Opuscula AvMed copay Greater than Pharmacy’s price

I AM A MEDICARE ADVANTAGE subscriber. Most of my Medicare years have been with AvMed – I had Humana for a year and quickly returned to AvMed – but my loyalty is starting to waiver.

Last year AvMed raised the “tier level” – this determines the copay - for one of my medications from Tier 2 to Tier 4. On request, it provided my Primary Care Physician (PCP) with a lesser-cost Tier 2 alternative: fenofribrate. (My PCP claims he never got the message; I complained and AvMed sent the information directly to me. For this and several other reasons I have a new PCP.)

Generic fenofribrate was a Tier 2 drug; the copay was $7 for a 30-day supply (30 tablets). For the 2017 calendar year, AvMed moved the drug to Tier 4 with a $75 copay. That’s a painful increase: from $84/year to $900/year copay.

WHY the two-tier jump is beyond my ken and, thanks to a crashed hard drive, my email contacts with AvMed “disappeared.” (To its credit, AvMed customer service is pretty good.)

Perhaps the jump is the work of the current incumbent at 1600 Pennsylvania Avenue and his “law-by-sneakiness” Patient Protection and Affordable Care Act (PPACA); he has mucked about with the healthcare system to the detriment of many.

I don’t know if fenofribrate is a Tier 4 drug for all 2017 Medicare advantage plans – I suspect it may be; if it is, AvMed’s $75 copay is competitive with other plans’ Tier 4 copays:

BlueMedicare HMO MyTime Plus (HMO) - H1026-061-0 - $65
Optimum Platinum Plan (HMO) - H5594-002-0 - $69
Simply More (HMO) - H5471-051-0 - $75
CareOne (HMO) - H1019-001-0 - $85
Harmony Maximum (HMO) - H4627-006-0 - $85
Humana Gold Plus H1036-065C (HMO) - H1036-065-0 - $85
Optimum Gold Rewards Plan (HMO) - H5594-001-0 - $85
Preferred Choice Broward (HMO) - H1045-005-0 - $85
Medica HealthCare Plans MedicareMax (HMO) - H5420-003-1 - $89
Humana Gold Plus H1036-237 (HMO) - H1036-237-0 - $97
Coventry Summit Ideal (HMO) - H1609-018-0 - $100

The exception was HealthSun HealthAdvantage Plan (HMO) - H5431-012-0 - $30.

The information above is from https://q1medicare.com/PartD-SearchMA-Medicare-2017PlanFinder.php#results

For kicks, I checked GoodRx.com for Fenofribrate in my area. The site returned RETAIL (full) prices of

Walgreens - $76
CVS and Target/CVS - $77
Kmart - $82

Of those, with free discounts or coupons, the price for a 30-day supply of fenofribrate dropped to

Walmart - <$22 (d)
CVS@Target - $32 (c)
Walgreens - <$33 (c)
CVS - $43 (c)
Kmart - <$50 (c)
Publix <$60 (d)

In the above, c = with coupon; d = discount.

There also is a discount card available at My DiscountRx Card.pdf, but I have no idea the amount of discount using that card at my regular (Publix) pharmacy.

The question remains: If Medicare is supposed to help limited income seniors, WHY IS THE COPAY HIGHER THAN THE LOCAL DISCOUNT OPTIONS?

It will be a little inconvenient to fill the fenofribrate script since my new PCP will have to give me three scripts for the medicine – coupons and discounts are “subject to change” and what is “best price” at one pharmacy one month may not be the following month. As it is today, I insist that all scripts (prescriptions) be given to me to take to the pharmacy of my choice; I lack confidence in medical practice front offices. Currently, all scripts are for 90-day supplies; it is more convenient.

I wonder, given the RETAIL cost of finofribrate (ibid.) how much AvMed is about to make when my copay is about the same as the full price of the drug at local pharmacies. Unless, of course, AvMed knows that the wholesale cost of finofribrate is about to drastically jump – rather like stock market insider trading. (But that fails to explain why the HealthSun HealthAdvantage Plan only has a $30 copay for Tier 4 drugs.)

There is more to Advantage plans that “just” medications. There are related plans (e.g., dental, vision, hearing) and hospital/ER/urgent care copays to consider as well as being able to see ANY provider on the plan’s provider list (e.g., Humana’s capitated lists that limit PCP referrals). As with auto and home/renter insurance, it pays to compare plans. What may be good for me may not be good for others. There are options not only within Advantage plans, but there is “straight” Medicare and extra cost Medicare Supplement plans

Fortunately I have a little time to select a plan for 2017. Interestingly, the deadline is December 7, a date most plan participants will remember as Pearl Harbor Day, that “infamous” day in 1941. (Sixty years later, on 9-11-2001 we were attacked again.)