Pedro Rodriguez, Medicare Insurance Agent

Answer: Short answer:

Usually no. Once the Medicare Open Enrollment Period (Oct 15 – Dec 7) ends and your new coverage starts on January 1, you generally cannot change plans again just because your doctor stops the medication.

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When you could change plans again

There are only a few exceptions called Special Enrollment Periods (SEPs) or the Medicare Advantage Open Enrollment Period:

1) Medicare Advantage Open Enrollment (Jan 1 – Mar 31)

If you enrolled in a Medicare Advantage plan, you get one extra change:

• Switch to another Medicare Advantage plan or

• Drop MA and return to Original Medicare (and possibly add Part D)

But you can only use this once per year, and not if you’re already in Original Medicare with Part D.

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2) Special Enrollment Periods (SEPs)

You may change plans outside enrollment only if you qualify for special situations, such as:

• Moving out of your plan’s service area

• Qualifying for Medicaid or Extra Help

• Losing other creditable drug coverage

• Plan contract changes or termination

Medication changes alone do NOT qualify for an SEP.

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Bottom line for the senior’s situation

• Switching plans for a specific drug is allowed during Open Enrollment.

• If the doctor later stops that drug after enrollment ends, the person usually must stay in the new plan until the next Open Enrollment—

unless they qualify for:

• The Jan–Mar Medicare Advantage Open Enrollment, or

• A Special

Answer: • According to a formulary & coverage-info page from the manufacturer (AstraZeneca), for Medicare Part D plans the drug is covered without prior authorization in about 8 out of 10 (i.e., ~80%) of cases. 

• They also say that for Medicare Part D enrollees, about 81% pay $50 or less per month out-of-pocket for BREZTRI. 

• Another source states: “Medicare drug plans may cover inhaler drugs for COPD including BREZTRI, but there is no nationwide guarantee of coverage — it depends on the plan’s formulary.” 

• For example, one drug-cost tracking site says ~87% of Medicare prescription-drug plans list BREZTRI, but cost‐sharing and tier placement vary widely. 

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⚠️ Important considerations & conditions

• Which plan? Coverage typically falls under a Medicare Part D prescription-drug plan or a Medicare Advantage plan that includes drug coverage (MAPD). 

• Formulary placement & tier: Even if the drug is on the formulary, it may be placed on a higher tier (i.e., higher copay/coinsurance) or require prior authorization/step therapy. 

• Out-of-pocket cost: While ~$50/month is cited as an average for many Medicare enrollees, some plans could have higher copays depending on tier, deductible, coverage gap, etc. 

• Nebulizers vs inhalers: This drug is an inhaler. According to one guide, inhalers are generally covered under Part D, whereas nebulized medications may sometimes fall under Part B. 

• State/plan variations: Because each plan sets its own formulary and benefit design, whether BREZTRI is covered and at what cost can vary by state, by plan, and by year.

• Savings programs: Although there are savings/assistance programs via AstraZeneca for BREZTRI, many of those do not apply to Medicare beneficiaries in the same way they do for commercial insurance. 

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🔍 What you (or your patient) should check

• Look at the formulary/drug list of the specific Medicare Part D or Medicare Advantage plan to see if BREZTRI is included.

• Check what tier it’s on (B

Answer: 💊 1. Compare Medicare Part D or Medicare Advantage drug plans every year

• Drug prices and coverage change annually, so compare plans during the Annual Enrollment Period (Oct 15–Dec 7).

• Use the Medicare Plan Finder at Medicare.gov website— it shows which plans cover your medications and at what cost.

• Sometimes switching plans can save hundreds of dollars a year.

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💸 2. Apply for “Extra Help” (Low-Income Subsidy)

• This federal program helps pay Part D premiums, deductibles, and copays for people with limited income and resources.

• Many people qualify and don’t realize it.

• Apply through Social Security (SSA.gov) or 1-800-772-1213.

