People who take only a few generic drugs will probably choose the lowest-cost Part D plan. But people who take brand drugs, especially expensive ones, need to do some research using the Medicare.gov Plan Finder.
Last week I met with Ken who currently takes five generic prescriptions. When we looked at the Medicare.gov Plan Finder, the most cost-effective plan for him has a very reasonable monthly premium of $12.60. He could even get his generics by mail for $0 co-pay. But… Ken has arthritis that is getting worse and may require him to take an expensive brand drug. His doctor has mentioned Humira, so we looked this up.
Humira is listed as a “specialty drug” on every Part D plan we looked at. (There are over 30 Part D plans to choose from in Arizona!) The retail price for Humira is around $2,400 per month and Ken would pay 33% of that, which is around $800. Ken would go into the donut hole after one month during which he would pay 46% of the retail cost, or $1,100. Ken would be in the donut hole for just two months followed by the “catasophic stage”. For the rest of the year Ken would only pay 5% of the cost of Humira, or $120 per month. But by this point in the year, Ken would have already spent about $3,000 on Humira.
Next we looked at Simponi, which is a injectable drug administered once per month. The retail cost for this drug (with insurance) is $3,500….and it is not covered by the $12.60 per month plan that works for Ken’s generics.
Ken turns 65 in three months, so I told him he can hold off a while before he enrolls in a Part D plan. I told him to consult with his doctor about his Part D dilemma. I doubt doctors understand how Part D works and how expensive drugs like Humira and Simponi are. When picking a Part D plan, Ken needs to think about his future needs and not just his current prescriptions.
I told Ken he will need to review his drug plan each year during the Open Enrollment Period. If his prescriptions change (or his Part D plan changes) he can pick a new plan at that time.
I have a video that explains Part D and the donut hole and I encourage people to watch it. How Part D works and how a person get into (and out of) the donut hole is kind of confusing.
Drugs for rheumatoid arthritis are very expensive and I have had clients who could not afford to spend $3,000 per year to get relief for their pain. I have also had clients with employer health insurance that covered most of the cost for expensive drugs. But when they retired and moved onto Medicare and Part D, they were shocked to learn how much they would have to pay for their prescriptions. Some could afford the higher costs and others could not. It seems like a crazy system to me.