JustCare

Tag: Medicare Part D

  • How to avoid overpaying for your prescription drugs

    How to avoid overpaying for your prescription drugs

    In a piece for the New York Times, Rebecca Robbins and Reed Abelson advise readers on how to avoid overpaying for prescription drugs. Most importantly, you should not assume that your insurer is saving you money on your drugs. Too often you will pay more for your drugs with insurance than you would if you paid for your drugs in full, without insurance.

    How is it possible you would pay more for your drugs with employer coverage or Medicare Part D coverage than without it? Three words: Pharmacy benefit managers or “PBMs.” These entities—prescription drug middlemen who work for health insurers and are often owned by them—are responsible for negotiating with pharmaceutical companies for lower-priced drugs. But, they can and do pocket a lot of the savings. They then determine which drugs your insurer will cover and your copay for each drug, your “formulary.”

    Three big corporations own the three biggest PBMs. UnitedHealth owns Optum Rx, CVS owns Caremark and Cigna owns ExpressScripts. These insurance corporations put their shareholders’ interests ahead of their customers’. What’s worse is that our government allows them to upcharge their customers.

    Robbins and Abelson suggest that you might want to know which PBM controls your formulary, but I’m not sure why. Caremark, ExpressScripts and Optum control 80 percent of the prescriptions filled in the US. And, there’s no evidence that any of them offer better prescription drug coverage than any other.

    How do PBMs game the system? In addition to being able to pocket and not pass along to you the discounts they secure from drug manufacturers, they can force you to take a brand-name drug when a lower-cost generic is available. They take money from the brand-name manufacturer to steer you to its drug and away from the generic; they might not include the generic on their formulary.

    Sometimes, PBMs include generic drugs on their formularies, but they charge copays for these drugs that are higher than the full cost of the drugs without insurance.

    What can you do? Always check to see whether you can get your prescription drugs at a lower price from Costco or GoodRx or Mark Cuban’s Cost Plus Drugs or from abroad. You often can. A colleague of mine was told the Medicare Part D copay for his drug was over $300.  When he asked the cost with GoodRx, he was told it was $30!

    Here’s more from Just Care:

  • Insulin costs: Biden v. Trump

    Insulin costs: Biden v. Trump

    If you are looking for our next president to lower your health care costs, there are multiple reasons to support President Biden over Donald Trump. One is insulin. Though Trump would like you to think otherwise, Juliette Cubanski and Tricia Neuman explain in a KFF report that Donald Trump did far less to contain the cost of insulin than President Biden.

    To be clear, both President Biden and Donald Trump have lowered the cost of insulin for people with Medicare and for no other cohort of the population. But, access to lower-cost insulin for people with Medicare is far greater under President Biden than it was under President Trump.

    Under President Biden, all 6,000 Medicare Part D prescription drug plans are required to keep the insulin copay at no more than $35 a month. President Trump did not require the Part D plans to charge a copay of no more than $35 a month; he made it voluntary. So, only 38 percent of Part D plans participated when he was president.

    As a result, the Trump administration only helped 800,000 people with Medicare needing insulin. The Biden Administration is helping all 3.3 million people with Medicare needing insulin.

    Under President Biden, all insulin products are covered. Donald Trump only required a subset of insulin products to be covered–one of each dosage form (vial, pen) and insulin type (rapid-acting, short-acting, intermediate-acting, and long-acting).

    Under President Biden, the insulin cap applies to drugs under Medicare Part D and Part B. The Trump administration only applied the cap to Medicare Part D and not to insulin drugs administered by a physician under Part B.

    President Biden is now proposing to ensure that everyone with commercial insurance also enjoys the $35 a month out-of-pocket cap on insulin. In fact, President Biden’s proposal was in the Inflation Reduction Act, but the Republicans took it out before it passed. And, Republicans in Congress want to repeal the Inflation Reduction Act, which would end the $35 out-of-pocket insulin cap, though Trump has not yet commented on this.

