new benefit starting next year. There is no free lunch
We are the only western country without national health insurance. Medicare-for-All like most other good ideas, ends up in the legislative dust bin due to powerful special interests lobbying and partisan politics. No one in the country should go to bed worried about what might happen if the next day someone in their family has a accident or is diagnosed with a disease. And old and young generations should not have to engage in political warfare over what should be a right of every citizen.
And, Yes, I am on Medicare - and would be a fool at my age and income not to be. Thus, the salutataory "Significant help for some of us to keep staying S&W"
BTW, under my current non-SOC treatment (by personal choice) this cap will have zero impact on my expected drug costs for 2025.
The average full cost of any new cancer drug on patent is north of $100K (and that's the low side). Under the wacky stand alone Part D, for anyone on Tier 4 drugs, pays an upfront deductible (either fully or partially thru increased premiums, then nothing in the "donut hole", and then when a max out-of-pocket expenditure is reached one goes to "catastrophic" benefits which cover a major portion for the rest of the year. The $2K cap will change some or all of this.
Each year the insurance companies that provide drug benefits revamp their coverage. The premiums change, along with their drug formularies, cost sharing with various pharmacies, etc. - with no consistency as to what drugs fall into which formulary "tiers". For example I had to switch from dutasteride to finasteride this year because, my new plan had dutasteride as a Tier 2 drug for which I would have had to pay a ridiculous "retail" price (until I used up my $500+ deductible), as it is a generic. On top of it all, insurance plans are individualized for every state. (Believe me, no one other that pharma in collusion with insurance could have dreamed up such a confusing system for drug insurance.)
Last year I got my scripts through an online subscription service, Scritpco. I did that even though I was paying monthly for a Part D Plan, as the cost was less that using the insurance. (Note that if you do not sign-up for Medicare or a drug plan when you first qualify, you will pay a yearly premium surcharge for all years later. There may be some exceptions for people who continue to work and have insurance elsewhere.)
Mark Cuban's CostPlus Drugs is often the best source for recent drugs that have just come off patent. His site show the retail price, the cost to manufacture, and cost via his service. Here is the cost for Abiraterone.
Listen, I'm not getting in a tit-for-tat with you. We don't have a national health insurance program and probably never will.I'm just illuminating the fact that to achieve this 2k cap, costs will be transferred to others in a variety of ways. And many who bear this new cost will be working class on a fixed income without this new fantastic benefit.
I do not disagree. On top of it all we have an influx of immigrants who are likely getting free health care (and housing and EBT cards) while our tax-paying citizens declare bankrupsy over unpaid medicla bills. Term limits (maybe age as well), 100% public financing of all elections. staggered 4 year terms for house reps, restricted employment by gov employees in any industry they regulate, banned insider-trading by government officials, etc. etc. - None will ever happen as long as those in power in both parties are benefiting by the status quo. (I didn't intend for this to be a political post, but here we are.)
Interesting read. What's your opinion? My thoughts are more denials of prescription drug coverage are in the future.
Many in the survey said they expected to tighten formularies and increase clinical criteria for coverage. Respondents in this survey said they plan to target a variety of high-spend drug classes, including diabetes, oncology, immunology and rare diseases.
Moon - With the 3 generic drugs I currently use, I don't get much beyond looking at the first three Part D Plans offered in my state. Fish(npfisherman)'s comment below made me realize that the 2025 Plans are already listed at the medicare.gov website site, so I did a run with the three drugs to see what the next year's available plan total cost would be. In 2025 there are 14 Part D plans available in my county. As is clearly the case with the results, for someone only using generics it hardly makes sense to take any of the higher-priced plans. So, like NP, I will once again stick with the Wellcare Value Script "zero-premium" plan I am also using this year.
The total cost of all three drugs for 12 months via a local CVS at my current dosing schedule is (including the $0 insurance premium) an unbeatable $95.40 on the Wellcare Value Script Plan. The next closest plan (also from Wellcare) has a total cost that is ~4.5 x that cost @ $425.40, And the most expensive of the 14 Plans offered is the Humana Premier Rx Plan @ $1,896.84total cost!!! For the same 3 generics! (That comes to a difference between the Humana and the zero-cost Wellcare plans of $1,801.44, which is more than just a little pocket change to this old dog. I guess the insurance industry figures if you can afford to pay a high monthly premium, you can also afford to pay high prices for your drugs? IMO, it defies any application of common sense logic!)
