This is insane. Only the government could sit around and dream this up, probably while drinking coffee and eating danishes, all while earning exorbitant amounts of money. Thank you for the explanation.
Thank you for this great video but Medicare Part D is way more complex then it needs to be or should be. This is almost impossible for the average person to figure out. Congress needs to reform Part D and allow Medicare to negotiate ALL drug prices.
This is absolutely a fantastic video. As an agent, this cap has been bugging the crap out of me that the numbers were not adding up, and I couldn't adequately explain it to my clients. Thank you!! You deserve to wear a medicare Superman cape in your videos!
This is the first explanation I have seen of the $2,000 cap, which provided this information. Thank you! The Medicare tool kept showing me plans and numbers that didn't make sense to me. Now I understand why. Only the government would take what should be a simple thing, and turn it into a convoluted mess. The current rules are a mess, and the new for 2025 simplified rules are still a mess. From the people that brought you the tax code, we present prescription plan rules.
All my working life my employer provided insurance had the option to deny surgeries if they considered them "not medically necessary". Apparently screaming headaches due to a pinched nerve in my skull... for 30 years... is "not medically necessary". No more. I will not go with any advantage plan, I don't care what the cost is.
Yes. This possibility is exactly why I went with traditional Medicare and Supplements vs "Medicare Advantage". I had enough of Insurance companies saying you can only see certain doctors in certain areas, and refusing to pay for medical service until your tried all of their alternatives. With Traditional Medicare the conversation on the best treatment is between you and your doctor only and pays for what you and your doctor decide is best. And not what is cost effective for the Medicare Advantage insurance company stock price.
@@JBoy340a What really bugs me about my issue: They give me opiates for the pain... and then send me letters telling me I should try to get off them! After denying the surgery that would fix it!
Unfortunately traditional medicare will only pay for treatments that are medically necessary. What they do pay for is without pre approvals but they can and do deny payment for treatments and tests. I've had two things denied by traditional medicare in my first year. It happens.
@@jsfbay1 Don't be overly concerned. My PCP sent me for an abdominal aortic aneurysm (AAA) screening following my welcome to medicare visit. Medicare denied the claim, BUT they went on to say that since I was not notified the procedure would not be covered then I am not liable for the cost. The provider had to eat the cost. I met all requirements except one, I have never smoked so the screening isn't covered. My wife is being sent for the same procedure in the next few weeks to the same radiology provider, our PCP told her the cost would be $99. Something changed in the rules and I was lucky to get a free screening that I wasn't apparently entitled to. Also coming out of the Welcome to Medicare visit a blood test was denied. The test is the A1C test for diabetes. In the MSN Medicare said that I was informed it was not covered so I am liable for the full cost. I was never informed of that by anyone. However the lab never billed me for it so I just ignored it. Medicare adjudicates claims just like a commercial insurer would and will deny claims if rules are not adhered to. That's insurance.
Finally a video that makes sense! Thank you for making this video. I now understand what will be happening next year. Your way of explaining it & your examples cleared everything up. Happy i found your channel.
Thank you so much for the explanation. I was really baffled and I had spent many years in the insurance business and considered myself to be fairly educated in insurance until this came around.
This should be an even easier source to find the different basic and enhanced plans: q1medicare.com/PartD-SearchPDPMedicare-2025PlanFinder.php?state=az&NL&#results
Thank you for this explanation. I couldn't figure out why my sister's best plan option showed she would meet her oop max mid-year after only paying $400 in drugs. Obviously it is an enhanced plan, has a high monthly cost and $0 deductible. You save me a call to the plan to try to get their customer service reps to explain to me how this could be right.
you are amazing! thank you. this means i need to look closer, so many things to look at and i'm sure i missed that. love this website! and you! thanks again, kathy
Minolta cameras used to have a slogan: "Only from the mind of Minolta." I think Part D needs a similar slogan: "Only from the mind of politicians and lobbyists." Minolta tried to merge its way out of financial trouble, but ultimately was bought out by Sony. Unfortunately, there'll be no savior coming to our rescue to "buy out" this Part D mess.
Yet another very useful video. Thanks! By the way, you've got quite aways to go to catch up to that dude in the picture at 1:36, LOL! That's a very impressive mustache!
@@garyolsen3741 That's different. What is or is not covered depends upon the formulary of the plan. That has nothing to do with if it is enhanced or basic. There maybe an enhanced plan that does not cover your tier 5 med. Each plan has a seperate formulary, even if the plans are from the same company.
@@JeanPierreWhite Yes, I understand. I have a great plan. Why are you trolling me here? I’m good, thanks. My point is that the $2000 Cap works for me with my enhanced plan.
@@garyolsen3741 Unfortunate you consider my comments as trolling. My interactions with others in response to my or their posts here have been good. Have a nice day.
Why is there no mention of this "standard" Part D coverage in a plan's Summary of Benefits? All of the plans's SofBs I've seen show the standard co-pay or co-insurance for each tier, using different types of pharmacies (Preferred Mail Order, Standard Retail, etc). And it explains that the only stages of the Part D coverage are the Deductible stage (if it has a Part D deductible) the Initial coverage stage (which has the co-pays/coi-insurance in the tiering chart I described above) and the Catastrophic coverage stage at $2K.
In my case, even though I'm on Medicare, I'm also still working as a self employed person. So I get a tax deduction for paying Part D insurance premiums, but no tax deduction for paying prescription costs. So I figure that tax savings/no tax savings into my total yearly cost.
Well done!!! I kept up barely, but what about the non-nerds or 80+ year olds (no offense to 80+ year olds and non-nerds). I'm sure it will only get more complex over the years.
I would say, hopefully, it doesn't get more complex, but it, of course, will! This one was hard to not make nerdy since it is inherently a very nerdy topic and explanation😅
I’ve watched many similar videos on the Medicare supplement. Your videos are the best in terms of content and presentation. Unfortunately I can’t take you as my agent because my company has engaged another firm and tied our hands with $$$ that can only be paid if we use the assigned“agency “😅😢😂
We have definitely seen that before where companies force you to use a specific third party! Either way, I'm glad you were able to get some value from the videos, and I'm sure you will still get excellent coverage
@@GiardiniMedicare I suspect there is some kickback going on. Their assigned “realtor” was not the best in my experience. Still I hope you can get that kind of deal with the cooperate sponsor. Their employees would get the best service.