    N.B. Rachel Cohrs Zhang reports for Stat that the idea for the $35 insulin cap came from Eli Lilly. The cap likely helps Lilly’s profits since it boosts insulin sales significantly, as more people can afford it. The cap doesn’t affect the price of the drug. So, everyone with Medicare ends up absorbing insulin’s lower out-of-pocket cost through higher premiums.

    Here’s more from Just Care:

  • Medicare Advantage insurers increasingly use step therapy for cancer drugs, delaying care

    Medicare Advantage insurers increasingly use step therapy for cancer drugs, delaying care

    A study by Avalere reveals that health insurers are increasingly delaying and denying drugs to cancer patients through the use of step therapy, reports Noah Tong for Fierce Healthcare.

    The American Cancer Society Cancer Action Network (ACSCAN) released a paper that demonstrates Medicare Advantage insurers are weaving step therapy into their prior authorization requirements. Sometimes, enrollees don’t even realize it. Step therapy is a means by which insurers require patients to use a less costly treatment before receiving a more costly one, such as requiring an X-ray before approving a CT scan or MRI.

    Some say that requiring prior authorization for cancer drugs helps ensure safety. Prior authorization can also save patients money. But, what the Medicare Advantage insurers are doing is troubling. Patients and doctors are too often unaware of what the insurers are requiring. In particular, delays in treatment are concerning.

    Kisqali and Verzenio are two breast cancer drugs for which Medicare Advantage insurers often require step therapy. They won’t cover these drugs unless other less costly drugs are shown to be ineffective. One concern is “embedded step therapy,” which could hide an insurer’s use of step therapy. It might not be included in an insurer’s Part D list of covered drugs.

    In the year between 2023 and 2024, overall, Medicare Advantage insurers used step therapy more often for breast cancer drugs and hepatocellular carcinoma, according to the American Cancer Society.  Medicare Advantage insurers required step therapy as much as 95 percent of the time. They did not appear to require it for biosimilar drugs Kanjinti and Trazimera.

    The bigger insurers tend to require step therapy more of the time than the smaller insurers. If the issue is truly safety, they should be using step therapy with the same frequency.

    To date, the Centers for Medicare and Medicaid Services, CMS, which oversees the Medicare Advantage plans, has allowed insurers to decide for themselves when to use prior authorization. Some use it a lot more than others, at times delaying and denying urgently needed care inappropriately.

    Prior authorization determinations should be standardized across all Medicare Advantage plans. Without standardization, people cannot meaningfully distinguish among MA plans. Moreover, MA plans can wrongly deny or delay care with little if any accountability.

    Here’s more from Just Care:

  • CVS plans to raise Medicare Rx premiums a lot in 2025

    CVS plans to raise Medicare Rx premiums a lot in 2025

    In an op-ed for MarketWatch, Brett Arens’s Roi warns about rising Medicare Part D premiums.

    The CFO at CVS is alerting people that Medicare Part D premiums will increase significantly in 2025. How much of that increase amounts to more profits for CVS? It’s already profiting from pocketing pharmaceutical company rebates instead of passing them on to its Part D enrollees in the form of lower out-of-pocket costs.

    A series of articles over the last few years highlight tactics CVS uses to maximize profits. For example, it sometimes makes its Part D enrollees buy brand-name drugs, for which CVS earns more. So, it’s no surprise that CVS is planning another premium hike. Premiums will be “much, much higher” says Thomas Cowhey, the CFO.

    CVS knocked up Part D premiums 20 percent this past year. This time round, the higher premiums will allow CVS to protect its profits from rising costs resulting from the $2,000 out-of-pocket cap for Part D coverage that goes into effect in 2025.

    CVS believes that more people will be filling their prescriptions once Part D has a $2,000 out-of-pocket cap. Costs will no longer be a barrier for some, after they spend $2,000 out of pocket. The question then becomes how many people have $2,000 to spend to reach that out-of-pocket cap when they need to?

    As of now, about one in seven people with Medicare say they are not filling their prescriptions because of the cost.

    Some analysts believe that the new $2,000 out-of-pocket cap in Part D will steer more people into Medicare Advantage plans. Medicare Advantage plans almost always include prescription drug coverage in their premiums. Medicare Advantage plans are likely to look less expensive than Traditional Medicare, where people would have to buy a stand-alone Part D prescription drug plan.

