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The Inflation Reduction Act was signed into law on September 16, 2022 and contains changes that will affect Medicare-eligibles who are enrolled in MAPD (Medicare Advantage Prescription Drug Plans) or separate Medicare drug coverage (Part D):
This article from the Kaiser Family Foundation contains an excellent overall summary of the Act and how Medicare beneficiaries will be affected.
These three provisions are effective January 1, 2023 and will affect all beneficiaries who are enrolled in MAPD or Medicare drug coverage (Part D).
The following changes to what is called the “standard” Part D prescription drug model will be made in 2024. The standard design of the Medicare Part D benefit currently has four distinct phases, where the share of drug costs paid by Part D enrollees, Part D plan carriers, drug manufacturers, and Medicare varies. [The Part D enrollee shares indicated below reflect costs by enrollees who are not receiving low-income subsidies (also known as “extra help.”] Note: All Part D plans must cover at least the Part D standard benefit or meet the requirements for “alternative benefits.” Benefit structures that are not standard but instead are actuarially equivalent are known as “alternative” coverage.
Note that entry into the coverage gap phase is based on the total cost of the enrollee’s medications in the deductible and initial coverage level phases, whereas a different calculation [called “true out-of-pocket” costs (TrOOP)] is used for calculation of the “out-of-pocket” threshold. Generally, TrOOP includes enrollee (i.e., NOT the total) payments for Part D prescription drugs, including the annual deductible, cost-sharing above the deductible and up to the initial coverage limit, and above the initial coverage limit up to the annual out-of-pocket threshold. The following items are also included in TrOOP:
The Inflation Reduction Act stipulates there will be NO CHARGE for medications once the enrollee meets the catastrophic phase in 2024. According to the Kaiser Family Foundation this will mean that once an enrollee who exclusively uses brand name drugs (and isn’t affected by the third and/or fourth bullets immediately above) personally pays approximately $3,300 in 2024 he or she will have no further costs for covered medications in 2024. (This number will be different if a person also takes generic medications or if either the third and/or fourth bullet above applies, as this will affect the TrOOP calculation).
Part D carriers currently pay 15% of the cost of medications once the out-of-pocket threshold is met. Drug plans will be required to pay 20% of the cost of medications once the out-of-pocket threshold is met in 2024. Medicare pays the balance of the cost once the out-of-pocket threshold is met.
Individuals on expensive medications will be greatly benefitted by this change to the catastrophic coverage stage. For example, the Kaiser Family Foundation has reported that enrollees on one of the top five high-cost, commonly used cancer drugs will be reduced by thousands of dollars in 2024. For example, those on Pomalyst will save $8,500; while those on Revlimid, Imbruvica, Jakafi, and Ibrance will save $6,400, $6,400, $5,900, and $5,000 respectively.
Because of this change to the catastrophic phase in 2024, those who buy some medications outside of the plan (e.g., from Good Rx or other non-plan resources) and who otherwise would meet the out-of-pocket threshold should consider changing their strategy and buy all their medications through the plan in 2024, as this could result in lower costs.
Plan designs and premiums for 2024 will be posted on medicare.gov and carriers’ sites on October 1, and present plan participants will receive Annual Notice of Change (ANOC) documents outlining plan changes and premiums in late September.
There will be many plan choices for 2024 and EVERY plan [i.e., both Medicare Advantage Prescription Drug and separate Medicare drug coverage (Part D)] will be changing because of the changes outlined above.
Drug formularies (the list of covered medications) differ between all carriers and even between different plans offered by the same carrier.
We’ve always recommended (see FAQ 6) that all Medicare-eligibles review their drug coverage on an annual basis starting October 1 and extending into the Annual Enrollment Period. Particularly because of the changes to the catastrophic phase it will be more important than ever for beneficiaries to determine that their drugs are in their plans’ formularies and that their present plans provide a good fit for them for the next year.
Other Changes For 2024
Drug plans will also experience significant change in 2025. Most importantly, the coverage gap phase will be eliminated (but copays and/or coinsurance amounts in this level will probably change for most plans), and the amounts paid during the second phase (initial coverage level) must remain unchanged until the enrollees’ maximum drug costs reach $2,000 for covered medications. The coverage gap and catastrophic levels will be eliminated, so all Part D plans will have either one or two levels (i.e., the initial coverage level and possibly a deductible level). There will be no cost for covered medications above the $2,000 maximum, and the maximum will be indexed starting in 2026.
Part D enrollees will have the option of spreading out their out-of-pocket costs over the year rather than face high out-of-pocket costs in any given month.
Also, the share of Medicare Part D drug costs paid by plans, drug manufacturers, and Medicare will change. Carriers’ costs will change from 75% to 65% in the initial coverage stage and from 20% to 80% in the catastrophic phase. Beneficiaries should expect significant plan redesign and possible changes in premiums in 2025 because of these changes.
Please see this article from the Kaiser Family Foundation for a more detailed summary of the 2024 and 2025 changes.
Unless you're eligible for a Special Election Period, you must enroll in a Medicare Advantage Prescription Drug Plan or Medicare drug coverage (Part D):
Note: Medicare begins the first of the preceding month for individuals whose birthday is the first day of the month.
Some Medicare Advantage plans (called "MAPD" plans) include prescription drug coverage while others (called "MA" or "MA Only" plans) do not.