@@dalaiyang1588 Assuming it is the same company I am thinking of, we have also heard the service is not great... But you can't deny the money they give you to use them
Sorry , but I am running my drugs on the Medicare plan finder, and then look at my plan. My enhanced plan has no premium and no deductible and I put in two tier 3 drugs that have a $40 copay. It’s not showing what you are saying. It is not cutting off my payment using the higher standard amounts like you said. It says I owe for the whole year, even though your method is only showing I owe til June..
I don't understand what I'm missing. When I plug in my 7 drugs I get a $0 annual premium + $2,000 maximum in drug costs = $2,000 out of pocket in one plan. Same drug list with a $89.20 monthly / $1,070.40 annual premium + $996.08 = $2,066.48 out of pocket in another. Fairly close with either choice. But, then adding 1 Tier 2 antibiotic changes the oop to $2,132.00. So, is it, regardless of how the drug costs Troop is calculated, still a case of being on the hook for about a grand in premium and two grand in drug costs? Based on what is shown in the video, one would think not, but how exactly are we supposed to be able to know to ask this question, much less calculate an apples to apples oop? If all I had done is plug in the 7 known drugs for 2025, I would have thought I'd be out $2,066 annually, not potentially $3,000. Don't like the exposure potential.
Premiums aren't included in the $2,000 cap. Overall just choose the plan with the lowest estimated costs (including premium and prescription costs) based on the medications you enter
Mr giardini. Question...plan D , DO TIER COSTS VARY FROM STATE TO STATE. MEDICAREs website doesn't show the tiers and the formulary. I.e. Utah ... rosuvastatin 20mg Medicare shows 0.00 However WELLCARE shows tier 3 And when i called WELLCARE he said it was tier 1. For 2025. Thank you Kathy
Tier costs can vary from state to state, even with the same company. For example, Tier 4 could be 45% in one state and 47% in another. However, the medications in each tier shouldn't really change from state to state. For the Rosuvastatin, you might be looking at different Wellcare plans. It is a Tier 1 with one of their Part D plans, but it is a Tier 3 with a different Wellcare Part D plan.
Is Nubeqa, an anti-testosterone med for prostate cancer patients for the rest of their lives, covered under any of Medicare drug companies? It retails for $14,700 per 30 day prescription.
@@sabio2009 Yes, I see it covered by many Part D plans for 2025. If you use this video as a guide, you can see which plans cover it: th-cam.com/video/0jNoG_NWJB8/w-d-xo.html
Thank you for putting up the chart to compare plans. This really help me understand better. I switch from wellcare classic to wellcare value. Premuim is 0 a month I wanted to understand the difference
Is it reasonable to get a higher premium plan (enhanced?) in order to have access to a larger formulary? If so, is there a simple way to get the number of medications in a plan's formulary? This question is based on my limited research of plans for my wife and I. We each tend to get one or two expensive drugs. Many of the part d plans in our area of Ohio are dropping such pricey drugs and increasing the deductable for the rest. Thanks for a better explanation of the true OOP!
I would say it is somewhat reasonable, depending on how much more you would have to pay for the enhanced plan. Overall, we still recommend choosing the plan with the lowest overall costs based on the prescriptions you expect to take during the upcoming year. To try and find more of a breakdown for how many medications are covered by a plan's formulary, usually Q1 Medicare has the best search tool we have found: q1medicare.com/PartD-BrowseMedicarePartDPlanFormulary.php
@@GiardiniMedicare Yes, I had found that site. It actually can tell you the exact number of drugs in a formulary (I located it through a Google search), but that feature was apparently not working a few days ago probably due to updates being processed. It can do it at the current time. Thank you very much.
Thanks for this very detailed explanation of how the Troop is calculated for 2025. I've been thinking about how to optimize the plan usage by adjusting frequency of medication refilling. Given the examples you showed how much could this potentially save by prioritizing tier 3 meds in the early part of the year by filling every 21 days? Here's my logic. For a one month supply of a medication you are allowed to refill after 21 days, for Tier 3 and above medications the contribution of the standard benefit amount is significant. Therefore would it be better to fill tier 3 and above medications every 21 days in the early part of the year to reach the $2,000 cap as soon as possible. Tier 1 & 2 meds would be filled as needed. Once you see medications being filled at zero dollars you can now fill Tier 1 and Tier 2 meds every 21 days to build up a "stash" which can be drawn down starting in January 2026 when you would not fill any tier 1 & 2 meds until your stash was depleted. Tier 3 meds would be filled as needed until the end of 2025 and then starting in 2026 you'd fill every 21 days again.
@@Sarahbee-o8t My wife is on Humira. Its about 6,000 a month. We applied for Patient assistance so that the manufacturer can carry the cost. A good agent will assist you with the patient assistance working with the doctors to make sure everything is done appropriately.
question. i take a pain medication. its a generic at no cost. my doctor prescribes 60 a month. i take 30 a month and fill it every other month. plugging the drugs into the medicare calculator if i get 60 for one month every month its zero. if i get 30 a month every month its zero. if i get 60 as needed (i check off every other month) it costs $518 for the year....... why? i called the company and the rep had no clue. he told me it a zero cost generic so dont worry about it. i worry about everything.
Hard to say without knowing the exact medication and plan, but typically, with pain meds and controlled substances, there are "dispensing limits" where the medication can't be filled at more than a 30-day supply. So, when you put it in Medicare.gov as technically a two-month supply, it goes above the dispensing limit and instead shows you the full cash price, which is higher. Like the rep at the company, I don't see any issue as long as you get it filled as a 30-day supply in the real world.
Did you try checking at the website for the drug plan? I've seen comments recently from people on a few of these "part D" videos saying that the numbers that the Medicare calculator comes up with don't match the numbers from the actual drug plan website. I'd definitely "worry" about it, and check directly with the drug plan.
So with an "enhanced" plan it seems that I should get prescriptions for as many $0 copay drugs as I can, whether I need them or not! Each one has in effect a NEGATIVE cost, since it gets me closer to the $2000 cap. Have I got that right?? What am I missing??