    Here’s more from Just Care:

  • Medicare Part D drug coverage stunts are rampant

    Medicare Part D drug coverage stunts are rampant

    When it comes to Medicare Part D prescription drug coverage, one thing’s for sure: Medicare Part D coverage stunts will continue without an overhaul. Insurers have way too much room to drive up drug costs for enrollees in order to profit handsomely. Cheryl Clark reports for MedPage Today that Medicare Payment Advisory Commission (MedPac) Commissioners are surprised by the huge variation in generic drug prices and availability among different Part D drug plans. It’s no surprise, it’s the “free market” run amok.

    Commissioners considered why one generic drug can cost someone with Part D coverage $1.06 at one pharmacy and $102 at a different pharmacy, sometimes even the same pharmacy chain. What goes into generic drug pricing? Lots of unknown factors in addition to the cost of manufacturing and dispensing the drug and the pharmacy’s costs. (But, you can be sure it’s all about insurer profits.)

    About 20 percent of Medicare spending on prescription drugs is for generics, and generics represent about 90 percent of the drugs that Part D plans fill. Generics are costing more and more.

    Some basic generic drugs, including cardiovascular drugs, are just plain “out of stock.” The big PBMs can’t even say when they will have these drugs in stock. Is it a supply chain issue? (Editor’s note: A David Dayen story in TAP reveals that 323 drugs are in short supply, many more than in the past, endangering people’s health and lives.)

    MedPac Commissioners want to know more about Medicare Part D, as if we need to know more to fix a multi-headed drug cost problem. The biggest players have so much power that they can keep drugs off the market if that helps them financially. A while back, I reported on a story about CVS not selling certain generic drugs because they profited more from only making the brand-name alternatives available.

    “Tying arrangements” are another cog in the pharmaceutical supply and price wheel. These agreements allow drug wholesalers and pharmacies to set the amount of a brand-name drug discount to the amount of generic drugs a pharmacy buys and the price it pays. Wholesalers can then charge more for generic drugs and give bigger discounts on brand-name drugs.

    In addition, bigger pharmacy chains can bargain for lower costs than independent pharmacies. They can also pay less for the same drug from wholesalers. The manufacturers might be charging the same price for a drug, but the wholesalers do not.

    And, the Part D the insurers don’t help matters, designing formularies that benefit their bottom lines and often cost their enrollees more. For more on the challenges of getting your drugs covered through Part D, check out this post from last week.

    Bottom line: You cannot assume that you are getting your drugs at the lowest cost through your Part D drug plan. You need to shop around. Too often you can pay a lot less without using your insurance. One MedPac Commissioner explained that with “irrational drug prices … beneficiaries in the know have to strategize multiple means to access their meds. GoodRx over here and a mail order for Mark Cuban over there, a patient assistance program over there, and the many other methods that … bypass the local pharmacist.” Of course, those not in the know, often the most vulnerable, pay more than they should.

    The Commissioner expounds on the problem: “It’s bad enough that the plans can dramatically change what medicines they cover and what costs for each year with different utilization management tools. But then to have multiple sources of the least expensive drug is just too much for older adults and adults with disabilities.” What’s worse, as I understand it, Part D plans can change the medicines they cover and their costs throughout the year.

    Michael Chernew, MedPac Chair, appeared not to be aware of this longstanding issue with Medicare Part D drugs, both generic and brand-name. He suggested that it was challenging to determine a way to fix the problem, even though every other wealthy nation has done so through negotiated drug prices.

    Here’s more from Just Care:

  • Medicare Part D plans can make it hard to get prescription drugs

    Medicare Part D plans can make it hard to get prescription drugs

    As you might already know, Medicare Part D plans can make it hard to get the prescription drugs you need. That’s not to say you shouldn’t have Part D coverage because it could protect you from out-of-control prescription drug bills. But, you still might spend less paying for your drugs out of pocket with a discount coupon from GoodRx or through Costco mail order or from a verified pharmacy abroad.

