Medicare prescription coverage issues

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ZZman

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I was with Blue Cross Blue Shield Insurance for decades with my employer. When I turned 65 my employer coverage dropped so we switched to Bcbs Medicare Advantage plans. Wasn't planning on having any issues but I was wrong.
Medicare Advantage wanted two prior authorizations done for prescriptions I have been taking for a while now. I would have thought Bcbs could see I have been taking these already for some time.
I also discovered that two prescriptions I take that are name brand have no generics or Bcbs doesn't cover the generic in their formulary. With commercial insurance I could use a manufacturer discount which made these two prescriptions relatively cheap. However you can't use these discounts on Government insurance so my price on these medicines skyrocketed.
Very disappointed..... 🙁
 
Hard lesson to learn, when shopping Medicare plans if you are on prescriptions check prescription coverage ahead of time among all the companies offering plans.

I understand in your case thinking BCBS would be the same as you had. Good news (if you can call it that) is you can switch plans in 8 months if you find better coverage for your specific drugs. Your out of pocket limit on drugs is $2,100

The time to switch plans expired March 31st next chance starts in the fall 2026 to be effective Jan 2027
 
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Boomer said:
This is a reason to go with a Medicare supplement and then take Part D to cover your medications. Never a bill for doctors or hospitals and good anywhere they accept Medicare so great for those who travel in the US.
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Drug plans are no different under Part D
You have to make sure of deductibles and price tiers. You have to make sure they cover your specific drugs. They also have a out of pocket limit of $2,100 same as advantage plans

As far as bills, you can’t say there is never a bill. There is a monthly bill for Part A,B,D and for the supplement plan typically Plan N or G that in the long term will cost hundreds of dollars a month
 
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ZZman said:
With commercial insurance I could use a manufacturer discount which made these two prescriptions relatively cheap.
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Talk to your doc, and your pharmacist. Find out the price as if you had no insurance - even contact the drug maker. Its very common for the pharma companies to give big discounts to those without insurance via coupons, etc. You might have to go to a different pharmacy and put you in there system without insurance.

There is also a website named after our current leader that lists negotiated prices and where to get them. I am assuming you have looked there already.

Good luck - I know patented drugs can be crazy priced.
 
Not to knock this off track, but I turn 64 in a couple weeks so will start my Medicare shopping journey. I have been told Advantage plans are not so good, as they generally have been screwed up by greed due to the way treatment is coded for more money in the insurance company pockets. I know my SS will be paying for part of my coverage, but wondering what you old(er) guys and gals have found to work best. I have cardiac care issues with a few necessary medications.
 
There are discount cards like GoodRx that would allow you to price the medication. Using a discount card like GoodRx or a copay card from the manufacturer like you did when you had commercial insurance is not allowed given you have Medicare coverage, although theoretically you can get a pharmacy to do it if you initiate, the pharmacy may ask you if you have prescription coverage and reject giving you that price since you have Medicare coverage.

Alarmguy's point that your OOP is capped at $2100 for the year on prescriptions is valid - not sure what the cost thru your plan is but you can also apply to have the copay spread out across 12 months. $2100/12 = max of $175/month.
 
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SC Maintenance said:
Talk to your doc, and your pharmacist. Find out the price as if you had no insurance - even contact the drug maker. Its very common for the pharma companies to give big discounts to those without insurance via coupons, etc. You might have to go to a different pharmacy and put you in there system without insurance.
Click to expand...

^^^^This is very good advice as it may be the only way to get your cost down on brand name drugs that aren't covered by the BCBS formulary list. Check for your drug's discount price on discount card sites including: GoodRx, WellRx, SingleCare, BuzzRx and your specific drug's website. You can opt to pay out-of-pocket by using the discount card without using your Medicare Advantage insurance, but be aware that the out-of-pocket cost will not apply towards the $2100/yr. out-of-pocket cap for 2026 (AKA, "catastrophic limit"). As such, you will need to do the math to determine which option will cost less at the end of the year.
 
