Nasty surprise from Medicare today

[orangecrush]

During last year's "window" (from October through November) to change prescription coverage, I got a letter from Medicare, saying in effect "We are moving you from prescription plan bla bla bla to plan bla bla blah.
If you disagree with this decision, you must file for another plan before the window ends".

I think they said something along the lines of "shouldn't change your coverage".

Today I needed three prescriptions. One was low dose Taladifil (Cialis) for prostate flow.

The pharmacist informed me my copay for the Taladifil alone was over $500, and the other two (an antibiotic and nasal steroid for post COVID) were almost $50.

I never paid more than $20 for multiple prescriptions before this with the old plan, the copay for the Cialis was a little over $2.

How the fuck did they get away with this?

Now I am fucked until next October at least.

I hope I don't get seriously sick.

[riversedge]

1. bummer.

[brush]

2. Call them asap. Protest that you were mislead and can't afford it.

Have you previous payment amounts handy to show them the outrageous price gouging. Lay it on thick...to a supervisor if you have to.

[orangecrush]

6. Will do

Prepared for 5 hours of elevator music on hold.

Oh wait - no Prozac! 😭

[lynintenn]

3. Try using Singlecare or Good RX

I get a great discount they them if your pharmacy accepts the.

[orangecrush]

9. Good Rx

$30 instead of $500 for Cialis.

[Rebl2]

60. My pharmacy

has something similar. Our county has a Rx card that can be used by pharmacy to reduce cost of a prescription.

[spooky3]

4. Isn't Cialis one of the drugs that Medicare is now negotiating the

price of? I don’t know how quickly any results will be implemented.

[orangecrush]

11. I don't know but

It was prescribed for me for flow, not as a boner pill.

The pharmacy said they were sending it back to the Doctor for pre-approval, whatever that means.

[Marthe48]

28. My friend has to get some of their meds pre-approved

I think it means the doctor lets Medicare know that my friend has a medical need for it. It is expensive and they'll have to have it for life. The pre-approval gets it paid for a fraction of the cost.

Good luck

[Ms. Toad]

30. Since they are willing to play with changing prices -

Go to GoodRx.com and print the coupon for the quantity and frequency of the meds and see if they will re-ring it using that price. It shouldn't be much more than $25.

They often fill ours under insurance and then re-ring it when we show up using the coupon. We haven't walked out of the store with the meds - but since they are willing to think about a price change via the doctor, they might process a GoodRx price change.

[Ms. Toad]

26. Not this year. n/t

[FloridaBlues]

5. I thought you can change Rx coverage anytime.

[orangecrush]

12. Apparently not

[ProfessorGAC]

20. Seems Variable

I searched "can you change part D plans at any time".
The first three things that popped up were:

The good news is most people with Part D are allowed to switch plans once a year, during the Open Enrollment/Annual Election Period (Oct. 15 – Dec. 7).
Nov 8, 2023
How To Change Medicare Part D Plans - National Council on Aging

The National Council on Aging
You can switch Part D plans as much as once per calendar quarter during the first three quarters of the year.
Feb 17, 2022
When Can I Join or Switch a Part D Prescription Drug Plan? - AARP

AARP
If you find a Medicare 5-star rated plan, you can change your Part D at anytime of the year to the 5-star plan*

Not exactly straightforward.

[Ms. Toad]

27. Once a year (Oct through Dec for the following year). n/t

[Freddie]

7. DH gets Taladfil via GoodRx for about $13/month

It’s not covered on our Part D either but it’s a cheap generic

[orangecrush]

15. I'll look into it

It really does a better job than flowmax, and helped lower my blood pressure.

[unc70]

34. Strongly recommend GoodRx -- $13 for 90 days

[moonscape]

61. I run most of my

meds through goodrx and rxsaver to see which is cheaper. About 25% of the time the cost is lower than through my Part D coverage. If it’s close, I run through insurance so get it applied against my deductible.

The process we have to go through is shameful and not all Seniors can manage it (understatement.)

[brer cat]

8. Do you know for certain that you have drug insurance, and

that it was applied by the pharmacy? I got a huge co-pay last year and when I questioned it, they found that my insurance had not been applied. From $2 to $500 has to be a mistake!

[orangecrush]

17. Medicare changed my drug plan

Without telling me my present running prescription would no longer be covered, and copays for everything else would go up drastically.

[brer cat]

22. That is really strange. I have never heard of Medicare making a change

without the person requesting it. Wonder if it was some kind of system glitch?

[Demsrule86]

23. Do you have advantage or regular medicare

[orangecrush]

37. Regular

[JohnSJ]

10. You might want to check Costco, we're generic prices are quite good on RXs. Try GoodRx to get an

idea of prices at different pharmacies without insurance. You might find prices at good Rx cheaper than what insurance prices are.