If you purchase a Medicare Advantage HMO or PPO plan without prescription drug coverage, you CAN'T purchase a separate Part D plan. You can purchase a separate Part D plan with a PFFS (Private Fee for Service plan) that doesn't provide drug coverage and with Medicare Savings Account plans and Cost plans (Cost plans are available on a very limited basis and are not available in Florida).
You can also purchase separate Medicare drug coverage (Part D) with a Medicare Supplement plan or with Original (Fee for Service) Medicare (i.e., without enrolling in either a Medicare Supplement or Medicare Advantage plan).
Although they must meet minimum Federal guidelines, Medicare Advantage Prescription Drug and separate Medicare drug coverage (Part D) differ markedly between carriers, and one of the most important differences is which drugs are covered and which are not. [There are 35 therapeutic categories of drugs, and carriers are required to include at least two drugs in each category, except they are required to include all drugs in these categories: HIV/AIDS treatments; antidepressants; antipsychotic medications; anticonvulsive treatments for seizure disorders; immunosuppressant drugs; and anticancer drugs (unless covered by Part B)].
Each carrier provides a formulary that lists which drugs are covered under that plan and which copay or coinsurance tier the drug falls into. Beneficiaries should always check the formulary to determine if their drugs are covered--and at which copay pay or coinsurance rate--before purchasing a plan. It's also a good idea to review your Medicare Advantage Prescription Drug or separate Medicare drug coverage (Part D) every year to see if your plan covers the medications you need now and may need in the upcoming year.
Be sure to talk to your doctor to see if you're taking the lowest cost medications available to you.
Because Part D plans can be designed to be actuarially equivalent to the standard benefit model (see FAQ 2) , these plans can have no or lower deductibles than required by the standard benefit model, copays and/or coinsurance can vary, and there can be other differences in plan design as well. Specific coverage will vary from plan to plan, so read your documentation carefully and make sure to check out which of your drugs are included in your plan’s formulary.
Medicare (CMS) publishes a formulary finder on their website that permits you to enter your medications, dosages, and frequency of use and then lists the carriers that cover these medications in their formulary. After you enter your drugs into the formulary finder there are various options as to how to present the findings: i.e., list in order of plans with the lowest premium; list in order of lowest premium AND cost of drugs; and list in order of plans with the lowest deductible.
Plans are required to include medication therapy management including step therapy, quantity limits and prior authorization. Part D sponsors may substitute generic drugs for brand name drugs if the generic drugs have the same or lower cost sharing and certain conditions are met. In accordance with the Comprehensive Addiction and Recovery Act (CARA), plans may impose certain limitations to manage utilization for beneficiaries who are at risk of misusing or abusing frequently abused drugs, such as opioids.
You may owe a late enrollment penalty (LEP) if, at any time after your initial enrollment period is over there is a period of 63 or more continuous days when you don't have Part D or other creditable coverage (i.e. coverage that, as a minimum, meets the Part D standard benefit model).
The late enrollment penalty is assessed for EACH month that you haven't had creditable drug coverage.
The amount of the penalty changes annually and is based on each year's national average Part D premium ($32.74 for 2023). The national average Part D premium for 2024 has not yet been announced, but under the changes required by the Inflation Reduction Act can not increase more than 6% per year.
Part D Prescription Drug Plan premiums are adjusted if your income exceeds a certain level. This additional premium (called the IRMAA) will be deducted from your Social Security check and is in addition to your premium for the basic plan. (You will have to pay Social Security directly for any IRMAA payments if you are not drawing Social Security.)
The Bipartisan Budget Reconciliation Act of 2018 changed how IRMAA is calculated. See FAQ 9 in the Medicare Overview section for details. See these charts for the 2023 IRMAA Part D premiums.
Here are a number of ways you can save on drug costs.
In addition, this article by Bankrate contains a number of good suggestions. Bankrate suggests looking into patient assistance programs at www.rxassist.org (this site contains a wealth of other useful information); shop around for the best prices on medications; tread carefully using current credit cards (look closely before choosing to use a medical credit card), and talk to your physician about switching to generics.
For a complete listing of plans available in your service area please contact 1-800-Medicare (TTY users should call 1-877-486-2048) or go to www.medicare.gov. Your copy of Medicare & You 2023 also contains a listing of 2023 plans available in your general area. You can also contact us at 877-734-3884 (TTY: 711) for this information. (Medicare & You 2024, is published and mailed to all those enrolled in Medicare (except for the most recent enrollees) in late September. We’ll include links to the 2024 version as soon as it is available. Note: the linked versions to Medicare & You do not contain listings of plans in your general area.)
Beginning in 2021 a five-year test program called the Part D Senior Savings Model became available for Medicare Advantage Drug Plans and separate Medicare drug coverage (Part D) to decrease the cost of certain insulins. Insulins (not all insulins are included) in this program can be in any drug tier and can’t cost more than $35 for a 30-day supply. A number of Medicare Advantage Prescription Drug Plans and separate Medicare drug coverage (Part D) plans have adopted this model, and an increasing number of plans have adopted this model each year since 2021.
Click on this link to learn more. By clicking on this link you are leaving this website.
NOTE:A person on a plan offering the Part D Senior Savings Model will pay the lesser of the Part D Senior Savings Model copay or $35 for any insulins listed in the formulary.
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