[2025] Medicare.gov Prescription Drug Plan Review by Suzanne McClain of NUMA

[@VANNGUYEN-rk5kb]

let say I have to get a new script for antibiotic for an UTI , drug not on my list , how does it work with these drug plans ?

[@suzannemcclain]

It must be on the formulary for it to be covered. Take your formulary to your doctor so they can prescribe a drug that is covered.

[@JeanPierreWhite]

That can happen. If it does look at discount cards. Three I always check are GoodRx, Singlecare and ScriptCycle You can go to their websites, put the drug in and they will show you discounted cost at several pharmacies in your zip code. Even if the drug *is* covered by your plan it's always worth checking these discount cards, if the savings are significant you can use them, but if its just a few dollars cheaper use your plan so it counts towards your deductible. Discount cards don't contribute to your deductible, so you need to save a significant amount of money to use them.

[@vickipayne7581]

I take 2 kinds of insulins: Tresiba ( at night) and Novolog ( fast acting before meals) . How to enter these insulins? I heard that all insulin suppose to be $35, but when I checked my current med D , the Tresiba was not covered and w/o insurance was showing cost 45000 / year. Which one to believe? Is the 35 dollars coverage only with Medicare D

[@suzannemcclain]

Did you go through the steps in this video to find the best plan for your insulin and other prescriptions?

[@anitacordellbrown3752]

Your video was helpful. Your explanation of how to use the Medicare.gov website was very clear and understandable

[@suzannemcclain]

Thanks!

[@JeanPierreWhite]

You guys missed a trick. On the example you used you showed how Kroger was the cheaper pharmacy on the UHC plan. However as you reviewed the detail costs between the two pharmacies did you notice that Eliquis was $50 cheaper at CVS. Preferred isn't always cheapest for everything. As a person on the UHC plan in this specific example you could have your Eliquis filled at CVS and the other drugs at Kroger. When reviewing the plans I always choose 5 pharmacies to see if there is an opportunity to save extra bucks. The chances are Eliquis is prescribed by your Cardiologist, so they send to CVS while the others maybe prescribed by your PCP so they send to Kroger. So it's not that difficult to optimize your costs when it comes to filling drugs.

[@vickipayne7581]

Please explain the $2000 max out of pocket new 2025 “benefit” ( acc to inflation reduction plan).. would this rule also apply if I would use GoodRX for insulin?

[@suzannemcclain]

No. When you use GoodRX you are not running the drug through your prescription drug plan.

[@JeanPierreWhite]

The $2,000 True Out Of Pocket Maximum is very complex. It warrants its own video. There is one out there if you search youtube. The $2,000 max is calculated one of two ways dependent upon if your drug plan is basic or enhanced. Your insurance agent can tell you, it's not obvious which is enhanced or basic. As a rule of thumb you want a drug plan which is classified as enhanced. It's possible to meet the $2,000 max well before you actually spend that much. Super super complex.

[@vickipayne7581]

@@JeanPierreWhite thank you for your reply. It is obvious to me that I need to look for an enhanced plan. How can I find a good insurance agent in my area? My previous insurance agent retired/ no more available.. Thanks.

[@JeanPierreWhite]

@@vickipayne7581 Search KZbin for 'The New $2,000 Medicare Cap: It’s NOT What You Think...' from Giardini Medicare. He explains how it works in great detail for both traditional medicare and advantage plans. On the video he provides a link to the CMS website where you can download a spreadsheet which provides details of every Part D plan for 2025. There you can find out which plans are Basic and which are Enhanced. It takes some sifting through but you can do it yourself. Just be sure to filter by PDP plans. You can contact Giardini's company from a number on that video and he should either be able to help directly or give you a name of someone that covers your area. The way the $2,000 cap works may not be known by all the brokers. It's a shame your broker retired, many Part D plans do not pay commissions so if all you are shopping for is a Part D plan then they may prioritize folks who are signing up or switching medical plans. One of the things I evaluated when choosing a broker is the age of the owner.

[@carolynh5648]

What do I do if I get my meds by mail order from Express Scripts through Mutual of Omaha?

[@suzannemcclain]

You will have to transfer your prescriptions to your new Medicare prescription drug plan.

[@elbs1978]

What if the premium is over $5,000? What would I do? And what does that mean? I’m so confused

[@suzannemcclain]

@@elbs1978 I'm sorry. I really don't know how to answer that. I would have to have more information.

[@christinesantel4426]

I have been on Basaglar for quite some time and it works great for me, however, NO ONE seems to be covering it in 2025. None of the choices given to me on the website covered it so I will be forced to change to a different medication. How is this type decision made to no longer cover a medication???

[@JeanPierreWhite]

Speak to your insurance agent. There are two possibilities. 1. Ask for a formulary exception from the insurance carrier. 2. Ask the drug manufacturer for patient assistance. 3. Switch to a generic if available. Your agent can help with both of these and will advise which is appropriate in your case.