[Doc Sportello]

13. You can change plans at other times but only if you meet certain criteria

https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan

[limbicnuminousity]

14. That is horrifying...

Am I understanding correctly that they can arbitrarily change your prescription coverage without needing prior authorization from you?

Being pushed into Medicare in the next month or so and dreading it. Now, more-so.

[orangecrush]

18. They did

If you experience this, recommend you call them immediately.

[Ms. Toad]

29. I'm guessing the plan OC was on was discontinued,

So they enrolled OC in a substitute - which is (at least in theory) better than just dropping coverage.

Medicare is the best health care plan I've ever had - had I had enough time to think and compare I probably would have put my spouse on it when she turned 65, rather than keeping her on my plan until she was 70. Get on original Medicare and a Medigap plan (a one and done choice) and pick the best drug plan you can for the drugs you are currently on. Medicare has a basic app to help you (my parents rely on that). I build a spreadsheet, because we have enough oddball prescriptions that I want to price-shop with GoodRx or Costco prices included. It's an investment of a few hours every year to check to make sure the prices haven't changed. We've made one change in 3 years (total of 6 person-years since there are two of us).

[limbicnuminousity]

36. Thank you!

People generally have wonderful things to say about Medicare. It's daunting not knowing exactly what to expect and stories like OC's induce a bit of anxiety. It sounds like Medicare is fine but the bureaucracy sometimes throws a wrench in things?

Now, when will the prescription plans cover medical marijuana? Opiods for chronic pain management are such a lousy option.

[Ms. Toad]

38. I'm sure medical marijuana won't be covered until the law changes.

The federal government isn't likely to pay for something it classifies the same as LSD, etc.

Check with your state SHIIP. They are wonderful in Ohio - and I've heard good things about them in every other state where I've talked with anyone who has used them. In Ohio they provided comparison information about the Medigap providers - both COLA adjustments and age-based increases for 3 or 5 years. So you can get a sense of who is likely to end up bieng more expensive over time.

[MagickMuffin]

16. This happened to us and we missed the deadline for no fault of our own

Called them up, explained what happened and that I wanted to change providers because the one I had wanted to start charging me monthly. Found a better deal. They helped me without any issues.


Good luck!

[orangecrush]

19. Thank you!

[limbicnuminousity]

31. I started receiving letters after the reply-by date

from Social Security. The paranoid part of my brain says this is part of the chaos inflicted by DeJoy and is intentionally screwing people with policy changes. Nearly got dinged with an unexpected $600 insurance premium for that very reason.

[XanaDUer2]

21. Fortunately, my pharmacy Publix

Is excellent and run GoodRX and other discount cards to get you the lowest price. They do this automatically.

[Ms. Toad]

25. Ouch!

The massive charge was probaly your annual deductible (ours is around $500 this year - which my spouse spent on Jardiance). The next bills should be lower.

But - your plan may be heading you toward the donut hole. Look for the total cost (paid by insurance and by you). If it really is that high, consider using GoodRx and/or Costco for prescriptions. (The mail order doesn't require local access to a Costco). Not knowing your precise prescription, it looks like it's about $25 for 30 -30 mg tablets. Costco price is similar.

We buy more than half of our prescriptions through Costco because it is cheaper buying them at Costco retail prices than to use insurance. I wish I had known about that option before I hit Medicare age.

I do a spreadsheet every year in October comparing all plans - and comparing the plan cost to the Costco cost. There's one drug that costs $1400 through some of the insurance plans but only about $50 through Costco. These plans change their formularies about every other year (in my experience). They lure you in with cheaper drugs the first year - then figure you'll stop checking and just stick with them. They also don't assume you will even consider GoodRx or Costco, or other non-insurance options. It is a royal pain, but we save thousands every year.

Seriously - even if you have a plan that is not being discontinued (which seems like what happened here), check your plan every year. We switched one of our plans this year because a different one was cheaper overall (premium + known medical costs).

[orangecrush]

39. I am calling Bob Casey tomorrow

This is inexcusable.

[xmas74]

47. I now take several meds

And have found a few on Cost Plus Drugs even cheaper than my insurance and GoodRx. I looked up the generic Cialis and they offered a 5mg pill, 90 pills, for under $11.

[Ms. Toad]

50. It definitely pays to shop around.

One of the Medicare plans in my area charges more than $44,000 for a years supply. I'm shocked at how much price variation there is for this med.

[xmas74]

56. I send my Medicare patients to that site often

Especially while we are waiting for a Medicaid QMB approval. It saves them so much while waiting for their approval.

[a kennedy]

32. This isn't anything really, but my high blood pressure and ulcer meds copays were $6.00

last year, they now are $15.00 copay. Not breaking me but damn…….

[PoindexterOglethorpe]

33. This entire thread is scary.

I'm extremely fortunate, and grateful, that my three prescription medications have no co-pay for me. They used to have some small, maybe five or ten dollar, co-pay, which went away a year or so ago.