Found a link recently that also shows the different basic and enhanced plans: q1medicare.com/PartD-SearchPDPMedicare-2025PlanFinder.php?state=az&NL&#results
Cameron, I REALLY like your videos but on this one, if PlanFinder ranks the total MOOP (premium + 12 mos copays) for you, why bother confusing the issue with labels like Basic, Standard and Enhanced? I think it makes folks believe they can't trust PlanFinder and should overinsure to get better value. What am I missing? You say in the description "Whether you’re on a standalone Part D plan or a Medicare Advantage plan, understanding this new cap is key to managing your drug costs". But wouldn't your understanding of how to use PlanFinder and Interpreting it properly really be the key for most beneficiaries? BTW THAT video was the best PF procedural video I've EVER watched. (But I couldn't find how to create you Medicare Account you said was in the description) Thank you.
You are correct that the best thing to do is still just plug the medications into plan finder and choose the option with the lowest overall costs (provided pharmacies and other factors work for the individual), but understanding how the cap is calculated is still important in my opinion. We have already talked to many people who mistakenly wanted to go with a plan simply because it showed them spending "$2,000" on the plan finder tool, not realizing that others plans showing lower OOP costs still had them reaching the $2,000 cap. Overall, your perspective is helpful, so thanks for the comment! Also, it looks like I forgot to add the link for creating a Medicare.gov account so I will go back and add that link to the description. Good catch!
It applies to both. But there are Medicare Advantage plans without prescription coverage, so the plan would have to of course have prescription coverage included
@@GiardiniMedicare So, I guess my question was, does the 2000 cap apply to people that have no Part D coverage? If all they have is Medicare Part A and Part B, but no part d, does the cap still apply?
What's the deal of I'm still working. Am I going to get penalized if I don't get a plan D now? Not ready to get medicare part B yet. Please answer me. I can't get an answer.
As I understand it, as long as you have employer insurance you may delay plan D. BUT when you decide to get plan D you will have to provide proof that you had coverage.i think your employer has to do this. I'd recommend calling Medicare and be sure of the regulations. Or There are brokers on TH-cam who explain it. 'How to delay Medicare without penalties'
Ask your employer if your current employer prescription coverage is "creditable" for Medicare Part D. If it is, you won't be penalized. If it is not "creditable" then you would need Part D now to avoid a penalty. No one can give an exact answer since it's up to your specific employer covergae. However, if you do end up needing Part D, you only need Part A to also get Part D.
@@8aNda1d One thing to be aware of is as of 2025 beacsue of the $2,000 cap many employer plans that are creditable in 2024 will NOT be creditable in 2025 because the employer plan due to the increased level of benefits on part d plans in 2025. To the OP. Make an appointment with an agent to figure this out.
What has changed? I’ve had D for 20 years. This sounds no different than what I’ve had except that the cap has changed and there’s no donut. What am I missing?!
The suggestion that Advantage Plans Coverage of tier 4, or more so tier 5, plans could be better than stand alone Part D plans very debatable. More often, they will be not prescribed, excluded and or denied. The other major omission to this presentation is not showing an example or two of a tire 4 or 5 medications and how the $2000 TROOP is achieved in a basic plan vs an enhanced plan.
If you run analyses and compare the lowest-cost Medicare Advantage option vs. the lowest-cost Part D option, you will likely see the Medicare Advantage plan come out ahead (based on our anecdotal experience)... Also, for tier 4 and tier 5 medications, since most have a coinsurance of 25%+, you will likely pay the full $2,000 out-of-pocket to reach the cap whether or not you are enrolled in a basic or an enhanced plan. Thanks for the feedback!
@@GiardiniMedicare Regarding tier 4 & 5 on Part D then, it's best to pick the lower cost plan provider, provided the specific medication is on their formulary. Regarding tier 4 & 5 medications on Advantage plans go, I hope your clients do not get push back or denials, and put on a lesser drugs before they even consider 4 & 5 medications, at all. You'll have some very disgruntled customers to deal with.
@@bertde3092 Agreed about going with the plan with the lowest overall costs and the medications on the formulary. I do wish I put that in the video, so I appreciate you bringing it up. As for Medicare Advantage, most of our clients still enroll in Medigap coverage. However, the prescription restrictions and denials are no worse with Medicare Advantage plans vs. Standalone Part D in our experience.
@@GiardiniMedicare This is an important distinction. Traditional Medicare has the benefit that you don't need pre approvals for MEDICAL care prescribed by a participating provider. However, traditional medicare does not have any drug coverage. You have to buy a standalone Part D plan which is subject to pre approvals and denials much like advantage medical plans. Its private insurance just like ADvantage medical plans. While I am happy with our Plan N medigap policies, I did not realize that Part D was subject to pre-approvals until my wife ran into that straight out of the gate for a Tier 5 speciality medication.
Before ponying up the $2,000 for Tier 4 or Tier 5 medications in January each year, first work with your agent and doctor to apply for Patient Assistance from the drug manufacturer. It can take a month or two and there are multiple hoops you have to go through. The reward however is free medication for up to a year. It is possible to avoid laying out $2,000 each January. You still want to choose a plan that covers the medication just in case the manufacturer decides they don't want to issue you the drugs for free anymore. Maybe the drug goes off patent, your income is too high etc.
@@GiardiniMedicare Yeah that plan does not cover it at all this year at least in my location. It was ozempic. But the good thing is I can go back to my favorite pharmacy next year.
@@GiardiniMedicare Yeah it is 90 or so a month but that takes care of the deductible. The last one I knew probably would not last. It was like 50 cents a month. I think it would have changed even without the new government changes.
It maybe overly complex, and more expensive in the long run, however ultimately it resolves the problem of folks that are on Tier 4/5 meds having to pay $8,000 or more each year, not by choice, just because they have a medical condition that they did not choose or cause. Benefits are enhanced under the IRA rules, but the politicians severely underestimated the financial cost of providing the better benefits.
It's essentially just that they offer benefits above and beyond the standard Part D benefit. This may be covering some medications not normally covered by Part D, or by having lower deductibles (or deductibles that exclude different medication tiers)... There isn't a really clear and easy definition, but here is some more info: www.medicareinteractive.org/get-answers/medicare-prescription-drug-coverage-part-d/medicare-part-d-coverage/filling-gaps-in-part-d-coverage
@@laurie6332 There are multiple plans that are enhanced and have low or no premiums. Doesn't mean they are automatically better than basic plans, but low cost enhanced plans definitely exist.
