Sage Insurance Advisors LLC, specializes in Medicare plans and represents insurance companies offering Medicare supplements, Medicare Advantage Plans, and Part D prescription drug plans.

Serving Northeast Indiana from 4233 East State Boulevard in Fort Wayne and online at SageInsuranceAdvisors.com.

hi there.

>> I'm Sandy Thomson, the host of this show coming up.

And the show though is really for you.

Our main topic tonight will be about the changes for Medicare and there are some really significant ones that I think you're going to want to know about.

Greg McDonald comes every year this time for a couple of our shows and explains what's going to be happening the next year and what these changes are and he's here with us tonight and will be with us again next week here on LIFE Ahead.

That's Wednesday night at seven .

Now do keep in mind if you haven't watched this before, this really is your show.

So I want you to call in if you have any questions.

We're really fortunate to have this expertize expertize with us tonight that can help guide you through these Medicare changes.

It gets pretty complicated (969) 27 twenty .

Meanwhile, if you didn't see him last year or the year before the year before the year before it's been a while.

>> Yes, very well.

This is Greg McDonald, an expert obviously on insurance and Medicare.

>> And Greg, you've been we were guessing 10 years maybe you've been a good 10 years 10 years doing this.

>> Yes, I still don't know everything about Medicare.

>> I should know even though you've been here sharing that with what keeps changing it constantly changes and this year particularly is they've made it very interesting for us.

>> Well, I would assume most of you probably have gotten your new pamphlet booklet Medicare and you for twenty twenty five.

If not you probably will be getting it very soon and there is what it will look like.

>> So watch your mailboxes for that.

Don't throw it away.

You may need to refer to it and Greg's going to give us some ideas of really what you should be paying attention to.

>> It's a pretty thick book I would say we're probably about a third of an inch or something.

>> I wouldn't want to sit down this.

It's better than a sleeping pill.

>> Well, that's true.

They put you to sleep.

But the thing is you don't need to know everything that's in here and it's indexed very, very well and there are lots of things written up in question form and then the answers there.

>> So it'll guide you through finding out what you need to know because it's going to be different for different people.

>> OK, let's talk about why there are so many changes this year.

>> Greg, I know we always talk about new changes but this year's really significant why?

>> Well, Congress passed the Inflation Reduction Act and that particular act really had some impact on the prescription drug plan program and it did some good things and it did some things that are going to impact people in a negative way to the biggest change that you're going to see is you may recall that the drug plans have a deductible then they have the initial phase and then you went into the coverage gap or donut hole.

>> Everybody was always oh I hate to get into that and then they have what they call the catastrophic phase.

>> Well, the coverage gap donut hole has been eliminated totally good because most people didn't really understand that and it was a surprise.

>> Yeah, it's always a shock.

>> All of a sudden you had a small copay and then then boom your prices went up and it's like wow, what just happened here?

>> Right.

And I get calls and I know what what yeah why why why so we don't have to worry about the coverage gap or what was the second thing that was.

>> Well yeah the coverage gap is gone.

OK so the way it's going to work for next year there's going to be a deductible in your plans now most of the plans that I've looked at will either have a deductible of five hundred ninety dollars or less and sometimes they'll split that they might have a five hundred ninety dollar deductible for brand name drugs and a zero deductible for tier one tier two generic drugs which are the less expensive for sure.

>> And so once that deductible is met you get in what they call the initial phase where you're paying approximately twenty five percent of the cost of the drug and insurance company is going to pay the rest for you right.

>> They're paying the rest and that might come in the form of a copay or you and you might not have a charge at all if if it's a low cost generic and then once you reach what they call their true out of pocket of two thousand dollars of your pay of what you pay, OK, it isn't quite as simple as that.

>> They have a formula that's basically the true out of pocket is a combination of what you pay and what the insurance company is paying.

>> So depending upon the drug you might spend two thousand dollars you might spend less than two thousand dollars.

OK, it just depends on the combination and your your drug plans formulary.

>> Yeah but once the two thousand dollar threshold is reached then all the drugs the rest of the year are paid for .

>> The insurance companies will pay it as long as the drug is on the plan's formulary and it used to be eight thousand last year the market was eight thousand dollars so a lot of people didn't made that but maybe they were well into 5000 or 6000.

>> Right, right.

So more far more people are going to hit it now and particularly because some of these drugs that we're taking now are really expensive .

I mean you have popular drugs like Felicity Alquist owes them pick those drugs have become increasingly popular but they have a high price tag and so those drugs will get you do that two thousand dollar threshold really in about a month they're some of them that's true.

Some of it that is exactly right.

It's about a month.

Yeah.