Granted, the more upper tier drugs one takes, the less the difference between total cost will be - and the closer/more quickly one will come to the $2K cap. And, for sure, medical insurance companies of all stripes will try to shift some of the revenue lost on drugs (due to the $2k cap) to co-pays and restricted coverage for expensive diagnostics and medical procedures. I would expect that 2025 will be a year of many surprises in costs for medical care, regardless of one being on Medicare, company-sponsored group, HMO, or individual insurance plans. One thing to be on the watch for is the need to have "pre-approval" from your insurer before having any "high-tech" scans or expensive procedures. (1) I also expect the approvals for many procedures will be more difficult to obtain. It short, we all need to be extra vigilant and up our advocacy in the year ahead. Get out in front of any and all expected changes in treatment and any advanced/more expensive scans for monitoring progression, esp. ones like PSMA and MRIs.
There will also likely be an extension of the controversy that has arisen over the last several years regarding Medicare "Advantage Plans", which include the "gap" coverage in Medicare Parts A & B, plus drug coverage, and some limited vision an dental coverage. Many people switched out of their original "Medigap" plans thinking, like basic Medicare, it was insurance issued and administered by the government. Only later were they to realize that it is private insurance sponsored by the goverment. Many came to find that they were not able to continue with their existing doctors and treatment centers, because they were not Advantage plan participants. For example, Mayo Clinic not longer accepts Advantage plans - see this:
As stated earlier, US citizens pay the highest medical costs in the world and there is no reason we should be subjected to such a deceptively complicated system of health insurance that is wasteful of time and resources - while providing substandard health outcomes in all major categories.
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(1) I got an on-the-fly Xray during a routine visit to my blood cancer HO back when I was on BCBS individual coverage, and because I did not get approval for it, BCBS not only refused to pay for the Xray, they also refused to pay for the routine blood labs done earlier that same day. Their plan actually stated that they would not pay for any "high-tech" scans OR LABS done on the same day WITHOUT prior approval. I paid for the Xray when I was billed, since not having my medical insurance policy in my hip pocket when my doc suggested I could get the Xray that day, I did what seemed at the time the most efficient thing to do for both me and the medical services "industry" and got the Xray. When I got a bill from BCBS for both the Xray AND the previously always-covered labs, I checked my policy I found the strange provision about need prior-approval for high-tech scan. Since I accepted that, under the provision of the policy, I should have gotten prior approval, I promptly paid the Xray portion of the bill and sent a letter formally contesting the refusal to cover the labs services. When I was unsuccessful in getting BCBS to drop the lab charges, I engaged the State Insurance Regulators - to no avail. In the end, no one at BCBS, the treatment center, the state insurance agent on the case, nor the doc himself could ever provide a logical justification for excluding labs done on the same day as a scan, regardless of having approval for the scan. My doc did say that they have patients come from long distance that often have to make a choice between paying out-of-pocket for such conflicted services (according to insurance policy fine print) or paying for overnight accommodations to have them done on separate days - when, BTW, the labs would be covered without question. Without a doubt this Twilight-Zone episode in healthcare services, logic-defying insurance coverage, and lax regulatory oversight remains one of the most confounding experience of my entire life. And, by the way, the final additional cost to me was around $775. ($350 for the scan + $525 for the normally covered labs.) When in my last conversation with the State's Insurance resolution agent she was unable (or unwilling) to provide any rational reason for fully-covered services becoming fully-UNcovered due to having a completely unrelated service done on the same day, I said I expected it was due to the "gotcha" factor that very few patients would be aware of the pre-approval required for scans/Xrays and most, like me, would end up having to pay for otherwise "covered services" that wold add significant $$ to BCBS's bottomline. All I got was "crickets" on the other end of the line. End of Story. Lesson learned. As is often said, "Fool me once, shame on you. Fool me twice, shame on me." Or as Who's song from the 60's states, "Won't get fooled again".
Stay very vigilant with your care and stay S&W. Ciao - cujoe
I help people (at least in Georgia) with their Medicare choices and, in essence, the cost of the 2k cap is being distributed to all Medicare recipients. Most of the insurance companies that provide advantage plans have terminated exiting plans to replace with plans not as robust as before. Premiums on all of the supplement plans are going up. The premium of most drug plans is going up as well. There are many who will benefit from the 2k cap, but all (on Medicare) will bear the extra cost. Not commenting on if this is good or bad, it's just the reality of Medicare (which I'm very happy to have).