I have an Advantage plan, for what it's worth.

[Ms. Toad]

42. Your Part D insurance is rolled into your MA plan,

(They can be either separate or combined). If your insurance provider discontinues your plan, you would likely be dumped into a new plan. And even if you just roll over you plan every year, rather than shopping for a new one, your insurance provider can change the details of your drug plan (coinsurance/copay) every year in January. Make sure you're watching the announcement about the next year's change which comes out September-ish.

[IcyPeas]

35. Medicare is too damn confusing.

[Ms. Toad]

41. Agreed.

The government needs to produce comprehensive material - aimed at a 5th grade reading/comprehension level. As it is, I've had to rescue two law professors who misread things . . . not to mention that even after spending close to 200 hours researching (both the law and plans) it was only the dumb luck of when my parents conceived me that kept me from being without any medical coverage for the month of January 2022.

[area51]

40. Another possibility might be

Mark Cuban's Costplus Drugs.

[Ms. Toad]

43. Just for grins I looked up all of the plans in my area.

Under the 20 plans available to me, the prescription costs for 60 pills (20 mg of Taladifil) range from $132.20/year to $44,782.90/year.

I thought the variation in cost for Potassium Citrate was crazy. It ranged from $65.94/year to $1407.38 - a 21-fold difference. The difference for your drug is 339 times from cheapest to most expensive.

Moral of the story: Every October - early December, make sure you run the drug costs for the drugs you use in the plans in your area!

[Tribetime]

44. Those prices seem way way way off

[orangecrush]

49. I agree

Pharmacy said I was "under covered" all of a sudden.

[xmas74]

46. Try cost plus drugs.

https://costplusdrugs.com/medications/tadalafil-5mg-tablet/

You can get 90 pills, 5mg for under $11.

[orangecrush]

48. Thank you!

[JT45242]

51. Try GoodRx have had some luck with it (when insurance was fighting over drug choice of the doctor)

GoodRx for generics is often better than a lot of these kind of plans.

Have a friend who is self employed and uses ACA coverage that doesn't have great prescription coverage and she uses GoodRx all the time.

[PJMcK]

52. That sucks

There’s a mail order pharmacy in North Carolina that sells generic versions of many drugs at deeply discounted prices. It’s called Marley Drugs and I use them for a couple of prescriptions. (I think their biggest business, based on their advertisements, is ED drugs; I’ve seen their ads for generic Taladifil and Sildenafil.)

Good luck!

[Squaredeal]

53. Get your script filled ivy a Canadian pharmacy

Much cheaper than what you were quoted.

[Voltaire2]

54. Part D is a horrible Republican mess.

It should be scrapped entirely and a prescription benefit should be rolled into standard Medicare (part B for example) with minimal copays. All drug prices should be set by Medicare.

[B.See]

55. HEADS UP: You said Medicare. If you (and anyone else) is on a Medicare Advantage Plan...

you can STILL switch from one Medicare Advantage Plan to another as late as March 30th of this year.

And I'm not sure, but you might still be able to enroll in a M.A. plan if you're on regular Medicare. I switched MA plans in first quarter of 2023 when I realized the insurer I'd been with for some time decided to fk me on prescription co-pays at the start of last year.

Best bet, go to medicare.gov. There you can compare plans, prescription coverages for each, out of pocket expenses, and in network providers. You can even chat with someone re. your options.

Good luck.

[moonscape]

62. If you switch to MA from

Original Medicare, you’ll never be able to get back on a Medigap plan without underwriting.

I’d recommend anyone on Original Medicare hold on tightly to their plan and not switch . But then, I have medical issues and would have been screwed on MA.

[snowybirdie]

57. Medicare itself

Doesn't insure drug prices. You had a separate provider. Call them.
BTW, there's a plan advertised on tv that sells Cialls for .87 cents a pill. Called something like the Friday Plan.

[orangecrush]

58. Thanks

[csziggy]

59. I got a similar shock last week

When I was released from the hospital in January, I had four new prescriptions - two are name brand with no generics available. Those two are over $1000 for a ninety day refill.

I hunted online and found discount coupons from the manufacturers giving the first 30 days of each for free - one offered discounts for additional months. But those coupons cannot be used by anyone on a "federal" plan, meaning Medicare.

I'm lucky to be able to afford those medications, but holy shit, that takes a big bite out of my budget. Of course, if they work, I can avoid open heart surgery, which I guess is worth the money. But it pisses me off that as a Medicare user I have fewer rights to a discount than other people.

Edited to add: I checked Goodrx for the medications - for one, I get offered the same discount coupon as I already found but it is restricted to "private subscription insurance" so doesn't apply to Medicare coverage. The other medication - the Goodrx "discount" price is more than I paid to my pharmacy - at my pharmacy!