[@RockingRod78]

Currently I get eliquis for $10. I don’t know what program that is but can I remain on that program with having medicare prescription plans?

[@suzannemcclain]

Hi there! 😊 As I mentioned in the video, making a mistake choosing a plan can have serious consequences. Without knowing all of the details I can't give you advice. Go through the steps in the video to figure out the best plan for your situation. If you are interested in having us do a Medicare plan review for you, please watch the second half of this video and then call our office 614-448-1834 Thanks!😊

[@maryellent6229]

HOW do you get Eliquis for $10? My doctor just put me on that this year, and it was $47 a month until the donut hole kicked in, now $146. Now for 2025 they want $1600 in January, $2000 for all medication‘s for the year.

[@RockingRod78]

@@maryellent6229 I don’t know what program it is but the pharmacist hooked me up. I think it’s a manufacturer’s discount program. I think I won’t be able to after I go on medicare.

[@JeanPierreWhite]

@@maryellent6229 It sounds like he is on commercial insurance prior to reaching 65. Manufacturer issue co pay cards to reduce costs down to $5 or $10. Once you are on medicare such help is not available. Instead shop the Part D plans carefully.

[@greenchronos3918]

medicare is a complex system for retired people Is this intention?

[@suzannemcclain]

I don't think so, but I don't think "user experience" is a top priority. :)

[@JeanPierreWhite]

It's way too complex. Especially since it's targeted at seniors. It's inexcusable.

[@carolrose3367]

MANUFACTURER WILL NOT COVER MEDICARE PATIENTS WITH THEIR SAVINGS PLANS.

[@JeanPierreWhite]

You can apply for patient assistance for Tier 4/5 meds. This is different to co pay cards that are used for commercial insurance. My wife is on patient assistance for Humira. She gets the drug at no cost vs paying over $6,000 per month without the assistance. Yes she's on Medicare.

[@bonniehonchell9963]

I wish just 1 person on KZbin, when doing these videos would put in PAIN medication & see how badly you're discriminated against. No plan will pay anything, nor can you get a mail order on your RX'S! Tired of all of it. I've wasted so much time trying to find a Medigap or drug plan better than my Advantage Plan!😢

[@JamiGoss-f3h]

How can a part D is flat out REFUSE to cover Medicare APPROVED medications😮😳🤷🏻‍♀️. I’m on RAPATHA and WEGOVY… every part D on Medicare.gov shows from 21k to 27k for cost of these 2 medications! Thought everything was covered over 2k for deductible at zero cost. I’m REALLY CONFUSED.

[@JeanPierreWhite]

The $2,000 max is for COVERED medications only. Approved does not equal covered. Medicare decides what is approved, insurance companies decide what they cover on their formulary. Wegovy under medicare has to be prescribed for diabetes, it's not approved for weight loss. Part D plans are required to include a minimum number of medications from different drug categories. It's up to the insurance company to select which drugs they will cover. The insurance plan does not have to cover all approved medications. Just not the way it works. Important fact: Traditional Medicare does NOT have pharmacy drug benefits at all. Never has, never will. Part D plans are not part of original medicare, they got added later and the plans are created and administered by insurance companies. Medicare does NOT adjudicate claims for pharmacy drugs like they do with medical and hospital coverage or part b drugs. CMS simply regulate the carriers who do provide Part D plans. This is why with Part D you may have to get pre approved for certain medications despite having traditional medicare which does not have pre approvals for medical procedures. Part D isn't traditional medicare its its own animal. What is particularly difficult for Medicare recipients is that insurance companies can change the formulary mid year after you have selected what you thought was a great plan. It can be problematic. When it comes to medical procedures insurance companies don't have to cover every procedure that is approved by the FDA. For instance I had a treatment for prostate cancer that was not covered by insurance. It was approved by the FDA, didn't matter. Had to pay the $25k out of pocket that year. This is just an example showing the difference between approved and covered. When selecting a plan thru the medicare website it will tell you how many of your medications are covered. You want to be sure all your medications are covered going into 2025 to take advantage of the $2,000 max out of pocket. Also ask your agent if the plan is classified as enhanced, you may pay less than $2,000 and still reach your max out of pocket.

[@JamiGoss-f3h]

@@JeanPierreWhite thank you very much. Wegovy was prescribed for my cardiovascular disease not weight loss, but it seems all part D plans offered in my area refuse to cover wegovy and Rapatha…but for CVD.

[@JeanPierreWhite]

@@JamiGoss-f3h That's too bad. It's odd that Medicare doesn't consider CVD as an underlying condition much like they do with diabetes.

[@JamiGoss-f3h]

@@JeanPierreWhite they just don’t want to pay for the overpriced medications. Our government should step in and not allow pharmaceutical companies and PBM’s to charge Americans more for drugs than they charge other countries.

[@JeanPierreWhite]

@@JamiGoss-f3h Agree the cost of the medications is the root problem.