Thanks. I was going crazy trying to figure out why on medicare.gov my current plan would run the full $2000 and a different company was under $300 while I had two tier 3 medications. I was concerned that the estimates were just wrong and would come back to mess me over later in the year. I ran it by the local ship medicare help and they didn't know either. Humana might have had issues recently but with the inexpensive drugs, accepting all my doctors, 2600 medical moop, no deductibles, and a huge otc benefit it's the way to go. I can live without the flex card and less optical.
Really sorry to hear about your recent diagnosis. It just makes navigating this alone seem impossible. If you use this link, you can connect with us or a different broker to walk through your options: gmedicareteam.com/map/
Very good advice. While it's possible to choose a plan that covers some of your meds and use discount cards for uncovered meds and save money overall, you run the risk that the drug prices and the discount program can't change during the year. You are then on the hook for whatever it costs without any financial limit. Better to pay a few bucks extra to make sure all your meds are "covered" even if you plan to buy using discount programs during the year. My wife could have saved $400 in 2025 by choosing a $25 Part D plan vs a $98 Part D plan, however the more expensive plan covers 12 out of 12 of her meds. She is also changing meds a lot right now as her docs are trying to improve her therapy which isn't ideal. She may find herself on 2 or 3 different meds. Better to have the more expensive plan that gives us the flexibility to choose alternative meds come 2025 as needs arise.
@@ninastump7616 I hadn't heard this before but it looks like you might be onto something!! I asked Chat GPT about this. This is what ChatGPT says "There is no widespread indication that prescription discount cards, like those offered through GoodRx and other similar programs, will be entirely discontinued. However, there are significant disruptions in the industry, such as the recent announcement by Change Healthcare, a major processor for these discount cards. Change Healthcare has been terminating its processing services for many discount card companies as of early 2024. This decision could impact the ability of some prescription discount card companies to continue operating, particularly those reliant on Change Healthcare for processing claims . This change does not mean all prescription discount card programs will vanish but could lead to fewer options or shifts in how certain discount cards operate. The industry might see transitions as companies look for new processors to continue offering their services . It's important for users of such cards to stay informed about potential changes with their specific discount card provider, as these shifts could affect where and how savings can be accessed." Thank You for alerting me to the possibility of discount cards going bye bye. This would be blow to Seniors because we can't take advantage of manufacturer discount cards for expensive meds. About the change at Change Healthcare. Change Healthcare is owned by Optum ( a major PBM). Optum are owned by United Healthcare. Optum offer their own Rx Discount Card through AARP. It's not very good in terms of pricing. This sounds like anti competitive behavior. I'd be surprised if this action doesn't get congressional attention especially after the Change Healthcare hack which has attracted much congressional criticism.
I learn great information from your videos, however, you constantly move your arms and hands like a conductor leading a symphony orchestra. This excessive movement is distracting and might make viewers like myself have to limit viewing time.
@GiardiniMedicare my Italian aunt flails wildly when she speaks. It's like that with all her Italian relatives also. Hand movements for them are like an intricate form of sign language combined with the verbal parts.
That spreadsheet with Basic/Enhanced was enlightening. I filtered on my state and PDP and all my medicare.gov choices right there in one simple view!! I was very surprised that my 2 top contenders are both Enhanced. They are low premium and low co-pay and one of them has my 4 meds as Tier 1. (other plans combo of 1,2 and 3). I'll never hit the $2k (G*d willing), but your video shows Enhanced is not a bad thing which I might have otherwise concluded. My current plan that I am getting rid of is surprisingly Basic. Moderate premium. In 2025 they are applying the deductible to Tier 2!!! No way. bye-bye...
This is insane. Only the government could sit around and dream this up, probably while drinking coffee and eating danishes, all while earning exorbitant amounts of money. Thank you for the explanation.
Thank you for this great video but Medicare Part D is way more complex then it needs to be or should be. This is almost impossible for the average person to figure out. Congress needs to reform Part D and allow Medicare to negotiate ALL drug prices.
This is absolutely a fantastic video. As an agent, this cap has been bugging the crap out of me that the numbers were not adding up, and I couldn't adequately explain it to my clients. Thank you!! You deserve to wear a medicare Superman cape in your videos!
Glad it could help you! I'll hold off on the cape for now🤣
This is the first explanation I have seen of the $2,000 cap, which provided this information. Thank you!
The Medicare tool kept showing me plans and numbers that didn't make sense to me. Now I understand why.
Only the government would take what should be a simple thing, and turn it into a convoluted mess. The current rules are a mess, and the new for 2025 simplified rules are still a mess.
From the people that brought you the tax code, we present prescription plan rules.
Glad it helped you! Tried to include as many important details as possible
@@GiardiniMedicarelike I said in my first comment just a moment ago. You are the best among the crowded Medicare education 👏👏👏👏👍👍👍👍
@@dalaiyang1588 I wouldn't say "best" but either way I'll take the compliment😄
the government? really you don't think the insurance companies had any input? wow
@@brin3mcompanies are happy to make this opaque
All my working life my employer provided insurance had the option to deny surgeries if they considered them "not medically necessary". Apparently screaming headaches due to a pinched nerve in my skull... for 30 years... is "not medically necessary". No more. I will not go with any advantage plan, I don't care what the cost is.
Yes. This possibility is exactly why I went with traditional Medicare and Supplements vs "Medicare Advantage". I had enough of Insurance companies saying you can only see certain doctors in certain areas, and refusing to pay for medical service until your tried all of their alternatives. With Traditional Medicare the conversation on the best treatment is between you and your doctor only and pays for what you and your doctor decide is best. And not what is cost effective for the Medicare Advantage insurance company stock price.
@@JBoy340a What really bugs me about my issue: They give me opiates for the pain... and then send me letters telling me I should try to get off them! After denying the surgery that would fix it!
Unfortunately traditional medicare will only pay for treatments that are medically necessary. What they do pay for is without pre approvals but they can and do deny payment for treatments and tests.
I've had two things denied by traditional medicare in my first year. It happens.
@@JeanPierreWhite Please share (if you're comfortable doing so.) That's *very* concerning.
