Medicare Part D: A First Look at Medicare Drug Plans in 2023

During the Medicare open enrollment period from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D prescription drug coverage, either a stand-alone prescription drug plan (PDP) for people in traditional Medicare, or a Medicare Advantage plan that covers all Medicare benefits, including prescription drugs (MA-PD). Highlights for 2023: For more information regarding Part D Plan Availability and Part D Premiums, click here. Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Prescription Drug Reporting Reminder

As previously reported, plan sponsors of group health plans must submit information annually about prescription drugs and health care spending to the Centers for Medicare and Medicaid Services (“CMS”). The first deadline is December 27, 2022, for reporting on calendar years 2020 and 2021. Additionally: To learn more, click here to download the document. Have any questions regarding this notice? Please call your Total Benefit Solutions health insurance experts today at (215)355-2121.

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Inflation Reduction Act: Limits Monthly Copayments for Insulin in Medicare

Beginning in 2023, limits copayments to $35 per month per prescription for covered insulin products in Medicare Part D plans and for insulin furnished through durable medical equipment under Medicare Part B, with no deductible. For 2026 and beyond, limits monthly Part D copayments for insulin to the lesser of: $35 25% of the maximum fair price (in cases where the insulin product has been selected for negotiation) 25% of the negotiated price in Part D plans Please call your Total Benefit Solutions Medicare health insurance specialists with any questions or concerns at (215)355-2121.

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Inflation Reduction Act: Capping Medicare Part D Out-of-Pocket Spending and Other Part D Benefit Changes

Changes would lower beneficiary spending, reduce Medicare’s liability for high drug costs, and increase Part D plan and manufacturer liability for high drug costs. Beneficiaries: Eliminates 5% coinsurance for catastrophic coverage in 2024 Caps out-of-pocket drug spending at $2,000 beginning in 2025 Allows spreading out of out-of-pocket costs over the year Limits premium growth to no more than 6% per year for 2024-2030 Medicare: Lowers share of costs above the out-of-pocket spending cap (“reinsurance”) Part D Plans: Increases share of costs above the out-of-pocket spending cap Modifies share of costs below the out-of-pocket spending cap Drug Companies: Requires a price discount on brand-name drugs above the out-of-pocket spending cap Modifies… Read More

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Inflation Reduction Act: Requires Drug Manufacturers to Pay Rebates for Drug Price Increases Above Inflation

Requires drug manufacturers to pay a rebate if drug prices increase faster than the rate of inflation (CPI-U) for: Single-source drugs and biologicals covered under Medicare Part B All covered drugs under Medicare Part D except those where average annual cost is <$100 2021 is the base year for measuring cumulative price changes relative to inflation The rebate amount is based on units sold in Medicare multiplied by the amount that a drug’s price in a give year exceeds the inflation-adjusted price Price changes are measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D); these measures include prices charged in… Read More

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Inflation Reduction Act Requires the Secretary of HHS to Negotiate Medicare Drug Prices

Modifies the current law “non-interference” clause to require the HHS Secretary to negotiate drug price with manufacturers for some drugs covered under Medicare Part B and Part D. Which drugs qualify for negotiation? The Secretary selects drugs to be negotiated from the 50 “negotiation-eligible” drugs with the highest total Medicare Part D spending and the 50 “negotiation-eligible” drugs with the highest total Medicare Part B spending. Which drugs are excluded from negotiation? “Negotiation eligible drugs” include brand-name drugs or biologics and exclude the following drugs: Drugs that have a generic or biosimilar available Drugs less than 9 years (for small-molecule drugs) or 13 years (for biological products) from their FDA-approval… Read More

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What Insulin Drugs are Covered Under the Part D Senior Savings Model?

Part D sponsors are required to include at least one vial and pen dosage form for each of the different types of Model insulins, where available – rapid acting, short-acting, intermediate-acting and long-acting – at a maximum $35 copay for a one-month supply through the deductible, initial coverage, and coverage gap phases of the benefit. Part D sponsors are encouraged to include additional insulin formulations, such as concentrated insulins, at the same $35 copay for a one-month supply. The Model doesn’t affect the cost sharing of insulin covered under Part B. For a full list of the insulin drugs covered by each plan, as well as which drugs are covered… Read More

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Prescription Drug Provisions in the Inflation Reduction Act

For the first time, requires the federal government to negotiate prices for some top-selling drugs covered under Medicare Requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries Eliminates 5% coinsurance for catastrophic coverage in Medicare Part D in 2024, adds a $2,000 cap on Part D out-of-pocket spending in 2025, and limits annual increases in Part D premiums for 2024-2030 Limits monthly cost sharing for insulin products to $35 for people with Medicare Expands eligibility for Medicare Part D Low-Income Subsidy full benefits Eliminates cost sharing for adult vaccines covered under Medicare Part D and improves access to adult vaccines under… Read More

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Understanding the Health Care Provisions in the Inflation Reduction Act

The Inflation Reduction Act includes several landmark health care provisions that would lower prescription drug costs for people with Medicare, reduce Medicare drug spending and extend enhanced subsidies for Affordable Care Act marketplace coverage. On Thursday, August 11, a panel of KFF experts held a web briefing to explain these provisions and how they would affect people and federal health spending, followed by a Question and Answer session. Click here to open article and view Web Event video. The legislation for the first time would require the U.S. Secretary of Health and Human Services to negotiate directly with drug manufacturers over the price of some high-cost drugs in the Medicare… Read More

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When is the Part D Senior Saving Model expected to end? How many years is the model?

