Has anyone had trouble with new Medicare cap on drug pricing?

I don't think it really matters what the Optum person told you. The specialty pharmacy bills your AARP prescription plan, which would know about the cap. You just need to make sure Optum has your plan information, because it's not automatic. I am assuming Tymlos is covered by your AARP plan?

Also, it's possible the Optum person is confused and is talking about the first month's bill.

I've spent many hours talking with more than one specialty pharmacy regarding Tymlos, and for sure it is a headache.

P.S. To anyone out there, never, ever, ever use Acaria as your Tymlos pharmacy. I can't stress this enough. I've used CVS and Walgreens, both acceptable.

Yes, I picked this plan and changed part D insurance because it covered all 3 of the drugs I might have been prescribed (wasn’t at the time sure which one). Good idea, I will call the AARP plan today

I'm curious about your Acaria comment. My workplace just switched our speciality pharmacy from CVS to Acaria. I have only worked with them on the phone and so far all seems ok, but I have not gotten my first shipment (supposed to arrive this coming Thursday) What I liked about CVS was I could have the Tymlos sent there, so I did not have to deal with coolers and ice packs - anyone have any suggestions for these? I hate to throw them out.

I also have OptumRx and I've received different answers depending on who I speak to. (Plus the phone connection is often bad, and the background noise of their call center is loud.) Good advice from njx58 above.

This is a review of Acaria I had posted on Google last year:

"My rating is actually zero stars. I know specialty pharmacies can be iffy, but it is not possible for any of them to be worse than AcariaHealth. Here's what happens when you call: you reach a call center in what is obviously another country. They are pleasant enough, but good luck getting your prescription filled. They put you on hold every two minutes to look something up, then tell you that the "team" is processing it. You can call every day for two weeks and be told the same thing. There is no online patient portal. I cancelled my order because I legitimately feared that I would not be able to get refills."

Perhaps you've had better luck with them. I was able to use CVS Specialty instead of Acaria, and I never had a problem, and they were easy to work with over the phone. This year I'm on a different plan, and I'm getting Tymlos from Walgreens; also a positive experience.

I also found the connection to be terrible. Hard to decipher the words being spoken

@daisylou, I just went through that the other night regarding a new Tymlos prescription. I dealt with someone from CVS specialty that was completely clueless, but tried again in the evening and was connected to a woman who was very knowledgable and explained the $2000 cap to me in terms I could understand.

On the other hand, a pharmacist from there called me yesterday afternoon because I had a thousand questions about Tymlos and I found her pretty ignorant. I was glad I had thoroughly read the literature beforehand on the Tymlos site because she was obviously not familiar with the drug.

She told me I could insert the needle into my stomach or my thigh, (I think just the stomach!), she told me there was NO warning about osteosarcoma on the Tymlos literature, she told me if I have any dizziness, drop in blood pressure, headache, etc. to call my doctor immediately (which scared me, since I thought that was pretty typical), she said I absolutely could not take less than 8 full clicks, and she had no idea or suggestions as to whether I should take it in the evening or morning for best benefit.

In the end, these are just people, like us, trying to learn the ins and outs of all these drugs, but they certainly need to get up to date on the latest Medigap info for 2025.

Ultimately, as I said, the pharmacy is simply going to bill your prescription plan. I don't expect CVS Specialty or Optum or anyone else to know much about $2000 cap, at least not anyone I'd speak to over the phone. It's your Part D plan that is going to pay the benefits. As long as the pharmacy has my insurance information, and the medication is covered, that's all they really need to know.

And, of course, you have to keep on top of it every month to make sure they're doing what they're supposed to do, i.e. not bill you after $2000 !

https://www.duanemorris.com/alerts/medicare_prescription_pricing_faces_uncertainty_revocation_executive_order_14087_0125.html
Maybe it has something to do with the recent EOs out of Washington DC

Good news. I spoke with someone at the insurance company AARP United Medicare RX and they did know about the $2000 cap, and assured me that once I met the cap, the rest of my meds would be “free”.