@@jsfbay1 Don't be overly concerned.
My PCP sent me for an abdominal aortic aneurysm (AAA) screening following my welcome to medicare visit. Medicare denied the claim, BUT they went on to say that since I was not notified the procedure would not be covered then I am not liable for the cost. The provider had to eat the cost. I met all requirements except one, I have never smoked so the screening isn't covered. My wife is being sent for the same procedure in the next few weeks to the same radiology provider, our PCP told her the cost would be $99. Something changed in the rules and I was lucky to get a free screening that I wasn't apparently entitled to.
Also coming out of the Welcome to Medicare visit a blood test was denied. The test is the A1C test for diabetes. In the MSN Medicare said that I was informed it was not covered so I am liable for the full cost. I was never informed of that by anyone. However the lab never billed me for it so I just ignored it.
Medicare adjudicates claims just like a commercial insurer would and will deny claims if rules are not adhered to. That's insurance.
Finally a video that makes sense! Thank you for making this video. I now understand what will be happening next year. Your way of explaining it & your examples cleared everything up. Happy i found your channel.
Happy you found it too! Thanks for watching
Thank you so much for the explanation. I was really baffled and I had spent many years in the insurance business and considered myself to be fairly educated in insurance until this came around.
Glad it helped!
Surfing the net about medigap, found you & subscribed.
Thanks for all that you do.
Thanks!
EXCELLENT presentation!
Great info. Thank you guys.
This was a great video my man! Thank you for this break down!
Where can we find the spreadsheet on standard and enhanced plans by state that you mention in your video? Thanks.
This should be an even easier source to find the different basic and enhanced plans: q1medicare.com/PartD-SearchPDPMedicare-2025PlanFinder.php?state=az&NL&#results
Only the government could put this mess together!
so you don't think the insurance companies had any input? think about it.
This has evolved over many years. Medicare trying to work within the system, and insurance companies try to game the system. Thus…this mess
Because of insurance industry pressure on politicians. Don’t blame the government without also including the money behind these decisions.
Thank you for this explanation. I couldn't figure out why my sister's best plan option showed she would meet her oop max mid-year after only paying $400 in drugs. Obviously it is an enhanced plan, has a high monthly cost and $0 deductible. You save me a call to the plan to try to get their customer service reps to explain to me how this could be right.
Crazy~only our government! Thank you!
Such a great and thorough breakdown!
you are amazing! thank you. this means i need to look closer, so many things to look at and i'm sure i missed that. love this website! and you! thanks again, kathy
Thank you very much!
Minolta cameras used to have a slogan: "Only from the mind of Minolta." I think Part D needs a similar slogan: "Only from the mind of politicians and lobbyists." Minolta tried to merge its way out of financial trouble, but ultimately was bought out by Sony. Unfortunately, there'll be no savior coming to our rescue to "buy out" this Part D mess.
Yet another very useful video. Thanks! By the way, you've got quite aways to go to catch up to that dude in the picture at 1:36, LOL! That's a very impressive mustache!
🤣 Can't imagine what I would look like with that
It’s even better than I thought!
As long as your plan is "enhanced" and not "Basic"
Yes, enhanced since basic won’t cover my Tier 5.
@@garyolsen3741 That's different. What is or is not covered depends upon the formulary of the plan. That has nothing to do with if it is enhanced or basic. There maybe an enhanced plan that does not cover your tier 5 med. Each plan has a seperate formulary, even if the plans are from the same company.
@@JeanPierreWhite Yes, I understand. I have a great plan. Why are you trolling me here? I’m good, thanks. My point is that the $2000 Cap works for me with my enhanced plan.
@@garyolsen3741 Unfortunate you consider my comments as trolling. My interactions with others in response to my or their posts here have been good. Have a nice day.
Why is there no mention of this "standard" Part D coverage in a plan's Summary of Benefits? All of the plans's SofBs I've seen show the standard co-pay or co-insurance for each tier, using different types of pharmacies (Preferred Mail Order, Standard Retail, etc). And it explains that the only stages of the Part D coverage are the Deductible stage (if it has a Part D deductible) the Initial coverage stage (which has the co-pays/coi-insurance in the tiering chart I described above) and the Catastrophic coverage stage at $2K.
I don't know why carriers aren't showing this in their plan documents. I'm assuming they would rather avoid the confusion
In my case, even though I'm on Medicare, I'm also still working as a self employed person. So I get a tax deduction for paying Part D insurance premiums, but no tax deduction for paying prescription costs. So I figure that tax savings/no tax savings into my total yearly cost.
Well done!!!
I kept up barely, but what about the non-nerds or 80+ year olds (no offense to 80+ year olds and non-nerds). I'm sure it will only get more complex over the years.
I would say, hopefully, it doesn't get more complex, but it, of course, will! This one was hard to not make nerdy since it is inherently a very nerdy topic and explanation😅
I’ve watched many similar videos on the Medicare supplement. Your videos are the best in terms of content and presentation. Unfortunately I can’t take you as my agent because my company has engaged another firm and tied our hands with $$$ that can only be paid if we use the assigned“agency “😅😢😂
We have definitely seen that before where companies force you to use a specific third party! Either way, I'm glad you were able to get some value from the videos, and I'm sure you will still get excellent coverage
@@GiardiniMedicare I suspect there is some kickback going on. Their assigned “realtor” was not the best in my experience. Still I hope you can get that kind of deal with the cooperate sponsor. Their employees would get the best service.
@@dalaiyang1588 Assuming it is the same company I am thinking of, we have also heard the service is not great... But you can't deny the money they give you to use them
Sorry , but I am running my drugs on the Medicare plan finder, and then look at my plan. My enhanced plan has no premium and no deductible and I put in two tier 3 drugs that have a $40 copay. It’s not showing what you are saying. It is not cutting off my payment using the higher standard amounts like you said. It says I owe for the whole year, even though your method is only showing I owe til June..
What medication (dosage and frequency) and which plan specifically? Would be interested to see that.
