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One thing I’ve been researching that I’ve not seen you comment on, except in passing, are the differences between Part D prescription plans and MAPD (Medicare Advantage Plans that have Part D embedded in them). The more I investigate this, the more complicated it looks, with the obvious danger being the top tier drugs and what they cost in the various coverage stages. It seems like this is a real potential sinkhole, especially for anyone with a cancer diagnosis. I’m perplexed as to how to evaluate them and wonder whether there are significant differences among plans?
In addition, do you find there is a good bit of confusion about the relationship of the MOOP (Maximum Out of Pocket limit) and Part D benefits under an MAPD plan? Namely the perception that what one pays for prescriptions applies to the MOOP?
This is a one of the most detailed and astute questions I’ve ever received. And thank you for introducing readers to the MAPD an acronym. It stands for Medicare Advantage/Part D.
There is one major difference in prescription coverage among Medicare Advantage Plans that insulin dependent diabetics need to be aware of. The Part D Senior Savings model has been introduced for 2021, which guarantees that those on insulin will have a $35 co-pay all year round and won’t pay higher costs in the Doughnut Hole as they have in previous years. This is a wonderful development and should save insulin dependent diabetics as much as $1,000 to $2,500. Be aware, it’s not mandatory that MAPD plans participate. Only two of the seven companies that offer them in Western PA and only one of the three most popular are. There are some other differences as well, such as what medications are on companies’ formularies. Some cover certain types of insulin and not others, or certain medications for COPD and not others, and so on. Tiers of the same drugs can be different between companies, which can be very significant if one has generics rated as Tiers 3 or 4 instead of Tiers 1 or 2, which is quite common. If you would like to compare how different plans and companies cover your meds and their costs, the best way to do that on your own is to go to Medicare. gov and click on the “Find health and drug plans” tab.
Other than just a couple of plans that are provided by former employers, all Part D, be it in an Advantage Plan or Stand-Alone Part D those on Supplements must purchase, have the same stages including the Coverage Gap, aka Doughnut Hole. In 2021, once someone has received $4,150 worth of medications, they’ll find themselves there, paying 25% of the retail cost of their medications. The common thought may be $4,150 worth of medication is a lot. No. It isn’t. The average brand name drug retails around $500 for a 30-day supply. Other widely used non-insulin injectable medications are as much as $800. Those who take these expensive drugs will hit the Coverage Gap in just 5 to 8 months, leaving them with co-pays of $125 to $200 until they have spent approximately $2500 out of their own pocket. You can’t avoid the Doughnut Hole by changing to another MAPD or Part D plan or company.
As far as cancer in concerned, be advised that infused chemo, along with other drugs that are administered in an outpatient setting such as Prolia, shots used to treat Macula Degeneration, or other infused medication such as Remicade are “Part B” drugs, covered by the medical portion of MAPD plans or Part B for those who have Supplements. There’s a very significant difference between the two types of plans when it comes to cost. With every Advantage Plan, even the most expensive, the insured’s responsibility for Part B drugs is 20% of the total billable amount, which makes it almost a certainty that those who need chemotherapy, Remicade, or expensive shots for Macular Degeneration will meet their MOOP. Those who have Supplements pay $0 for infused chemo and other Part B medications. Another significant difference between MAPD and Stand-Alone Part D coverage is the $445 deductible those on Stand Alone Part D must pay for Tier 3, 4, and 5 drugs. There is no deductible for medications with MAPD plans. You are indeed correct what one pays for medications does not go towards the MOOP. With MAPD plans, medical and prescriptions are basically two separate policies. Anyone who gets their Advantage Plan premiums taken out of their Social Security check will see on their annual statement the cost for their HMO or PPO is actually divided up, with one amount applied to medical and another Part D. And it’s certainly possible that someone could meet their MOOP and hit their Doughnut Hole. Those who take two or more common brand name drugs such as Eliquis, Xarelto, Ozempic, Trulicity, Tradjenta, Januvia, Advair, Breo, Flovent, among others, will generally spend $3,000 or more out of pocket on medications, in addition to whatever they paid in medical bills.
A very common mistake people make is thinking they need to pay more for Part D or an MAPD “in case”they get put on an expensive medication. You do not. All Part D, be it Stand Alone or that which is provided in an HMO or PPO, are regulated. There are several consumer protections including what is known as an “Exception to the Formulary,” in the event you are prescribed a medication not on your plan’s list of covered drugs. In this situation, the Advantage Plan or Part D company must give you what is known as an “Emergency Transitional Supply”, 30-days of the medication you were prescribed. This gives you and your doctor time to decide if using another drug that is on formulary will work or to file an appeal. If your doctor has a valid reason why you can’t take the alternatives due to having used them before unsuccessfully, an allergy, etc., he or she can submit for an exception. I estimate they’re 95% successful. The staff at The Health Insurance Store works tirelessly to help our clients find ways to avoid paying high prices in the Doughnut Hole. We determine eligibility for PACENET, research drugs costs from legitimate Canadian pharmacies, and find Patient Assistance Programs and foundations. I’m actually creating a new position and will soon be hiring a “Prescription Drug Caseworker,” whose sole job it will be to work individually with those who are taking expensive medications and come up with a plan (s) to reduce costs associated with them. I’m excited to offer clients this additional service, one I feel has become a necessity as Part D gets more confusing and prices continue to climb.
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