A lot depends on your health. I take a cancer drug that is $1`80,000/year without insurance. I pay $2100 the first of January and for the rest of this year, all my drugs are "no charge". And I take a lot of meds. I also have at least one PET scan and one CAT scan a hear, numerous doctors visits with oncologists, dermatologists (my previous cancer drug for chronic lymphocytic leukemia caused two severe skin cancers on my back...Mohs surgery required), cardiologist (had a quad bypass 21 years ago) and family doctor (I am insulin dependent also caused by my cancer drug). Yes, I pay just over $220/month for Medicare supplement Plan F but if I was on an Advantage plan, the out of pocket costs for all this stuff would exceed my premium payments. So I never get a bill for any service; the supplement pays everything that Medicare does not cover. Also, I pay $96/year for my Part D coverage. It covers all my very numerous medications.
 
Same issue with Mom only she has traditional Medicare, a Part B supplemental plan, and a Part D plan for Prescriptions. Had to switch Part D carrier this year due to the old one tripling the premium. One drug, and one of the cheapest drugs they have to cover, suddenly required a certification from the doctor that it's necessary.

Which reminds me, I need to contact the carrier to see if the doctor sent in the info yet. Refill time is coming up...
 
Boomer said:
A lot depends on your health. I take a cancer drug that is $1`80,000/year without insurance. I pay $2100 the first of January and for the rest of this year, all my drugs are "no charge". And I take a lot of meds. I also have at least one PET scan and one CAT scan a hear, numerous doctors visits with oncologists, dermatologists (my previous cancer drug for chronic lymphocytic leukemia caused two severe skin cancers on my back...Mohs surgery required), cardiologist (had a quad bypass 21 years ago) and family doctor (I am insulin dependent also caused by my cancer drug). Yes, I pay just over $220/month for Medicare supplement Plan F but if I was on an Advantage plan, the out of pocket costs for all this stuff would exceed my premium payments. So I never get a bill for any service; the supplement pays everything that Medicare does not cover. Also, I pay $96/year for my Part D coverage. It covers all my very numerous medications.
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It's hard to predict what out of pocket costs would be as they depend on area and policy.
My Advantage MOOP is (max out of pocket) is $3,500. a year. The policy cost me the Part B cost of $202 a month vs the $430 that you are paying.

Specialists cost me $5 co-pay, Family doctor $0 co-pay. Drug plan included and co-pays for the drugs so I dont have to pay a deductible upfront.
In addition two dental visits per year and up to $2,500 in dental work included.
Also free eye exam and $300 in free eyewear or contacts

Plan F not available to the OP but plan G is. This is were you live comes in important, A place like NY where @demarpaint lives plan g is off the wall expensive however so is Advantage plans in NY with stupid high out of pocket expenses.

I agree with you, depends on your health, but your cancer and all drug costs are no different with an Advantage plan. Scans can cost $150 to $300 or so a year, again depends on the area. It truly is a case on the individual, where they live, how their health is and how much they want to pay. With that said, the co-pays with Advantage plans is greatly exaggerated from reality.

I will say this, no matter what you choose, Medicare is a GREAT system, one of few government agencies in my mind that works so well.

How you chose does matter, once in an Advantage Plan, you are given one year to opt out if new to medicare and able go back to supplement in many states, if you dont you are stuck in the Advantage plans system but can switch those plans any year of your choosing. Only other way to go back to traditional medicare is if the Advantage plan you have is no longer offered the following year or if you move to an area that its not offered.

It not as simple as it was just a few years ago, Advantage plans were squeezed by the government not giving them increases annual increases in payments, from the pervious administration that has since changed so time will tell.

For the 5 years since having Medicare, I have had Advantage Plans the first 3 years, then Medicare A,B,N&D for the 4th year and now back to an Advantage plan for the 5th year. I just dont want to pay an extra $300 or more a month for the same health care. I do get concerned about the rising MOOPs but so far I am in a state with reasonable costs.
 