I don't understand what I'm missing. When I plug in my 7 drugs I get a $0 annual premium + $2,000 maximum in drug costs = $2,000 out of pocket in one plan. Same drug list with a $89.20 monthly / $1,070.40 annual premium + $996.08 = $2,066.48 out of pocket in another. Fairly close with either choice. But, then adding 1 Tier 2 antibiotic changes the oop to $2,132.00. So, is it, regardless of how the drug costs Troop is calculated, still a case of being on the hook for about a grand in premium and two grand in drug costs? Based on what is shown in the video, one would think not, but how exactly are we supposed to be able to know to ask this question, much less calculate an apples to apples oop? If all I had done is plug in the 7 known drugs for 2025, I would have thought I'd be out $2,066 annually, not potentially $3,000. Don't like the exposure potential.
Premiums aren't included in the $2,000 cap. Overall just choose the plan with the lowest estimated costs (including premium and prescription costs) based on the medications you enter
Mr giardini. Question...plan D , DO TIER COSTS VARY FROM STATE TO STATE.
MEDICAREs website doesn't show the tiers and the formulary.
I.e. Utah ... rosuvastatin 20mg
Medicare shows 0.00
However WELLCARE shows tier 3
And when i called WELLCARE he said it was tier 1.
For 2025.
Thank you Kathy
Tier costs can vary from state to state, even with the same company. For example, Tier 4 could be 45% in one state and 47% in another. However, the medications in each tier shouldn't really change from state to state.
For the Rosuvastatin, you might be looking at different Wellcare plans. It is a Tier 1 with one of their Part D plans, but it is a Tier 3 with a different Wellcare Part D plan.
my rosuvastatin is Tier 1 in two plans and Tier 3 in two plans. Go figure...
Is Nubeqa, an anti-testosterone med for prostate cancer patients for the rest of their lives, covered under any of Medicare drug companies? It retails for $14,700 per 30 day prescription.
@@sabio2009 Yes, I see it covered by many Part D plans for 2025. If you use this video as a guide, you can see which plans cover it: th-cam.com/video/0jNoG_NWJB8/w-d-xo.html
Thank you for putting up the chart to compare plans. This really help me understand better. I switch from wellcare classic to wellcare value. Premuim is 0 a month I wanted to understand the difference
Glad it could help a bit! It's a confusing but important change
Not one of my doctors took wellcare or my friends Dr. Would not take either.
@@aliekatsmom That would apply to Medicare Advantage plans, but not Part D plans.
Boy is this strange.
Is it reasonable to get a higher premium plan (enhanced?) in order to have access to a larger formulary? If so, is there a simple way to get the number of medications in a plan's formulary?
This question is based on my limited research of plans for my wife and I. We each tend to get one or two expensive drugs. Many of the part d plans in our area of Ohio are dropping such pricey drugs and increasing the deductable for the rest.
Thanks for a better explanation of the true OOP!
I would say it is somewhat reasonable, depending on how much more you would have to pay for the enhanced plan. Overall, we still recommend choosing the plan with the lowest overall costs based on the prescriptions you expect to take during the upcoming year.
To try and find more of a breakdown for how many medications are covered by a plan's formulary, usually Q1 Medicare has the best search tool we have found: q1medicare.com/PartD-BrowseMedicarePartDPlanFormulary.php
@@GiardiniMedicare Yes, I had found that site. It actually can tell you the exact number of drugs in a formulary (I located it through a Google search), but that feature was apparently not working a few days ago probably due to updates being processed. It can do it at the current time. Thank you very much.
Thanks for the video, but the vibrating buzz at 1:04 was too much for my ears through the earbuds!
Interesting! No one else has mentioned that
Great video. I would just like to see a plan that covers all my drugs.🙄
Which medication are you having trouble finding?
Are the enhanced plans Advantage plans?
Many advantage plans are enhanced plans, yes.
Thanks for this very detailed explanation of how the Troop is calculated for 2025. I've been thinking about how to optimize the plan usage by adjusting frequency of medication refilling.
Given the examples you showed how much could this potentially save by prioritizing tier 3 meds in the early part of the year by filling every 21 days?
Here's my logic.
For a one month supply of a medication you are allowed to refill after 21 days, for Tier 3 and above medications the contribution of the standard benefit amount is significant. Therefore would it be better to fill tier 3 and above medications every 21 days in the early part of the year to reach the $2,000 cap as soon as possible. Tier 1 & 2 meds would be filled as needed.
Once you see medications being filled at zero dollars you can now fill Tier 1 and Tier 2 meds every 21 days to build up a "stash" which can be drawn down starting in January 2026 when you would not fill any tier 1 & 2 meds until your stash was depleted. Tier 3 meds would be filled as needed until the end of 2025 and then starting in 2026 you'd fill every 21 days again.
You're not wrong, but I also don't want to speculate and create a "game plan" for people to game the system, so I will leave that to others.
Just 1 of my prescriptions costs 2,000 dollars.
@@Sarahbee-o8t My wife is on Humira. Its about 6,000 a month. We applied for Patient assistance so that the manufacturer can carry the cost. A good agent will assist you with the patient assistance working with the doctors to make sure everything is done appropriately.
question. i take a pain medication. its a generic at no cost. my doctor prescribes 60 a month. i take 30 a month and fill it every other month. plugging the drugs into the medicare calculator if i get 60 for one month every month its zero. if i get 30 a month every month its zero. if i get 60 as needed (i check off every other month) it costs $518 for the year....... why? i called the company and the rep had no clue. he told me it a zero cost generic so dont worry about it. i worry about everything.
Hard to say without knowing the exact medication and plan, but typically, with pain meds and controlled substances, there are "dispensing limits" where the medication can't be filled at more than a 30-day supply. So, when you put it in Medicare.gov as technically a two-month supply, it goes above the dispensing limit and instead shows you the full cash price, which is higher.
Like the rep at the company, I don't see any issue as long as you get it filled as a 30-day supply in the real world.
Did you try checking at the website for the drug plan? I've seen comments recently from people on a few of these "part D" videos saying that the numbers that the Medicare calculator comes up with don't match the numbers from the actual drug plan website. I'd definitely "worry" about it, and check directly with the drug plan.
@GiardiniMedicare my Dr does a new prescription every time I get it which I think is why it has never had a cost with my current plan.
@@freecycling6687the website for the company comes up n/a when I put in them all and try to get a price.
So with an "enhanced" plan it seems that I should get prescriptions for as many $0 copay drugs as I can, whether I need them or not! Each one has in effect a NEGATIVE cost, since it gets me closer to the $2000 cap. Have I got that right?? What am I missing??
