Medicare part D max out of pocket change for 2025 -how it affects costly mpn drugs

[Eferret]

I was talking to a Medicare Advantage salesperson today about 2025 Medicare Part D coverage. I currently am covered under my employer's plan, but they want to reduce my hours below the required minimum for company coverage. So I will probably have to apply for Medicare Part D.I asked the salesperson to lookup Besremi because my hematologist said I could switch from hydroxyurea. She said it is in her Medicare Advantage plan's formulary and would fall under the $2,000 maximum out of pocket if it is "authorized". I would assume that to get Besremi, the doctor would have complete some paperwork with the insurance company beyond just handing me a prescription. I would be interested if anybody could give more specific information. Thanks.

[hunter5582]

Medicare Part D plans vary quite widely. You would have to look at the specifics of the Prior Authorization for each plan to see how the process would work. Even though it is on the formulary, it will be at the highest tier in the list. Some plans may have a step requirement, making you fail on a cheaper drug first. You would need to check on that specific plan to find out.

To put things in perspective, compare the cost of the two NCCN preferred medications for treating PV. A month supply of Hydroxyurea = $25/60 caps. A month supply of Besremi = $16, 900 (2 syringes). It is small wonder that profit-driven Part D plans would rather push you onto hydroxyurea. That does not mean that you cannot access Besremi, just that it is more difficult. The first time I tried to access Besremi the Part D plan rejected it. My doc could not win on appeal. I had to file my own appeal, which I won. I have not needed to refile but it does take extra work each year from the doc to get the Besremi approved.

The $2,000 cap on out-of-pocket expenses for Medicare Part D is a game changer for all of us using Medicare. It will make the more expensive medications more affordable. Unfortunately, it will not change other unsavory practices like clawbacks, spread pricing, or rebates. Perhaps we will make progress there in the future.

A note of caution regarding the salesperson you speak to about the Medicare Advantage/Part D plan. They work for the insurance company and will try to sell you the plan, not to fully inform you. They are not working on your behalf. While they might not overtly lie to you, they will certainly leave things out in an effort to make the sale. It is much like buying a used car. Caveat Emptor. You need to be very specific in the questions that you ask. You should be able to get the information you need to make an informed choice but will need to work to do so.

Wishing you all the best.

[Eferret in reply to hunter5582]

Thanks for your encouragement to keep moving ahead with getting Besremi when I get onto Medicare. My allele burden is 91.3, and my WBC is 18.6, so I think the sooner I get on Besremi the better.

I called PharmaEssentia and they said they will help me get the prior authorization for my plan and get me financial help if I qualify.

Thanks to everyone at MPN Voice for being my second family!

[EPguy in reply to Eferret]

As you found, Medicare dos not allow the direct payments we got with commercial insurance. There are various programs to help pay for these drugs for those with qualifying income. What is and when is covered can vary with some groups, so if you get a no from one path there can still be others.

This is one well known one:

panfoundation.org/

[Ovidess in reply to Eferret]

Look into the Pan Foundation if PharmaEssentia can't give you a "grant."

[Mishie14]

Totally agree with Hunter's update. When we were close to retirement we reached out to our independent insurance agent who includes Medicare in his scope. He has Medicare sales licenses for states around the US Great Lakes where we live. Yes, there is a rebate/fee he gets paid monthly for each sold add-on plan but he's not bound to any one provider. Yes, be specific--provide a list of the prescription drugs needed and various tests (examples SCT, MRI, echo cardio). He came back with a spreadsheet by named Medicare supplement and advantage plans that showed the fixed and variable costs for the coverage we needed. It was very helpful in making the best decision about the preferred option for each of us. Each fall there is a provider change window in case your circumstances so require. I did have to change once in 2022 when ET diagnosed. He found a better/reduced cost part D drug plan for me. I have not gone beyond peginterferon (following HU and anagrelide tried first and had to stop). So far the much more costly IFN for the last 18 months has been covered and with no issues. This is a milestone year, however, for capping out of pocket drug cost for patients so hoping it does not drive providers to find other ways to get paid more as noted by Hunter. Hope you find a helping hand to guide you through the process. Good luck.

[EPguy]

The insurance companies promote Advantage plans, as it is a good profit source for them. Before you select one you should be sure you don't want the "other option". This is traditional medicare with a supplemental insurance from some of the same Cos that offer Advantage. It's also known as Medigap.

This stuff is mind numbing. I had to learn about it this year.

Advantage is called Part C. The Medigap is called Part A and Part B+ Supp+Part D (four parts) Advantage to Advantage for simplicity.

Advantage has lots of good features, dental, etc but usually more limited Dr network and often prior auth for specialists. But there are varying options and fees within Part C. Supplemental PPO has few Dr restrictions and pays the balance for most of what traditional medicare does not. But supplemental costs more; there is a monthly premium for the extra flexibility.

Supplemental requires getting a separate drug plan, this is Part D Hunter refers. If you go with Advantage (Part C) you get the drug plan with it, no no need to get a part D yourself. Since Bes or Rux pts exceed the $2,000 limit on our 1st month, we can use the cheapest drug plan, ~$17/month or less for 2025.

The 2,000 limit just starts for 2025. This is from the Biden "Inflation Reduction Act" (strange when politics affects something so directly) Before that it was really complicated and expensive for these high cost drugs I think 8-12,000. Since you would be newly starting the expensive med at the same time as starting medicare, getting authorization for the Bes could have extra hurdles, as Hunter says check carefully for which ever plan you consider. I brought over my Rux easily bec I was already on it, no prior auth required.

**Important note: If you select a Part C (Advantage) plan, you have 12 months to decide whether you want to stay. After that in most states you will be locked out forever from choosing the Medigap option since MPN is likely a disqualifying pre-existing condition. They don't look at pre-existing conditions when you 1st sign up or if you downgrade to Advantage. I switched my husband to Medigap, he had near no medical record so he could get in at age 72.

[Wewo01]

I went through Boomer Benefits when I was ready to enroll in Medicare this past year. My agent did all the work to find the best Part D plan that would cover my Jakafi and then my specialty pharmacy helped with getting a grant. Good luck!

[mpnunlocked]

Hunter is correct about Medicare Advantage - it is a private insurance company that will not provide you with all the facts you need. Please go to the medicare.gov website - it will assist you in comparing the cost of drug plans based on the medications you take or plan to take. Open enrollment is going on now to December 7th - so act fast.

Also, each state has a Seniors Health Insurance Information Program (SHIIP) which can assist you. And, there are local volunteer advisors who can help you navigate the web sites if you have difficulty. They are not affiliated with any insurance company, but have volunteered to work for Medicare.

Private companies exist to make a profit, not to help anyone.

[Eferret in reply to mpnunlocked]

Just as important as the drug costs is having all of your doctors and hospitals in the network. My company pays for my portion of the Medicare Advantage plan and all of our providers are included. It is the same company as my employer-sponsored insurance, so we can depend on them.

[sbs_patient]

I've had a Medicare Advantage plan offered by the Geisinger health system here in Central PA. This is a century-old highly regarded regional health organization with its own doctors and hospitals. The GHP Medicare Advantage plan is pretty generous, including Johns Hopkins and UPenn in its network of hospitals/providers. However, it covers a very limited, mostly rural, area, that fortunately includes State College, where I live. I switched from HU to Ruxolitinib back in 2022; it's about as expensive as Besremi, but has so far always been in their formulary.