Category: 2021-12

The Deductible

The maximum allowable deductible for Prescription Drug Plans (PDPs) in 2022 is $480. That doesn’t mean that everyone pays the $480 before your plan’s benefits start to kick in.

Many plans wave the deductible for tiers 1 and 2 generics. There is one plan that waives the deductible for only tier 1 drugs.

That means that if you take a tier 3, 4, or 5 prescription, generally speaking you will have to meet the deductible before the plans kicks in with its benefits.

There are a few higher premium plans that have a reduced deductible, and lastly, there are just a few spendy plans that have no deductible. Premium wise, these plans can start hitting the $100 per month level. As mentioned, the preponderance of the plans that are the best buys for most members have the $480 deductible.

Because so many of what used to be brand name prescriptions have gone generic, most people’s prescriptions are all generics. Here are just a few examples. The generic name follows the brand name.

Lipitor: Atorvastatin

Crestor: Rosuvastatin

Diovan: Valsartan

Micardis: Telmisartan

Prozac: Fluoxetine

Zoloft: Sertraline

Proscar: Finasteride

Flomax: Tamsulosin

Singular: Montelukast

Plavix: Clopidogrel

Here are some drugs that went generic so long ago that most people don’t recognize the original brand name:

Glucophage: Metformin

Toprol XL: Metoprolol succinate ER

Norvasc: Amlodipine

New Brand Name Drugs

The pharmaceutical industry has produced new brand-name drugs. Unfortunately, these new drugs are expensive—even with the help of the PDP.

For A-fib and other heart rhythm disorders: Eliquis and Xarelto

For diabetics: Jardiance, Trulicity, Tresiba, Ozempic, and Rybelsus.

What Puts You into the Coverage Gap, aka the Donut Hole

Once the total retail cost of your prescriptions hits $4,430, you go into the coverage gap. Remember, this is the full retail cost, not what you have paid in copays.

Let’s says “Allice” a taking a few low-cost generics but also the name brand and tier 3 drug XYZ. XYZ has a full retail cost of $600 per month. Alice’s PDP has the $480 deductible and a $47 copay for tier 3 drugs after she has met her deductible.

She’s paying $47 per month copay for XYZ and very little for her generics. Everything is doable. In August, Alice is rudely shocked when her pharmacist informs her that she owes $150 for her fill of XYZ. WHAT HAPPENED? she asks in stark disbelief. Her pharmacist explains that she is now in the coverage gap.

Here’s the math that put Alice in the gap.

7 months of XYZ (7 x $600) is $4,200. Throw in a little over $200 for the full retail cost for her generics for 7 months. At the beginning of August, the retail cost of her meds has exceeded $4,430. Alice is now in the coverage gap.

She now pays 25% of the retail cost of her brand name drugs and generics while she is in the coverage gap for the remainder of the year. Please keep in mind that it makes no differences if her Part D plan is embedded inside of a Medicare advantage plan. It all works the same

What Gets You out of the Coverage Gap?

When your True-out-of-Pocket (TRooP) cost hits $7,050, then you exit the coverage gap phase and go into the final Catastrophic coverage phase. Does this mean that you have spent $7,050?

The answer is no. The good news is that the manufacturer’s discount counts towards your TRooP totals. Let’s see how it works with Alice’s $600 XYZ prescription. Once she is in the gap, here’s how the $600 is covered.

Alice pays 25% or $150

The manufacturer of XYZ discounts the drug by 70% or $420

The PDP pays 5% or $30

The $150 that Alice pays along with the manufacturer’s discount of $420 counts towards Alice’s TRooP costs.

Catastrophic coverage phase

According to Medicare.gov, once you hit the Catastrophic coverage phase, you will pay no more than 5% of the cost for covered drugs for the rest of the year

Your PDP pays 15% and Medicare pays 80%. We have seen a few cases where a member had such expensive drugs that he blasted through the coverage gap and into the Catastrophic phase within the first few months of the year. End

by Lance & Isaac Reedy

A client of mine, John S. from Moose City, Wyoming received a text on his cell phone with something to do with services for his computer. Since John received a text to his phone, he thought there might have been some sort of legitimacy to it. John’s story went something like this.