I mean... technically you're not wrong, but I can't say we would suggest that😅
How can I tell if a plan is enhanced or basic? Is it only plans with high premiums and no yearly deductible?
Best way is using the 2025 Landscape file that I talked about in the video: www.cms.gov/medicare/coverage/prescription-drug-coverage
Found a link recently that also shows the different basic and enhanced plans: q1medicare.com/PartD-SearchPDPMedicare-2025PlanFinder.php?state=az&NL&#results
Cameron, I REALLY like your videos but on this one, if PlanFinder ranks the total MOOP (premium + 12 mos copays) for you, why bother confusing the issue with labels like Basic, Standard and Enhanced? I think it makes folks believe they can't trust PlanFinder and should overinsure to get better value. What am I missing?
You say in the description "Whether you’re on a standalone Part D plan or a Medicare Advantage plan, understanding this new cap is key to managing your drug costs". But wouldn't your understanding of how to use PlanFinder and Interpreting it properly really be the key for most beneficiaries? BTW THAT video was the best PF procedural video I've EVER watched. (But I couldn't find how to create you Medicare Account you said was in the description) Thank you.
You are correct that the best thing to do is still just plug the medications into plan finder and choose the option with the lowest overall costs (provided pharmacies and other factors work for the individual), but understanding how the cap is calculated is still important in my opinion. We have already talked to many people who mistakenly wanted to go with a plan simply because it showed them spending "$2,000" on the plan finder tool, not realizing that others plans showing lower OOP costs still had them reaching the $2,000 cap.
Overall, your perspective is helpful, so thanks for the comment! Also, it looks like I forgot to add the link for creating a Medicare.gov account so I will go back and add that link to the description. Good catch!
Do you have to have a part D plan, or an advantage plan to get the 2000 cap?
It applies to both. But there are Medicare Advantage plans without prescription coverage, so the plan would have to of course have prescription coverage included
@@GiardiniMedicare So, I guess my question was, does the 2000 cap apply to people that have no Part D coverage? If all they have is Medicare Part A and Part B, but no part d, does the cap still apply?
@@Squddle no
What's the deal of I'm still working. Am I going to get penalized if I don't get a plan D now? Not ready to get medicare part B yet. Please answer me. I can't get an answer.
As I understand it, as long as you have employer insurance you may delay plan D. BUT when you decide to get plan D you will have to provide proof that you had coverage.i think your employer has to do this. I'd recommend calling Medicare and be sure of the regulations. Or There are brokers on TH-cam who explain it. 'How to delay Medicare without penalties'
Ask your employer if your current employer prescription coverage is "creditable" for Medicare Part D. If it is, you won't be penalized. If it is not "creditable" then you would need Part D now to avoid a penalty. No one can give an exact answer since it's up to your specific employer covergae. However, if you do end up needing Part D, you only need Part A to also get Part D.
@@8aNda1d One thing to be aware of is as of 2025 beacsue of the $2,000 cap many employer plans that are creditable in 2024 will NOT be creditable in 2025 because the employer plan due to the increased level of benefits on part d plans in 2025.
To the OP. Make an appointment with an agent to figure this out.
What has changed? I’ve had D for 20 years. This sounds no different than what I’ve had except that the cap has changed and there’s no donut. What am I missing?!
The cap and no donut hole are both massive changes. Other than that, $0 Part D vaccines, $35/month insulin cap, and more.
The suggestion that Advantage Plans Coverage of tier 4, or more so tier 5, plans could be better than stand alone Part D plans very debatable. More often, they will be not prescribed, excluded and or denied.
The other major omission to this presentation is not showing an example or two of a tire 4 or 5 medications and how the $2000 TROOP is achieved in a basic plan vs an enhanced plan.
If you run analyses and compare the lowest-cost Medicare Advantage option vs. the lowest-cost Part D option, you will likely see the Medicare Advantage plan come out ahead (based on our anecdotal experience)... Also, for tier 4 and tier 5 medications, since most have a coinsurance of 25%+, you will likely pay the full $2,000 out-of-pocket to reach the cap whether or not you are enrolled in a basic or an enhanced plan. Thanks for the feedback!
@@GiardiniMedicare Regarding tier 4 & 5 on Part D then, it's best to pick the lower cost plan provider, provided the specific medication is on their formulary.
Regarding tier 4 & 5 medications on Advantage plans go, I hope your clients do not get push back or denials, and put on a lesser drugs before they even consider 4 & 5 medications, at all. You'll have some very disgruntled customers to deal with.
@@bertde3092 Agreed about going with the plan with the lowest overall costs and the medications on the formulary. I do wish I put that in the video, so I appreciate you bringing it up.
As for Medicare Advantage, most of our clients still enroll in Medigap coverage. However, the prescription restrictions and denials are no worse with Medicare Advantage plans vs. Standalone Part D in our experience.
@@GiardiniMedicare This is an important distinction.
Traditional Medicare has the benefit that you don't need pre approvals for MEDICAL care prescribed by a participating provider.
However, traditional medicare does not have any drug coverage. You have to buy a standalone Part D plan which is subject to pre approvals and denials much like advantage medical plans. Its private insurance just like ADvantage medical plans.
While I am happy with our Plan N medigap policies, I did not realize that Part D was subject to pre-approvals until my wife ran into that straight out of the gate for a Tier 5 speciality medication.
Before ponying up the $2,000 for Tier 4 or Tier 5 medications in January each year, first work with your agent and doctor to apply for Patient Assistance from the drug manufacturer. It can take a month or two and there are multiple hoops you have to go through. The reward however is free medication for up to a year. It is possible to avoid laying out $2,000 each January.
You still want to choose a plan that covers the medication just in case the manufacturer decides they don't want to issue you the drugs for free anymore. Maybe the drug goes off patent, your income is too high etc.
Politics are never straight forward, and always cost more than expected.
That's a good way to summarize it😅
Some companies will take your GoodRx purchases towards your deductible and cap.
Never seen that be the case
I just know with the same drugs mine went from a total cost of 800 dollars to around 1700 dollars next year.
