Very hard to say, because it depends on your insurance and income, and likely your diagnosis, as well as how cooperative/creative your doctor is with coding.
- There is a $25 copay plan, but you have to have regular (not Medicare/Medicaid) insurance and meet financial requirements
- Some insurance covers it, at least for diabetes, but of course copays will vary
- Most insurance companies adamantly do NOT cover weight loss drugs
- I’m not sure how Medicare Part D plans will handle it, including what requirements they will require (do you have to have diabetes? do you have to have tried cheaper meds and failed?) and what the copays will be at each step of the pre-deductible, after deductible, donut hole, and catastrophic levels.
- Also, starting in 2025, max copay for Medicare will be $2000, so that could make it good for anyone who can afford whatever the premiums will be.
- However, yesterday I was talking to the guy who helps us figure out which Part D plan to pick for next year, and he told me Medicare now has a vastly improved website for doing it yourself, but he walked me through it to show me the features, so I put in Maunjaro just to see the prices, and I was pleasantly surprised. Keep in mind that these are THIS YEAR’S prices, as 2023 data won’t be live until October 15th. And I have ZERO idea what the requirements will be for prescribing it under these plans, and the requirements may differ between plans.
So this is what I saw for October 2022, for the highest dosage, which assumes I’m just starting in this plan for the last 3 months of the year, so it’s all pre-deductible (actually, all pre-donut hole since it appears the deductible doesn’t apply to this tier of medication), under the Cigna Extra Rx PDP plan (which happens to be the one Charles has this year), which has a monthly premium of $69.50 but only a $100 deductible:
October
WALMART PHARMACY 10-3604, Preferred in-network pharmacy, $42.00
SAFEWAY PHARMACY #1511, Preferred in-network pharmacy, $42.00
CVS PHARMACY #05791, Standard in-network pharmacy, $47.00
$47.00
WALGREENS #3657, Preferred in-network pharmacy, $42.00
Mail Order Pharmacy, Preferred in-network pharmacy, $126.00 (3 month supply)
Compare to this to the information from GoodRX, again:
View attachment 2754
So it would be TOTALLY doable with a Medicare plan that covers expensive meds, IF it would also cover the prescription without limitations of proving diabetes or other requirements like failure with cheaper drugs.
Putting the drug into Cigna’s website and picking the same plan gave another interesting view:
Monthly Premium1
$69.50
Annual Deductible
$0 for Tiers 1, 2, 3 & 6
$100 for Tiers 4 & 5
Est. Retail Drug Cost2
$504.00
Total Est. Annual Cost
$1,338.00
That is freaking reasonable!!
Also, I noticed this:
View attachment 2755
NO PRIOR AUTHORIZATION REQUIRED!!
I’m thinking it’s time to talk to my GI doctor about prescribing this for me, starting in January, and picking this plan. Although I noticed that my ADD and depression meds are MORE expensive on this plan than the Mounjaro. Weird. Still, if the Mounjaro helps me lose weight and keeps me from vomiting in the middle of the night, totally worth it.
Again, this is the plan Charles currently has, and we’ve already received notification that his insulin costs on this plan will be capped at $0/month or $35/month for next year, depending on which form he uses (I’m guessing his long-acting, once/day Lantus will have the $35 copay).
I will run the numbers again after October 15th to make sure they are the same or similar for 2023. But this is encouraging.