I mean I just get astounded when I hear people talk about you know, they went to get a prescription filled and it was six hundred and forty dollars for one thing or one.

>> Well I had in fact I had a meeting today with client and she's on Enbrel.

>> Well Enbrel is nine thousand dollars a month and so with her she'll hit that threshold the first you know in January.

Yeah.

So and that's why there's more expensive drugs than that out there.

So yeah some people have hit that right away.

>> Well then but it doesn't matter I mean she's going to get her two thousand just like everybody else but not anymore because it's more expensive.

>> Well she has the two thousand dollar and then that number is zero.

The rest there.

>> Oh I see yeah.

Wow that will make a huge make a huge difference difference.

What about you talked about things tier one obviously being less or maybe not even having any copay.

>> Correct.

Is it possible that a lot of people have medications that are not on tier one that if they just ask the doctor to rewrite the prescription they could do that?

>> How does that work?

Well, yes, I there are drugs for example.

Warfarin is a long it's blood there.

It's been around for a long time.

OK, OK. And there's zero copay for that for most things but there are other drugs that are doctors feel are more effective, less risk and they're higher priced and so they'll go on those types of blood thinners at a higher cost.

So can you request like a low cost drug like warfarin?

Yes, but and it's like OK, what's best for your health and so you're going to have to, you know, monitor that to see what what's going to be best for you.

>> Well, you know, when I hear on TV all the time now timely I'm sure but you know, is that the diabetes drug is now thirty five dollars a month as compared to what was it before when is that going to continue?

>> Yes, that's the insulin.

So insulin insulin is what you're talking about.

OK and yes they have a cap at thirty five dollars for all insulin products so no of Humalog those types of things.

>> Yeah there's thirty five dollars is a maxed out and that won't change.

That will not change.

OK and there's talk that there may be more drugs that move down the scale is that that's true.

>> They have a negotiation program where they take ten drugs a year and they work on negotiating a lower price.

>> Medicare itself works with the drug companies.

>> Who makes the decision on what those ten drugs are the government?

Oh, OK. >> OK, they take the most popular drugs that are expensive and then work on trying to reduce that cost through negotiated drug kingpins.

That pharmay right pharmacy OK Pharma Big Pharma and everybody says big big big pharma.

>> Oh well I want to be in so I'm going to use this as well OK inflation reduction and is this something that it took place obliviously this year.

>> Mm hmm.

But doesn't go into effect until twenty twenty five right.

Well we've seen some things phased in.

>> Oh yeah we've seen some things phased in but this twenty five is where the big change comes with the drug program itself.

And one thing I'll mention about that because we talked about the two thousand dollar limit or cap on how much a person can spend and in the case of my friend with Enbrel she had like I have a two thousand dollar hit right off front.

>> They introduced what they call the Medicare prescription payment program MP three because we have to initialize everything we can't describe but we have to initialize it.

>> Right.

But anyway, what that does is it allows you to spread the cost of the drug out over the year.

So in her case she could apply to her insurance company and asked to join that program and if that's the case they would take that two thousand and they would break it up in twelve months segments so she doesn't have a big hit right up front.

>> Oh, OK.

So once a month for a year payment plan.

>> Yeah.

All right.

No wait a minute.

Did you say that's in effect now it starts in January starts in January any drug or so if it's any drug but really it doesn't make any sense for inexpensive drug.

Sure, sure.

It's going to be those that hit the deductible that are high priced drugs and you don't have to start this in January.

You can start at midyear any time.

So if you're prescribed Eliquis let's say in May and you find that hard to meet right up& front, you can apply for that and spread that out for the remainder of the calendar year .

OK, all right I think I get that OK don't forget you give us a call here to ask Greg questions about Medicare and insurance and you'll help, right?

>> I will try.

OK, OK. >> You mentioned some of the drugs.

The one that you said that I hear so much about now is Olympic.

>> I am I saying that right?

You are OK.

I know that's not as big in Bahrain as it is Hollywood because I guess that it's being used a lot for weight loss.

>> Right.

Is there another reason for it I can say that much about it is a diabetic drug.

>> Oh, diabetic drug.

OK, it's a diabetic drug.

And the thing about some of these weight loss drugs psychosomatic they're not approved for Medicare for weight loss.

>> Aha.

So if your doctor if you want to get it for weight loss, understand Medicare's not going to pay for that.

You have to have another reason.

What you know the the weight loss thing was epic was kind of like oh a side effect right there what they like a surprise like oh look what happens when you change.

>> Yeah yeah.

It was like with drugs it was for blood pressure and all of a sudden they had another side effect with it and they oh we-cd that's kind of what is happening with those epik and we govey in some of these others that have come on and yeah they've been proved effective but they're not approved for weight loss under Medicare.