Definitely possible! All depends on your plan's coverage for next year
@@GiardiniMedicare Yeah that plan does not cover it at all this year at least in my location. It was ozempic. But the good thing is I can go back to my favorite pharmacy next year.
@@stanley8574 Nice! Sounds like you found a different plan that will cover it well.
@@GiardiniMedicare Yeah it is 90 or so a month but that takes care of the deductible. The last one I knew probably would not last. It was like 50 cents a month. I think it would have changed even without the new government changes.
@@stanley8574 You can ask your plan for a formulary exception.
did i miss what a standard benefit- define it. A nightmare
The standard benefit is discussed at the 8:00 minute mark
WoW!!!!! what idiot politician came up with this plan? This SUCKS!!!!!!
It maybe overly complex, and more expensive in the long run, however ultimately it resolves the problem of folks that are on Tier 4/5 meds having to pay $8,000 or more each year, not by choice, just because they have a medical condition that they did not choose or cause.
Benefits are enhanced under the IRA rules, but the politicians severely underestimated the financial cost of providing the better benefits.
What makes a plan enhanced?
It's essentially just that they offer benefits above and beyond the standard Part D benefit. This may be covering some medications not normally covered by Part D, or by having lower deductibles (or deductibles that exclude different medication tiers)... There isn't a really clear and easy definition, but here is some more info: www.medicareinteractive.org/get-answers/medicare-prescription-drug-coverage-part-d/medicare-part-d-coverage/filling-gaps-in-part-d-coverage
That's my question too because it seems much more expensive
@@laurie6332 There are multiple plans that are enhanced and have low or no premiums. Doesn't mean they are automatically better than basic plans, but low cost enhanced plans definitely exist.
Thanks. I was going crazy trying to figure out why on medicare.gov my current plan would run the full $2000 and a different company was under $300 while I had two tier 3 medications. I was concerned that the estimates were just wrong and would come back to mess me over later in the year. I ran it by the local ship medicare help and they didn't know either. Humana might have had issues recently but with the inexpensive drugs, accepting all my doctors, 2600 medical moop, no deductibles, and a huge otc benefit it's the way to go. I can live without the flex card and less optical.
Are you seeing evidence that insurance companies are starting to drop more expensive medications from their formularies because of the $2,000 cap?
Personally, we haven't noticed that happening more than most years.
I don’t understand any of this..I need major help..My plan worked for me but now I have Cancer. HELP ME SOMEBODY!!!
Really sorry to hear about your recent diagnosis. It just makes navigating this alone seem impossible. If you use this link, you can connect with us or a different broker to walk through your options: gmedicareteam.com/map/
Really hope you don’t have a advantage plain! They are great plans until you get sick !
So basically, we have to pay for Rx drugs for the first 6 months and we get 6 months free! Sort of like a BOGO sale, huh?? 😁😁😁😁
Yup
make sure all your meds are covered. if not the $2,000.00 is not counted. at less that how I understand it.
You are correct!
Very good advice. While it's possible to choose a plan that covers some of your meds and use discount cards for uncovered meds and save money overall, you run the risk that the drug prices and the discount program can't change during the year. You are then on the hook for whatever it costs without any financial limit. Better to pay a few bucks extra to make sure all your meds are "covered" even if you plan to buy using discount programs during the year.
My wife could have saved $400 in 2025 by choosing a $25 Part D plan vs a $98 Part D plan, however the more expensive plan covers 12 out of 12 of her meds. She is also changing meds a lot right now as her docs are trying to improve her therapy which isn't ideal. She may find herself on 2 or 3 different meds. Better to have the more expensive plan that gives us the flexibility to choose alternative meds come 2025 as needs arise.
@@JeanPierreWhite I personnally agree, better safe than sorry later. Hey, I thought I hear somewhere the Rx cards may have a problem or going away.
@@ninastump7616 I hadn't heard this before but it looks like you might be onto something!! I asked Chat GPT about this. This is what ChatGPT says
"There is no widespread indication that prescription discount cards, like those offered through GoodRx and other similar programs, will be entirely discontinued. However, there are significant disruptions in the industry, such as the recent announcement by Change Healthcare, a major processor for these discount cards. Change Healthcare has been terminating its processing services for many discount card companies as of early 2024. This decision could impact the ability of some prescription discount card companies to continue operating, particularly those reliant on Change Healthcare for processing claims
.
This change does not mean all prescription discount card programs will vanish but could lead to fewer options or shifts in how certain discount cards operate. The industry might see transitions as companies look for new processors to continue offering their services
.
It's important for users of such cards to stay informed about potential changes with their specific discount card provider, as these shifts could affect where and how savings can be accessed."
Thank You for alerting me to the possibility of discount cards going bye bye. This would be blow to Seniors because we can't take advantage of manufacturer discount cards for expensive meds.
About the change at Change Healthcare. Change Healthcare is owned by Optum ( a major PBM). Optum are owned by United Healthcare. Optum offer their own Rx Discount Card through AARP. It's not very good in terms of pricing. This sounds like anti competitive behavior. I'd be surprised if this action doesn't get congressional attention especially after the Change Healthcare hack which has attracted much congressional criticism.
I learn great information from your videos, however, you constantly move your arms and hands like a conductor leading a symphony orchestra. This excessive movement is distracting and might make viewers like myself have to limit viewing time.
Unfortunately I have talked like that my entire life, so I don't see it changing! Hope you can still learn from the info. Thanks for the feedback
Good grief...
@GiardiniMedicare my Italian aunt flails wildly when she speaks. It's like that with all her Italian relatives also. Hand movements for them are like an intricate form of sign language combined with the verbal parts.
@@joannasisemore7184 My entire family talks that way too🤣 With a last name like Giardini it is impossible not to!
@@tikkin11 No good deed goes unpunished.
That spreadsheet with Basic/Enhanced was enlightening. I filtered on my state and PDP and all my medicare.gov choices right there in one simple view!! I was very surprised that my 2 top contenders are both Enhanced. They are low premium and low co-pay and one of them has my 4 meds as Tier 1. (other plans combo of 1,2 and 3). I'll never hit the $2k (G*d willing), but your video shows Enhanced is not a bad thing which I might have otherwise concluded.
My current plan that I am getting rid of is surprisingly Basic. Moderate premium. In 2025 they are applying the deductible to Tier 2!!! No way. bye-bye...