SPOOKY STUFF . . . All about Medicare Part D and nothing about politics . . .

2025 Wellcare Value Script PDP . . .

Wellcare Value Script only has generic insulin on formulary with the exception of the concentrated formulation. The generics are not A/B rated which means they are NOT interchangeable. When drugs aren't interchangeable, the pharmacy MUST call the doctor to get a new prescription for the generic name-by law they can not substitute it themselves. This is going to cause a huge time crunch for pharmacies and doctors across the country!! 

This may also put some pharmacies who don't know any better or start skirting the law due to time and pressure, to make the change without getting a new Rx for the generic. If audited by Wellcare after the fill, they will be back charged and Wellcare will NOT pay for the drug dispensed.

Cigna Medicare Sold to HCSC

Health Care Service Corporation (HCSC) is acquiring Cigna's Medicare business for $3.3 billion in an all-cash deal: 

What's included

Cigna's Medicare Advantage, Medicare Part D, Medicare Supplemental Benefits, and CareAllies businesses 

When it will close

The deal is expected to close in early 2025, subject to regulatory approvals 

What it means for customers

There will be no changes to coverage, benefits, or costs until the transaction is complete. Cigna Healthcare will continue to serve customers and handle claims.

If you are/will be enrolled in a Cigna plan for 2025 you should consider making a different choice before 12/7/2024

If you have a Cigna Medigap (Medicare supplement) plan, and are healthy enough to pass underwriting, you should consider a different Medigap plan for 2025. 

If your health prevents you from changing to another Medigap, look at Medicare Advantage options.

Aetna SilverScript Preferred Pharmacy Network

For 2025, there are no preferred pharmacies but not all pharmacies are in network.

Translation . . . if you fill your Rx with a network pharmacy your copay SHOULD be the same as any other participating pharmacy. 

A preferred pharmacy means you should pay a LOWER copay than you would with a standard or out of network pharmacy . . . but this doesn’t happen with Aetna. Plans without a preferred network means you will often pay more for your meds vs a plan with preferred pharmacies.

But if the pharmacy you use is not in network your refill may not be covered.

Other Agents May Not Show All Your Options

Several carriers have decided not to pay commissions on some PDP and MAPD (Medicare Advantage Prescription Drug) plans for 2025. As a result, SOME agents are only telling clients about the plans that pay a commission.

And SOME agents are encouraging clients to drop their current plan and enroll in a different plan for the simple reason that the NEW plan pays a commission.

This is a DECEPTIVE sales practice that benefits the agent but may cost YOU money. Agents who sell Part D plans are required by Medicare to tell you about all options, including plans they may not be authorized to sell.

I have NEVER received a commission on PDP contracts so I have nothing to gain or lose by suggesting a different drug plan . . . and I don’t promote MAPD plans. If someone wants an MAPD plan I refer them to an agent I trust.

Formulary Changes 2025

Some medications that were on your plan formulary in 2024 may not be on formulary for 2025. Other meds that are tier 1 this year could be tier 3 or higher in 2025.

Formulary specific changes are too numerous to mention. Best advice is to verify ALL your meds are on the 2025 plan formulary and the copay is affordable.

Not all GLP-1 weight loss meds are covered by Part D. Don’t just ASSUME because something was covered this year means it will be covered next year.

FDA Warning about GLP-1 Medications

Nov. 6, 2024 – The FDA has updated the labels for all GLP-1 weight loss drugs with a warning about pulmonary aspiration during general anesthesia or deep sedation. The affected drugs are liraglutide (Saxenda, Victoza), semaglutide (Ozempic, Rybelsus, Wegovy), and tirzepatide (Mounjaro, Zepbound). 

“This was a safety-related labeling change for the glucagon-like peptide-1 receptor agonist product class,” an FDA spokesperson said.

According to the new label: “There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations.”

https://www.webmd.com/obesity/news/20241106/new-fda-warning-added-popular-weight-loss-drugs

Part D Prior Authorization

Many brand expensive name drugs require PA (prior authorization) before they can be filled by your pharmacy. If you are changing plans OR pharmacies for 2025, call the pharmacy and ask if any of your meds require a PA. Just because a drug is on the formulary does not mean the pharmacy and/or plan has a record of the PA approval in your file.

