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Newsletter

Medicare - February 2024

IN THIS ISSUE...
  • UNDERSTAND THE CHANGES THAT HAVE BEEN MADE TO DRUG PLANS FOR 2024 AND THAT WILL BE MADE IN 2025


  • HOW PHARMACY BENEFITS MANAGER (PBM) LEGISLATION WOULD TRANSFORM HEALTHCARE


  • FINDING LESS EXPENSIVE MEDICATIONS


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News & Updates For Medicare Beneficiaries

This month’s newsletter contains three different articles concerning prescription drugs.


The first article explains the changes that have been made to outpatient drug plans for 2024 and that are scheduled to be made in 2025 in accordance with the Inflation Reduction Act.


The second article explains what a pharmacy benefits manager is and explains what is meant by spread pricing.  There is bipartisan support in Congress to regulate the practices of pharmacy benefits managers, require more transparency in drug pricing, and eliminate or reduce the effects of spread pricing. It is probable that some legislation affecting pharmacy benefits managers will be part of any legislation passed to fund the government for the balance of FY 2024. We advise readers to understand the effect of changes that have been made to 2024 drug plans (see the first article of this newsletter) and to avoid buying any medications outside of their drug plan if they would otherwise meet the TrOOP threshold for 2024.


The third article appeared in the January 21 issue of USA Today and contains suggestions on finding less expensive medications.

UNDERSTAND THE CHANGES THAT HAVE BEEN MADE TO DRUG PLANS FOR 2024 AND THAT WILL BE MADE IN 2025

Significant changes have been made to outpatient prescription drug plans (both Medicare Advantage Prescription Drug Plans and Stand-Alone Part D Plans) this year, and even more significant changes will be made next year.

 

The two most significant changes made this year are the elimination of copays and coinsurance once an individual hits the catastrophic phase of their drug plan and the liberalization of eligibility for low-income subsidies (extra help”) for those earning between 135% and 50% of the Federal Poverty Level.

 

In 2025 the coverage gap (aka “donut hole”) phase will be eliminated and copays/coinsurance paid during the initial coverage level will be paid until the beneficiariy’s out-of-pocket costs for covered medications reach $2,000. This number will be indexed starting in 2026. There will also be significant changes in Part D plan, manufacturers, and the government (i.e., Medicare) cost shares between 2024 and 2025. As a result of these changes, we expect significant plan design changes in 2025 and, possibly, premiums for 2025.

 

Learn more about these changes by clicking on these links:

 

What Changes To Drug Plans Have Been Made For 2024?


What Changes To Drug Plan Provisions Will be Made For 2025?

HOW PHARMACY BENEFITS MANAGER (PBM) LEGISLATION WOULD TRANSFORM HEALTHCARE

The following article appeared in the January 24 issue of Modern Healthcare.


The pharmacy benefit manager industry could look a lot different soon if Congress follows through with bipartisan efforts to pass bills governing the sector.

 

PBMs such as CVS Caremark, Express Scripts and OptumRx would face new transparency requirements that would give health insurance companies, employers, customers, and regulators new insights into how they negotiate prices for prescription medicines—and how much of the savings they generate find their way to patients and plan sponsors. Pending legislation also would prohibit lucrative practices such as spread pricing.


Related: Congress is taking aim at PBMs. Here's why and what happens next.


If Congress surmounts its protracted efforts to fund the federal government for the remainder of fiscal 2024 and to reauthorize key programs, a handful of PBM measures could see action in 2024. One bill, the Lower Costs, More Transparency Act of 2023, passed the House 320-71 last month.


Less than two years after Congress and President Joe Biden enacted policies targeting drugmakers, their attention to pharmaceutical prices has moved on to the PBM industry, which has played an increasingly large role in the healthcare system over the decades. CVS Health subsidiary CVS Caremark, Cigna subsidiary Express Scripts and UnitedHealth Group subsidiary OptumRx dominate the sector and are key examples of how consolidation and vertical integration have transformed the healthcare system.


Under the bills Congress is considering, PBMs would be required to disclose drug rebates and discounts and to scale back business practices, including spread pricing. This could diminish PBM profits and force companies to rethink how they generate value for clients.

 

Read the entire article here.

FINDING LESS EXPENSIVE MEDICATIONS

Read this article that appeared in the January 21 edition of USA Today for tips on finding less expensive medications. Before following any of these recommendations read the first article of this newsletter and make sure that using one of these methods does not adversely affect your ability to reach the catastrophic threshold in the event you are on a large number of medications or utilize one or more expensive medications and have a chance to reach the catastrophic threshold in 2024 and thereby qualify for zero cost medications under your drug plan for the balance of 2024.

About Paul Cholak


Paul is a licensed, independent health and life insurance agent and has over forty years of benefits experience and specializes in helping Medicare beneficiaries obtain health insurance. However, he offers a complete array of life and health insurance products to individuals of all ages.


He guides Medicare beneficiaries through the steps of getting insurance and is available to help clients both BEFORE and AFTER they've made their purchase decision.


Disclaimer for Part C and D plans: "We do not offer every plan available in your area.  Any information we provide is limited to those plans we do offer in your area.  Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-2048) to get information on all your options."

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