>> So what do you do?

I mean do you have to do so for example, a lot of it let's say you have a heart condition, OK and one of these drugs impacts your your circulatory system, right?

>> Sure.

Well, you can use that if it's prescribed for the the circulatory problem and obesity is part of the problem when it comes to diabetes and and yeah.

>> Real problems.

So if it's prescribed for those reasons Medicare will cover some of these but not for weight loss itself.

>> OK, so most private insurance companies would regardless of whether or what it's referred it depends it all every company has their own formulary which is a list of drugs that they cover .

>> OK, and since we're talking about that they have tiers as we're talking about generics to every insurance company we have a tier two tier usually the lower tier the lower the price yeah OK.

But sometimes a company will take an expensive drug and put it on a lower tier and use it as a loss leader.

>> Oh I think a common plan apparently common so when you come to these things this is why every year it makes sense to check out your drugs and see how they're going to work on on your current plan or if there was a plan that would be more cost efficient for you.

>> So then you take a list of your drugs in the how many milligrams you know the whole information you take that to your telling me I'm telling this correctly you would take that to your insurance agent and have them see if that's for the insurance plan you have or you need to change things.

>> The thing the things that agents have that make help with being an advantage.

We have software that we can plug these things into and really rapidly the Terman OK, which plans are going to be make have everything on there and how it would lower cost now an individual can do that by themselves if they want on Medicare dot gov you can go through there and do your own as well so it's however you want to do it.

>> But agents have the advantage of being experienced in this and we can do it pretty quickly.

>> Sure.

And make it convenient for you.

I mean I suppose you could do that at home if you want to sit in front of your computer for several hours but not really knowing what you mean and you'd have to go to all the different insurance companies you do it.

>> Yeah.

Yeah it becomes I I have one of the first times it was so funny this was in and two thousand six and we had a gentleman called me and he was a retired engineer and he would call me every week during the entire enrollment period and asked me about a plan.

I said here's my drugs and so he asked me first off which plan would to recommend I said this one he said OK, I'll get back with you.

And every week he called me and then at the last week in first week in December because the enrollment period goes October 15th, December 7th he says Hey, I want to meet with you and so I won't meet with him.

>> He said I want to show and he's like I said, he's he had his paper he had written out every plan cost of his drugs on every single plan.

>> Wow.

And he said, you know what I found out he said the one you recommended was the one that was the least expensive.

>> Oh.

Surprise, surprise, surprise, surprise, surprise.

>> We have a phone call.

James is on the line here.

James wants to know this.

How can I qualify to get paid to care for a parent through Medicaid or is that Medicare?

>> There you go see it.

It's that constant confusion between Medicare and Medicaid.

>> I wish the two names were totally different but they're not.

Yeah.

And keep in mind, James, the difference between the two programs Medicare is the federal program for the aged or disabled.

>> Medicaid is a state program for those that are financed we challenged what you're referring to would have to be qualified through Medicaid, through the state Medicaid office.

You need to contact them and explain the situation, put in an application, go through them and I'm sure you can begin that process.

>> James online by just Googling Medicaid again it's Medicaid and begin to look for infomation about your particular situation or maybe there will be a phone number but perhaps there that you can use in the Medicaid office here in Fort Wayne is down there on the old Sears building there on what is an Ruzzo.

>> Yeah, I know that building well yeah.

>> I grew up going to Sears for school clothes Yeah.

So yeah it's going to lower the bowels of that building.

>> Oh I did not know that.

What's the rest of the building used for you know no I don't it's a lot of government offices and oh all right it's in your foster park I do know that right isn't it.

>> No ma'am.

Well Foster yeah.

Foster's on the other end of it.

Yeah that's right.

OK, we're good.

Well see there was a reason we did this show tonight so we can figure out the geography of Fort Wayne.

>> OK, we've talked about the minimum premium payment plan.

>> Is there any situation where you can't arrange a monthly payment or do you do this through the pharmacy or the doctor know if you want to use utilize this payment program you would put an application into the insurance company itself?

>> Oh OK.

In that case you would not make a payment at the pharmacy.

>> You would pay the insurance company and they're tasked with collecting that and then paying the drug company.

>> OK, and so you just kind of put this in perspective.

There's some good things with this, right?

>> So we're capping this and we're allowing payments.

The downside of it is the insurance companies have to pay more now it's costing them more because they're picking up this additional payment.

>> They're having to come up with this collection program and paying.

So what are they doing?

>> Well, they're going to spread the cost out over everybody everybody everybody else.

So capital what happens for people who are not don't take a lot of drugs.

>> You're going to see some costs go up.