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🏦 3. Check state programs (Medicare Savings Programs or SPAPs)

• Some states have State Pharmaceutical Assistance Programs (SPAPs) or Medicare Savings Programs that help pay drug costs or premiums.

• Contact your State Health Insurance Assistance Program (SHIP) for free help.

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🏥 4. Ask about generic or lower-cost alternatives

• Your doctor or pharmacist can often prescribe a generic or therapeutic equivalent that’s just as effective and much cheaper.

• Some drug plans offer tier exceptions if a lower-cost drug doesn’t work for you.

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💳 5. Use preferred or mail-order pharmacies

• Some Part D plans have preferred pharmacies with lower copays.

• Mail-order options can offer a 90-day supply at a reduced rate.

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🧾 6. Review your medications regularly

• Bring all your medications to your doctor or pharmacist once a year for a “medication review.”

• You might find duplicate or unnecessary prescriptions you can safely stop (with your provider’s guidance).

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🧬 7. Check manufacturer savings programs

• Some pharmaceutical companies offer patient assistance programs (PAPs) for expensive brand-name drugs like Repatha.

• Visit Medicare.gov/Drug-Savings for details.

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⚕️ 8. Consider the $2,000 Out-of-Pocket Cap (starting in 2025)

• Beginning January 1, 2025, Medicare will cap out-of-pocket costs for Part D at $2,

Answer: The best time to do this is during Medicare’s Annual Enrollment Period (AEP):

📅 October 15 – December 7 each year.

During this period, you can:

• Review your current coverage (whether you have Original Medicare + Part D or a Medicare Advantage plan).

• Compare new plan options for the coming year.

• Switch plans, add or drop drug coverage, or move back to Original Medicare.

Any changes you make take effect January 1 of the next year.

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🧭 You should also review your plan anytime your needs or costs change, such as:

• Your medications change or you start a new prescription.

• Your doctors or preferred hospitals are no longer in your plan’s network.

• You move to a new ZIP code or state (this can trigger a Special Enrollment Period).

• Your income changes and you may qualify for Extra Help or a Medicare Savings Program.

• Your plan announces premium or copay increases for the next year.

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Tip:

Even if you’re happy with your plan, check each fall that it still covers your medications, doctors, and pharmacies — plans update their benefits and drug lists every year.

Answer: Sí — en general, el medicamento Repatha (nombre genérico evolocumab) sí está cubierto por la mayoría de los planes de Medicare Part D (que cubren medicamentos con receta). 

Detalles importantes que debe saber

• Que esté “cubierto” no significa que esté incluido en todas las medicinas de todos los planes — la cobertura precisa dependerá del formulario (lista de medicamentos cubiertos) del plan específico de Part D. 

• Los costos para el paciente varían mucho:

• En muchos casos el copago puede ser alrededor de US $50 o menos al mes para usuarios con Medicare que lo tienen cubierto. 

• Si el beneficiario califica para el programa de “Extra Help” (subsidio por bajos ingresos) bajo Part D, el costo mensual podría reducirse notablemente (por ejemplo se mencionan cifras de ~US $11 al mes para algunos casos) 

• Si el medicamento se administra en un consultorio médico u otro entorno ambulatorio en vez de una farmacia para uso propio en casa, los costos pueden estar cubiertos por Medicare Part B en lugar de Part D. 

Qué hacer

• Verifique el formulario (“drug list”) de su plan de Part D para confirmar que Repatha esté incluido.

• Pregunte al plan si hay requisitos adicionales como autorización previa (“prior authorization”) o terapias paso-a-paso (“step therapy”) antes de que permitan Repatha. 

• Revise los costos específicos para su plan (deducible, copago, coinsurance) y compare opciones de planes si necesita cambiar.

• Si lo que está recibiendo es la administración en un entorno médico (no en casa), consulte si aplica en Part B en lugar de Part D.

Si lo desea, puedo verificar para su estado (Florida) cómo lo cubren los planes de Part D localmente para Repatha, para que tenga una vista más localizada. ¿Le parece bien que lo haga?