Since CMS is testing the Part D Senior Savings Model to lower costs and improve health care quality, it has a set period for when it’s available. Part D plans participating in the Model first became available on January 1, 2021. The Model extends until December 31, 2025, but the plans participating in the Model may change each year. Please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121, if you have any questions or concerns.

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What kind of plans can participate in the Part D Senior Savings Model?

Most Medicare Part D plans that people choose from during Open Enrollment can participate in the Model. This includes stand-alone Medicare Part D Prescription Drug Plans (PDPs) as well as Medicare Advantage Prescription Drug plans (MA-PDs) that offer enhanced alternative Part D coverage. Private fee-for-service plans (PFFS plans), employer/union only direct contact plans (local coordinated care plans, prescription drug plans, PFFS plans), section 1876 cost contract plans, dual-eligible special needs plans (D-SNPs), section 1833 health care prepayment plans, Program of All-Inclusive Care for the Elderly (PACE) organizations, Medicare-Medicaid plans, and religious fraternal benefit plans (local coordinated care plans and PFFS plans) aren’t eligible to participate in the Model. Please contact… Read More

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What is copayment?

A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible. Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20. If you’ve paid your deductible: You pay $20, usually at the time of the visit. If you haven’t met your deductible: You pay $100, the full allowable amount for the visit Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests. and visits to specialists. Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have… Read More

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What is the Part D Senior Savings Model?

The Part D Senior Savings Model allows participating Part D prescription drug plans to offer a broad set of formulary insulins at a maximum $35.00 copayment per month’s supply, throughout the deductible, initial coverage, and coverage gap phases of their Part D drug coverage. This means that participating Part D plans offer enrollees predictable, stable copayments for insulin to help enrollees save money on their drug costs. If you have any questions, please contact your Total Benefit Solutions Inc Medicare specialists at (215)355-2121.

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Premium Formulary Adoption Swells Among Large Group Clients

The Premium formulary is an option for large group clients wanting access to a formulary that manages traditional, non-specialty drug costs without compromising clinical outcomes. In many cases it saved early adopters nearly 10% per member per month on their plan’s traditional drug spend. Overall, members saved on drug costs without rigorous additional step therapies, prior authorizations, or other invasive utilization management strategies. Members transitioning to the Premium formulary will receive communications about the change, potential disruptions to their drug therapies, and clinically appropriate and cost-effective alternatives. Blue KC will continue to make quarterly updates to the Premium formulary and will send subsequent member communications about those changes and appropriate… Read More

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Medicare Part D Notification Requirements

Employers sponsoring a group health plan with prescription drug benefits are required to notify their Medicare-eligible participants and beneficiaries as to whether the drug coverage provided under the plan is “creditable” or “non-creditable” prior to October 15th, 2018. Please follow this link for more information:   Medicare Part D Notification Requirements       As always, if you have any questions or concerns about this notification or your specific policy, please contact us at 215-355-2121

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The History of Medicare

  A brief history of Medicare in America Landmark social program now covers 58.5 million Americans By Steve Anderson Discussion about a national health insurance system for Americans goes all the way back to the days of President Teddy Roosevelt, whose platform included health insurance when he ran for president in 1912. But the idea for a national health plan didn’t gain steam until it was pushed by U.S. President Harry S Truman.On November 19, 1945, seven months into his presidency, Truman sent a message to Congress, calling for the creation of a national health insurance fund, open to all Americans. The plan Truman envisioned would provide health coverage to individuals, paying for such typical expenses… Read More

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Prevent Osteoporosis with Screenings

10 Facts About Osteoporosis By Kathleen Hall This silent disease significantly raises your risk for fractures and disability. 1. Losing bone density is a normal part of aging. We reach peak bone mass between ages 25 and 30, and then slowly lose begin to start losing bone mass at age 40. For women, reduced levels of estrogen after menopause accelerate bone density loss. “Women lose 1.5 to 2 percent of their bone density per year in the first 10 years after menopause,” says Laura Ryan, MD, clinical associate professor of medicine in the division of endocrinology, diabetes, and metabolism at The Ohio State University Wexner Medical Center in Columbus. 2. You don’t lose… Read More

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New Medicare Card Mailing Update!

Check the Status of Your New Card *Cards have finished mailing to American Samoa, the Northern Mariana Islands, Guam, and to people who get RRB benefits.   Three Things To Know Your new card will automatically come to you. You don’t need to do anything as long as your address is up to date. If you need to update your address, visit your My Social Security. Once you get your new Medicare card, destroy your old Medicare card and start using your new card right away. Your new Medicare Number is a unique combination of numbers and letters. Your new number uses numbers 0 thru 9. The letters S, L, O,… Read More

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The Four Stages of Medicare Part D (2018)

The Four Stages of Medicare Part D Coverage                          

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