    First, the good news. Beginning next year, your out-of-pocket costs for drugs that Medicare Part D covers will be capped at $2,000 a year. The Inflation Reduction Act, one of President Biden’s big accomplishments is responsible for that limit as well as negotiated drug prices for some of the highest cost drugs in Medicare.

    But, corporate health insurers offering Part D like to make money, so they are finding ways to shift more costs on to their enrollees.Part D insurers are making it hard for their enrollees to fill certain prescriptions. Either these insurers are not covering certain medicines altogether or they are forcing people to go through multiple hoops before they will pay for certain drugs, according to a recent Health Affairs study.

    For the most part, if a Part D plan does not cover a drug, then that drug is not subject to the $2,000 out-of-pocket cap.

    How do Medicare Part D insurers limit their prescription drug spending and/or boost their revenue?

    1. They don’t include certain drugs on their formulary; they now don’t cover 30 percent of drugs, up from 21 percent 13 years ago. Apparently, they are now not covering come drugs that treat cancers and autoimmune disorders.
    2. They promote brand-name drugs for which they get large rebates from pharmaceutical manufacturers and make copays for generic substitutes more expensive or simply don’t cover generics.
    3. They restrict access to drugs through prior authorization requirements. In 2020, they restricted access to 44 percent of them.
    4. They require the use of generics and won’t cover brand-name alternatives.

    Why does the government permit these restrictions?

    Here’s more from Just Care:

  • Billions in Medicare savings from Medicare drug price negotiation by 2031

    Billions in Medicare savings from Medicare drug price negotiation by 2031

    A new report from Nicole Rapfogel at the Center for American Progress (CAP) finds that the Inflation Reduction Act’s provision allowing Medicare to negotiate drug prices for its highest cost drugs will reduce drug spending by tens of thousands of dollars a year for millions of people with Medicare and save Medicare millions of dollars a year.

    On September 1, 2024, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, will announce the prices it has negotiated with pharmaceutical corporations on ten drugs that treat, among other things, diabetes, kidney disease, blood clots and heart failure. Beginning in January 2026, the cost of these drugs should drop considerably.

    The ten drugs cost Medicare significantly more than other drugs it covers either because they have very high prices or because they are widely used. A total of nine million people currently use their Part D drug benefit to fill prescriptions for these drugs. These ten drugs represent roughly 20 percent of Medicare’s annual drug spending under Part D.

    CAP projects that the price of one insulin product, NovoLog FlexPen will fall $30 a month and the price of one cancer drug, Imbruvica, will fall $6,548 a month. The price of Eliquis, which 3.5 million people with Medicare take, could drop by $123 a month.

    Currently, Americans pay many times more than people in other wealthy nations for several of these drugs. For example, a dose of Stelara, another drug whose price Medicare is negotiating, which treats people with autoimmune conditions, costs $2,900 in the United Kingdom and $16,600 in the US. Moreover, Americans paid $6.5 billion in taxpayer dollars for the development of Stelara.

    While Medicare is only negotiating the price of 10 drugs this year, by 2030 it will have negotiated the price of 80 drugs. CAP estimates that Medicare will save $25 billion as a result of drug price negotiation in the six years between 2026 and 2031.

    Of course, the pharmaceutical corporations are trying to block these price negotiations in the courts, claiming that the government should not be interfering with the prices private corporations set. What they fail to say is that they developed these drugs with $11.7 billion in taxpayer dollars, The Lever reports. And, the pharmaceutical corporations made $70 billion on these drugs in 2022.

    Here’s more from Just Care:

  • Biden brought down the price of insulin significantly; a Trump presidency could undo that

    Biden brought down the price of insulin significantly; a Trump presidency could undo that

    Drug prices remain out of control, and there’s a lot that President Biden could still do to bring them down. But, Americans should give President Joe Biden credit for reducing the cost of insulin significantly, a huge achievement for which he has not gotten the credit he is due, writes Jonathan Cohn for Huffington Post. If Trump is reelected, he could undo this.

    In fact, President Biden is responsible for several new laws that are bringing down the cost of health care and making it a little more affordable. [Editor’s note: Not nearly enough, but far more than President Trump.]