Answer: Medicare is the federal health insurance program mainly for people age 65 and older, and for certain younger people with disabilities or specific medical conditions. It’s made up of four parts, each covering different types of care:

1. Part A – Hospital Insurance

• Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

• Most people don’t pay a premium for Part A if they (or their spouse) worked and paid Medicare taxes long enough.

2. Part B – Medical Insurance

• Covers doctor visits, outpatient care, preventive services, and medical supplies.

• You pay a monthly premium for Part B, and there’s usually a deductible and coinsurance.

3. Part C – Medicare Advantage

• These are private plans (approved by Medicare) that bundle Part A and Part B coverage, often including prescription drugs (Part D), vision, dental, and hearing benefits.

• You must have both Part A and Part B to enroll in a Part C plan.

4. Part D – Prescription Drug Coverage

• Helps cover the cost of prescription medications.

• Offered through private insurers approved by Medicare; you pay a monthly premium.

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Other important points:

• You can get coverage directly through Original Medicare (Parts A & B) or through a Medicare Advantage plan (Part C) — but not both at the same time.

• Medigap (Medicare Supplement Insurance) is optional insurance that helps pay costs Original Medicare doesn’t cover (like copayments and deductibles).

• There are specific enrollment periods each year when you can sign up or make changes.

• Medicare doesn’t usually cover long-term care, routine dental, vision, or hearing aids, unless you have a plan that includes them.

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Answer: English

65+ and AEP is here… do you need to do anything?
Yes — the Annual Enrollment Period (Oct 15–Dec 7) is your chance to check if your plan still fits. Review your drug list, costs, and coverage — if it doesn’t work, switch now so you’re set for next year.

Español

¿65+ y llegó el Período Anual de Inscripción (AEP)… tienes que hacer algo?
Sí — del 15 de oct al 7 de dic es tu oportunidad de revisar si tu plan todavía te conviene. Verifica tu lista de medicinas, costos y cobertura — si no encaja, cámbialo ahora y aseguras tu próximo año.

Answer: English

65+ and thinking of changing your Medicare Advantage plan?
You have two main windows : Oct 15–Dec 7 (Annual Enrollment) to join, switch, or drop a plan, and Jan 1–Mar 31 (Open Enrollment) if you already have Advantage. Act in these periods, and your new coverage starts the next month.

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¿65+ y pensando en cambiar tu plan de Medicare Advantage?
Tienes dos ventanas principales : 15 de oct – 7 de dic (Inscripción Anual) para unirte, cambiar o salir de un plan, y 1 de ene – 31 de mar (Inscripción Abierta) si ya tienes Advantage. Haz el cambio en esas fechas y tu nueva cobertura comienza al mes siguiente.

Answer: English

65+ and got your ANOC in the mail?
Yes — you should always review your Annual Notice of Change with your Medicare agent. It shows changes in costs, coverage, and drugs for next year, so you can decide if it’s time to stay or switch plans.

Español (Gancho Viral Storytelling)

¿65+ y recibiste tu ANOC por correo?
Sí — siempre debes revisar tu Aviso Anual de Cambios con tu agente de Medicare. Allí verás cambios en costos, cobertura y medicinas para el próximo año, y podrás decidir si quedarte o cambiar de plan.

Answer: English

65+ and wondering if your kids can help with Medicare?
Yes — your son or daughter can help you review options and even talk to Medicare or your plan, as long as you give them permission. With the right authorization, they can make the process easier and stress-free.

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¿65+ y te preguntas si tus hijos pueden ayudarte con Medicare?
Sí — tu hijo o hija puede ayudarte a revisar opciones e incluso hablar con Medicare o tu plan, siempre que les des autorización.

Con el permiso correcto, todo se vuelve más fácil y sin estrés.