The scammer told John that he was eligible for a $500 refund for (fictious) “computer services” that he hadn’t used. This is the bait that the scammers use to get you to go along with their scheme. A promise of an unexpected windfall…which also doesn’t exist.

John then allowed iScam Computer Services (ICS…fictious of course) to install a program that allowed remote access to his computer. Remote access software allows someone else on the internet to control your computer. There are many programs that do this, but two common ones are Teamviewer and AnyDesk.

Once the scammers had remote access to John’s computer, they directed him to log into his bank account. Then the scammers edited the bank account page on John’s computer to make it look like they over-refunded the money they promised him.

Note: Despite how real it may look, the scammers never actually send any money. The webpage that they doctor to make it look like they sent you money, isn’t real. It only exists in the memory on your computer and nowhere else. Reloading the page on your web browser would overwrite the fake numbers and expose the truth.

Anyhow, back to the scam. The scammers pretended to send John money. However, instead of the $500 they promised him, it was actually $5000!

Sounding utterly distraught the scammer then told John about how he is going to lose his job.

Note: The scammer is not distraught at all. It’s just part of his script. Sometimes, they will further guilt trip you by telling you about how their family is going to starve because of this terrible “mistake.”

Then, the scammer had an “idea.” He directed John to go out and buy him $4500 worth of gift cards. This would allow the scammer to “refund” the money to his boss and so that he wouldn’t get fired.

The exact mechanisms vary, but this is the essence of the refund scam.

The scammers will pretend to send you money, only there will be a “screw up” and too much fake money will be sent to you. Then, the scammers will ask you to refund them the difference with your real money.

The scammers are manipulative and will do and say whatever they think will work to get you to do their bidding. The scammers may say they are from Apple, Microsoft, Google, BestBuy, The Geek Squad, or something else. Many of the scammers are from one of many corrupt call centers in India.

Fortunately, this story has a happy ending. After the scammer directed John to go out and buy some Walmart gift cards for the “refund.” John started smelling a rat and he never followed through with the scam. Out of an abundance of caution, John also contacted his bank and closed his account.

Several of our clients have reported to us an account of them getting scammed, and that’s our motivation for alerting you. The scammers are very clever people, and they use crude psychology to scam their victims.

Last month, in our article Shady Advertising and Scams, I (Lance), mentioned how my daughter Hannah came within a hair’s breadth of becoming a victim of a refund scam herself. In her case, the fake money was in the form of a bogus money order. She fell for the scam. Her saving grace was that the scammers were too greedy. The check for real money that Hannah wrote bounced because she didn’t have enough money in her bank account because of the Scammer’s rubber check to cover the “refund” amount.

Any email that speaks of Amazon, Walmart, Target, or XYZ rewards is a tip off, but the scammers depend on your curiosity to open a suspicious email. “Let’s open it and see what’s inside.” DON’T DO IT!

The following is a list of emails and texts to immediately delete or phone calls to hang up on.

• IRS problems. The IRS will contact you by mail if you owe them money.
• Problems with you bank. Same thing: Your bank will contact you by mail.
• Warning from your email provider that there is some looming problem which requires you submit your password information.
• Computer services and ink jet cartridge deals.
• Rewards for doing the billionth Google search.
• Work at home deals or business opportunities.
• A call from “Amazon” of a fraud alert on your account.
• And dozens of others

The electronic and digital world we are now living in is like driving on a steep and twisty mountain road with no guard rails. Getting involved with something that’s dubious at best is like missing a turn and going off the cliff.

If you’re in any doubt about the legitimacy of any unsolicited email, text, phone call, or piece of junk mail, please contact a knowledgeable person to advise you accordingly before you open Pandora’s box. These trusted sources are your guard rails. End