Thanks, good summary. What surprises me is that with this new landscape, my wife's zero premium plan with Wellcare remains zero premium next year, and my 50%-subsidized-by- former-employer UHC plan will cost 50% more, and her run-of-the-mill drugs are receiving greater insurance reductions than mine. With the $2K cap, and using India whenever costs are too high means that I am not too fussed about this all, but it does seem like a Rube Goldberg construct.
Ciga - I've used the same Wellcare zero-premium plan as your wife in 2024 and with the cost-sharing pricing for the three generics I currently use, I have used the insurance for all scripts this year. However, as mentioned above, I did have to change my 5-ARI from dutasteride to finasteride to get the Tier 1 generic pricing. In 2023 I mostly used Scriptco and got 90 day scripts at the beginning and end of 2 quarters that allowed me to get a 12 month supply with only 2 quarterly Scriptco subscription payments. In retrospect, I would actually have done better to have used CostPlus for that year.
The real problem for most people on Medicare is the need to yearly reevaluate which plan will be best for total out-of-pocket costs (drugs + insurance). For those that know what their specific drug use will be for the next year, the dot-gov site has a very useful comparison tool that will allow you to input your scripted drugs, select any 3 insurance plans, and see total yearly cost comparison (drugs + Insurance) for the selected 3 plans. For those who do not/cannot know what their scripted drugs will be, it is more of a crap-shoot to pick the lowest total cost plan each year.It is a true burden on many people to have to yearly negotiate such a complex system for meds that are essential for their well-being. (Altho' the $2K cap will make that a bit less onerous for those on Medicare.)
As is often said, "We have the best healthcare money can buy." Here is the latest comparison on how our most expensive (by a factors of ~1.5 to 3 x) healthcare delivery system compares to other wealthy OECD countries - where a lot of that cost is allocated, and what sort of outcomes we are getting for all those $s.
How Does the U.S. Healthcare System Compare to Other Countries?, Peter G. Peterson Foundation, August 15, 2024:
1. Yes, I have often used the dot-gov site, but with a $2K cap I expect my only question now is do I stay with my subsidized plan or lose the subsidy forever and go with Wellcare.
2. Yes, we have more expensive health care than other countries, and are not doing so well on relative longevity etc. stats (which I attribute partly to greater poverty), but the statistic does not include wait times and other non-financial considerations. I have lived in, and been treated in, many different countries and, as long as one has the finances, i would take ours. Most amusing to me was my nano-iron scan at Radboud Netherlands--they were unable to accept payment until they later sent me a bill.
Agree with most of those points. However, both Germany and AU had PSMA diag/theranostics for as long as 5 years before they were apporved by FDA for use outside of trials here in USA. I have also read/heard accounts of American citizens needing urgent care while abroad and getting pocket-change bills for services in the ER. Walk into an ER in the States without insurance and (if they are willing to admit you) you may end up with second mortgage on your house to pay the bill. And we all should know by now that US consumers pay drug costs that are many multiples of what they do in ALL other countries around the globe. In reality, the US consumers and taxpayers (without their consent on the matter) are subsidizing drugs for the rest of the world.
Yes. That is why I went to Radboud for a scan. The technology failed an FDA application and Professor Dr. Berentz told me the long story during the infusion preceding the scan. Flawed application, no radiologist involved, so the company gave up and, after a very involved process he described, he was able to buy the technology.
Is there bad stuff here? As I said, "as long as one has the finances." Without, it is a horror show, some good parts, some horrible. Off topic, but speaking of ProfDr Barentz, he told me he recently had a wealthy Chicago client for the scan who had a pacemaker. Barentz did not want to risk doing the 3T MRI at Radboud, so the guy flew to Radboud in his private plane, did the infusion, then they both flew back to Chicago for the MRI, then the plane took Barentz home. That guy had the finances.
I have WellCare too.... I pay quite a bit for Medicare and feel that it is a mitzvah for others that receive care for less... (No, I am not Jewish, but my Drs are Jewish...Does that make it count??)
Those that have, should give more, or are we an island unto ourselves when it is time to be giving??
Thanks to all parties for keeping us apolitical.... After all, isn't there enough stress just having cancer??
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