Part D plans are being squeezed considerably in 2025 and could be looking for any way to avoid paying for expensive medications.

Prior authorization limits coverage of a drug to patients who meet certain requirements. Before you can fill the prescription, your prescriber must contact your plan to show the drug is medically necessary and that you meet certain requirements. Plans may also use prior authorization when they cover a drug for only certain medical conditions it's approved for, but not others. When this occurs, plans will likely have alternative drugs on their list of covered drugs (formulary) for the other medical conditions the drug is approved to treat.

Step therapy is a type of prior authorization. In most cases, you must first try a certain, less expensive drug on the plan’s formulary  that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, some plans may require you first try a generic drug (if available), then a less expensive brand-name drug on their drug list before you can get a similar, more expensive, brand-name drug covered.

https://www.medicare.gov/drug-coverage-part-d/what-medicare-part-d-drug-plans-cover/drug-plan-coverage-rules

MAPD Enticement 2025

Some Medicare Advantage Prescription Drug plans (MAPD) include drugs on the formulary but omitting that drug from their PDP (stand alone Part D prescription drug plan).

This appears to be intentional as a way to steer folks with high priced medications away from stand alone PDP and into their MAPD plan. Medicare Advantage plans can effectively SUBSIDIZE losses on the Part D coverage by using PROFIT on the medical portion. Essentially, they are taking money out of one pocket and putting it in another.

MAPD plans increase profits by delaying and denying medical claims. Your loss is their gain.

Keep in mind, if you currently have original Medicare and a Medigap (supplement) plan, if you leave Medicare to enroll in the MAPD the following will happen.

You may lose access to your current providers (physicians, hospitals, clinics). Giving up original Medicare means your INSURANCE carrier will decide the type of care you receive, not your doctor.

MAPD plans are like the Hotel California . . . you can check out but you may never leave. Many who would like to leave their MAPD plan and switch to a Medigap plan may not qualify. MAPD plans do not medically underwrite applicants . . . but Medicare supplement plans DO underwrite.

MAPD plans are fine for routine care but often come up short when you have a major claim . . . plus your OOP (out of pocket) cost can be $6,000 per year or more.

2025 Medicare Premiums, Deductibles

The standard monthly premium for Medicare Part B enrollees will be $185.00 for 2025, an increase of $10.30 from $174.70 in 2024. The annual deductible for all Medicare Part B beneficiaries will be $257 in 2025, an increase of $17 from the annual deductible of $240 in 2024.

In Closing . . .

If you have not reviewed your 2025 PDP options, do so now before it is too late.

If you asked for a review, and have not received a response from me, please reach out again. I am not ignoring anyone but some things have been trampled in this mess. Likewise, if we discussed changing drug plans, and I have not notified you of the new enrollment, don’t hesitate to remind me.

Be a wise shopper. Now, more than ever, you will find lower drug copays by using a discount card like GoodRx or SingleCare.

Pay your premiums when due.

Almost every year I get a call from someone who missed a premium and their insurance lapsed. If the error is caught in time you can save your plan by paying the back premiums.

But if you fail to catch up on the premiums on a timely basis, the only way to get your insurance back is to pass medical underwriting. If your health prevents reinstating your policy your other option is to enroll in a Medicare Advantage plan during the next open enrollment.

With new coverage you still have no coverage for claims and unpaid bills that occurred before your new plan is effective.

Sometimes failing to pay your premium is an oversight . . . sometimes your premium is not paid because your funds were low. A few folks pay premiums automatically by credit card and then fail to update the card when they get a new one.

I have had a few people who neglected to pay their premium because they were in the hospital and, understandably, paying bills was not on their mind.

One client went without a Medigap plan for two years until he could pass underwriting. Several chose to continue with only Medicare Part A, or have Part A and Part B. You are more likely to run up high medical bills from outpatient (Part B) charges.

With Part A coverage only, your OOP (out of pocket) exposure is roughly $1600 (per admission) when you don’t have a supplement plan.

But without a supplement plan you are responsible for outpatient Part B charges without limit. You pay until you get well, run out of money or die.

Pay your premiums when due . . .

Consider this your last call at closing time. If you need something from me, including reminding me that I have not followed up on a review or plan change, you need to contact me no later than Friday, 11/22/2024.

Enjoy your holidays!

bob