You're going to see on the advantage plan some of the we're seeing some drug deductibles in these plans where we didn't before.

Some of the ancillary benefits aren't quite as good as they were in the past.

>> I mean it's not dramatic but you can see a little bit of a difference where usually very year we find that the advantage plans the benefits got a little bit better.

>> A little bit better.

Well, this year not as much well so I guess what I'm hearing Van is which is not unusual happens with a lot changes it's very good for some- people, especially those taking a lot of medications.

>> But because of the changes in the way it's handled and now the insurance companies have to take care of the monthly payments, whatever there's more paperwork, more office people it's just going to insurance company right and in here to see some of that in the drug plan premiums now the premiums are being subsidized by the by the government this year to help keep the costs down.

>> OK, OK.

So it isn't as a dramatic a change as it was right.

>> Once the government saw how high the prescription drug plans premiums were going to be, they thought oh, we got to check this a little bit.

>> So they came up with a program to help subsidize the insurance companies on these drug plans in return for not increasing premiums more than thirty five dollars a month.

Oh, OK.

So companies kind of worked in between there you see somebody there taking full advantage of that thirty five dollars and some of them have just kind of narrowed their formularies a little bit and you know kind of worked that way.

>> So we see in general drug plans cost more this year and well and I guess the point that I was thinking about in terms of like it happens with a lot of things because they're now having to do additional work paperwork, office work or whatever.

>> Right.

Work for the payment.

>> What do you call payment plans?

Yeah, prescription payment plan then they that means somebody has to pay for it so it's going to be everybody everybody that's signed up for that insurance is all going to happen.

>> They're all going to have to contribute a little bit a little bit more and it's going to benefit people that have a lot of medications.

Yes.

But people that don't sorry that's just kind of the way it is.

>> But you know, it's sort of like taxes.

It's like you know, we pay our property taxes and if you don't have children you're paying for the schools anyway.

>> You're paying for the schools anyway.

>> Exactly and right.

Just I mean it just that's the way it is.

We just want to make sure that we're bringing these things up so it's not a big surprise to you.

All right.

Let's talk about prior authorizations.

>> Any changes in that area?

No, I think what happen one of the ways that the insurance companies are going to help minimize some of these costs is they're they're narrowing their drug list, the drugs that they're covering.

>> They're going to change some of the newer drugs, fewer drugs.

Some of them are going to have fewer drugs on their prior authorization means that the government the company has to approve that your use?

>> Yeah.

One thing to avoid if you possibly can is a thing they call step therapy which happens if if a company uses step therapy on a drug they will fill the prescription initially but they're going to tell you that you need to use a lower priced drug the next time around and the only way you get around that is you have to have a physician apply to the insurance company saying why you have to have this drug and it goes before a board there in the insurance companies say OK, does it do we want to approve this or not?

And sometimes they do and sometimes they don't.

>> If you can avoid step therapy, avoid it.

It just sounds very complicated .

>> Yeah, time consuming.

And what kind of reason would the physician give?

>> You might say monitor.

Let's just say that there's a brand name drug and you've tried all the generic alternatives.

>> Oh I say it did not work and so in that case they can say this is why now here's the thing right now you have this opportunity to change plans if you have this opportunity and then you get into January and say I want this drug and the company will say you have an opportunity right now if it happens in May, that's kind of a different story.

But yeah, I don't and some people will say well the we we went through the step therapy thing and earlier this year and they covered it this year there's no guarantee they're going to cover it next.

>> It's like they do it for the rest of the year and ti have an opportunity to to you know, change plans and you know, going back to my my client with Enbrel she was on a plan for years will this year that plan is not going to cover Enbrel this next year they're not going to cover it.

>> So even though she's been on this plan for years and it's she's likes that well now she's going to have to change plans if she wants that drug covered and that's important right now if you have a drug list, check your drug plan, make sure it's still going to work for you next year because a lot of these premiums are going up in some of these drugs are not going to be covered with the plan you currently have.

>> Well, that's one of the reasons that we're having this show tonight and again next week when Greg will be here once again at seven thirty right here you'd be right here, OK, because things do change and we're doing it early in Octoberso that you are mentally prepared and so you do some of this homework before it's too late.

Medicare and you twenty twenty five.

Our topic tonight and our topic again next Wednesday night with Greg MacDonald.

>> Meanwhile try to stay safe and stay healthy was the next Wednesday Sage Insurance Advisors LLC, specializes in Medicare plans and represents insurance companies offering Medicare supplements, Medicare Advantage Plans, and Part D prescription drug plans.

Serving Northeast Indiana from 4233 East State Boulevard in Fort Wayne and online at SageInsuranceAdvisors.com.