Answer: English

65+ and just started a new prescription?
Not every Medicare plan covers the same drugs. Check your plan’s formulary (drug list) — if your medicine isn’t covered or costs too much, you can switch during enrollment periods to save money and stay covered.

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¿65+ y empezaste una nueva medicina este año?
No todos los planes de Medicare cubren los mismos medicamentos. Revisa el formulario (lista de medicinas) de tu plan — si tu medicina no está cubierta o es muy cara, puedes cambiar de plan en los períodos de inscripción para ahorrar y mantener tu cobertura.

Answer: English

65+ and thinking of switching to Medicare Advantage?
Here’s the truth You only get two windows: Oct 15–Dec 7 or Jan 1–Mar 31 (if you already have Advantage). One simple choice today = new coverage next month

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¿65+ y pensando en cambiarte a Medicare Advantage?
La verdad Solo hay dos ventanas: 15 de oct – 7 de dic o 1 de ene – 31 de mar (si ya tienes Advantage). Una decisión simple hoy = nueva cobertura el próximo me

Answer: English

65+ and wondering if Medicare Advantage is just private insurance?
Nope — it’s still Medicare, but managed by a private company, often with extra perks like vision and dental.

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¿65+ y piensas que Medicare Advantage es solo un seguro privado?
No — sigue siendo Medicare, pero administrado por una aseguradora privada, muchas veces con beneficios extra como visión y dental.

Answer: English

Does Medicare cover vision care?
Original Medicare (Part A & B) does not cover routine eye exams, glasses, or contacts.
it does cover eye care related to medical conditions (like cataract surgery or glaucoma testing).
Many people add a Medicare Advantage plan or vision insurance for full coverage.

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¿Medicare cubre la visión?
Medicare Original (Parte A y B) no cubre exámenes de la vista de rutina, lentes ni contactos.
Sí cubre cuidado ocular relacionado con condiciones médicas (como cirugía de cataratas o exámenes de glaucoma).
Muchos agregan un plan Medicare Advantage o seguro de visión para cobertura completa.

Answer: English

“65+ and Medicare feels like a puzzle? You’re not alone.”
I’ve helped so many seniors turn confusion into clarity 
 With me, 65+ means peace of mind, the right plan, and no stress.

Español

“¿65+ y sientes que Medicare es un rompecabezas? No estás solo.”
He ayudado a muchos adultos a convertir la confusión en claridad

Conmigo, 65+ significa tranquilidad, el plan correcto y cero estrés

Answer: If you had health coverage through your job or your spouse’s job, you may qualify for a Special Enrollment Period (SEP). You’ll have 8 months after your job or coverage ends to sign up for Medicare Part A and/or Part B without penalties.

If you don’t qualify for SEP, you may face late enrollment penalties:

* Part B: 10% extra for each year you delayed, added for life.

* Part A: Usually free, but if not, a 10% penalty applies for twice the years delayed.

Next steps:
✔ Check your coverage history.
✔ Contact Social Security to confirm your enrollment options.
✔ Enroll as soon as possible.
✔ Consider extra coverage like Medigap or Part D.

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Pregunta de un Adulto 65+:
“¿Qué debo hacer si no me inscribí en Medicare a los 65 años y ahora me estoy jubilando?”

Respuesta:
Si tenías seguro médico por tu trabajo o el de tu cónyuge, puedes calificar para un Período Especial de Inscripción (SEP). Tienes 8 meses desde que termina tu empleo o cobertura para inscribirte en Medicare Parte A y/o Parte B sin multas.

Si no calificas para SEP, pueden aplicarte multas por inscripción tardía:

* Parte B: 10% extra por cada año de retraso, de por vida.

* Parte A: Usualmente gratis, pero si no lo es, se aplica una multa del 10% por el doble de los años de demora.

Próximos pasos:
✔ Revisa tu historial de cobertura.
✔ Contacta al Seguro Social para confirmar tus opciones.
✔ Inscríbete lo antes posible.
✔ Considera cobertura adicional como Medigap o Parte D.