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ZZman said:
I was with Blue Cross Blue Shield Insurance for decades with my employer. When I turned 65 my employer coverage dropped so we switched to Bcbs Medicare Advantage plans. Wasn't planning on having any issues but I was wrong.
Medicare Advantage wanted two prior authorizations done for prescriptions I have been taking for a while now. I would have thought Bcbs could see I have been taking these already for some time.
I also discovered that two prescriptions I take that are name brand have no generics or Bcbs doesn't cover the generic in their formulary. With commercial insurance I could use a manufacturer discount which made these two prescriptions relatively cheap. However you can't use these discounts on Government insurance so my price on these medicines skyrocketed.
Very disappointed..... 🙁
Click to expand...
You have the option to pay for your own drugs without Medicare.
If you find a drug on any of the mentioned GoodRX type discount cards you can buy it that way if it is cheaper. You cannot use the discount card in conjunction with your medicare coverage but you do of course can pay for it out of pocket with a discount card.

"Who can use GoodRx?
Anyone can use GoodRx, regardless of whether they have commercial insurance, Medicare, Medicaid, or no insurance. Your patients should tell the pharmacist they will use a GoodRx discount instead of their insurance when they pay for their prescriptions. Is GoodRx free to use? GoodRx is 100% free for everyone to use."
https://insuredandmore.com/can-i-use-goodrx-if-i-have-medicare-part-d
 
Boomer said:
A lot depends on your health. I take a cancer drug that is $1`80,000/year without insurance. I pay $2100 the first of January and for the rest of this year, all my drugs are "no charge". And I take a lot of meds. I also have at least one PET scan and one CAT scan a hear, numerous doctors visits with oncologists, dermatologists (my previous cancer drug for chronic lymphocytic leukemia caused two severe skin cancers on my back...Mohs surgery required), cardiologist (had a quad bypass 21 years ago) and family doctor (I am insulin dependent also caused by my cancer drug). Yes, I pay just over $220/month for Medicare supplement Plan F but if I was on an Advantage plan, the out of pocket costs for all this stuff would exceed my premium payments. So I never get a bill for any service; the supplement pays everything that Medicare does not cover. Also, I pay $96/year for my Part D coverage. It covers all my very numerous medications.
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Yes, F plans are great! Too bad that they have been discontinued for new enrolls. You are lucky to be grandfathered in!
 
JohnnyG said:
Yes, F plans are great! Too bad that they have been discontinued for new enrolls. You are lucky to be grandfathered in!
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Plan G is almost exactly the same. It is the same with one exception. It has a $283 deductible on Plan G
Also Plan F is not available to new beneficiaries after 2020

Also know if you travel a lot MANY advantage plans offer better overseas insurance.
Just be careful to check as many policies are changing.
With Plan G or Plan F you are responsible for a full 20% of the emergency bill overseas. So maybe wise to get travel insurance

My Advantage Plan covers everything except a $150 co-pay in emergencies.
 
alarmguy said:
Plan G is almost exactly the same. It is the same with one exception. It has a $283 deductible on Plan G
Also Plan F is not available to new beneficiaries after 2020

Also know if you travel a lot MANY advantage plans offer better overseas insurance.
Just be careful to check as many policies are changing.
With Plan G or Plan F you are responsible for a full 20% of the emergency bill overseas. So maybe wise to get travel insurance

My Advantage Plan covers everything except a $150 co-pay in emergencies.
Click to expand...
Amy idea how the premiums compare? I currently pay $290.10/mo for my Saphire Blue coverage, and the Wife the same.
Drug coverage from Humana is the real ripoff @ $115.90/mo.

I have no out of pocket expenses or co-pays with either plan. $0.
 
alarmguy said:
@demarpaint
Not to rub salt in a wound, as you know I escaped from New York almost 20 years ago now.
Check out my new Advantage plan
https://www.humana-medicare.com/BenefitSummary/2026PDFs/H1036335001SB26.pdf
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Rubbing salt in a wound, why not? I'd kick someone if they were down. ;) I have the last of the PPO plans available in my area that is paid for from what they withhold from my SS. I'm considering looking at the HMO plans for possibly less out of pocket costs. At a quick glance your coverage is a lot better than the garbage offered in NY that's for sure!!!
 
For a Part D plan, look up WellCare. At $96/year, they are a HECK of a lot cheaper than the Aetna plan I had at almost $200/month!
The employer from whom I retired put me on to them. Cover all the same drugs and excellent service.
 
I checked the discount card programs and they are more money. I am going to try Amazon Pharmacy and see what they are.
 
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