    With insulin, which millions of diabetics rely on for their well-being to process sugars in their bodies, the list price can be hundreds of dollars. That price is insane. People in other developed countries pay as little as 10 percent of the amount we pay for their insulin. Their governments negotiate the price of insulin and every other drug on their behalf.

    About 25 percent of Americans with diabetes cannot afford insulin and other basic needs. In some cases, people forego insulin to the detriment of their health. They might not have health insurance and cannot afford the full cost of insulin. Fortunately, thanks to the Affordable Care Act, fewer Americans than ever are uninsured.

    As of 2023, because of the Inflation Reduction Act, older adults and people with disabilities should pay no more than $35 a month for an insulin prescription. If they have two prescriptions, it would cost them $70. Since the government has not yet negotiated the price of insulin, it’s not clear how much more everyone with Part D prescription drug coverage is paying in premiums as a result of the Inflation Reduction Act.

    Unfortunately, reports are that some Part D drug plans have stopped covering insulin in response to the $35 maximum copay. If you have diabetes, make sure that your drug plan covers your insulin prescriptions.

    As of January 1, 2024, people who do not have Medicare should also see lower insulin prices. The three major companies that manufacture insulin have reduced their prices to $35 a month voluntarily. One policy expert explains, however, that the price drop actually helps these companies maximize profits: “They’re lowering prices to avoid paying rebates to Medicaid programs and therefore maximize profits.”

    If President Trump is reelected in November, watch out. His administration would likely undo President’s Biden important legislation on insulin prices. And, many of the 8.4 million Americans who rely on insulin would again be struggling to afford it or, worse still, forced to go without it.

    Here’s more from Just Care:

  • Some Medicare prescription drug plans dropping insulin coverage

    Some Medicare prescription drug plans dropping insulin coverage

    One of the many design and structural defects of the Medicare Part D prescription drug benefit is that the health insurers offering coverage have enormous latitude to determine the drugs they will cover. Not only does that mean the insurers might not cover some basic generic drugs, it means that they might cover some drugs today and different drugs tomorrow. With a recent legal requirement that limits out-of-pocket costs for people with Medicare using insulin, Medora Lee reports for USA Today that some Part D prescription drug plans are dropping coverage of insulin.

    Because insurers cannot charge people with diabetes more than $35 a month for each insulin product they take, Part D insurers might be able to keep down premiums and attract healthier members by dropping insulin coverage. The insurers also might project greater profits if they do not cover certain insulin products. So, anyone with Medicare in need of insulin better beware.

    You should check to ensure that your Part D prescription drug coverage will pay for the insulin you take in 2024. If not, you should switch to a different Part D plan if you can. Keep in mind that your Part D plan can change the drugs it covers at any time. However, if it does, you generally have a right to coverage of your medically necessary drug throughout the rest of the year if you have no alternative.

    It’s a travesty that Part D  insurers can game the Medicare system to the detriment of people with diabetes. It’s equally problematic that they can game the system to hurt people with all different sorts of prescription drug needs. For example, CVS was found not to have generic versions of some drugs on its Part D formulary; it profited more from only having the brand-name drugs, for which it received rebates and otherwise benefited financially.

    It’s also deeply concerning that Part D insurers can charge higher copays for some drugs than Costco charges for the full cost of the same drugs. One Just Care reader reported that to keep his costs down, he had to get his drugs from different sources.  Costco had lower prices for some drugs and his Part D plan had lower costs for others.

    In 2025, people with Part D will not pay more than $2,000 out of pocket for drugs their insurer covers. That’s the good news. I’m willing to bet that the Part D insurers find a way to take advantage of this new consumer protection, while making it harder for their members to get the drugs they need.

    Congress should come to its senses and establish one prescription drug benefit that meets everyone’s needs. It should not allow Part D plans to meet only some prescription drug needs. Right now, the Medicare Part D benefit is designed to line the pockets of insurance companies and pharmacy benefit managers not to bring down drug costs as much as possible for people with Medicare or to ensure that their Part D coverage meets their current and future prescription needs.

    Here’s more from Just Care:

  • 2024: Medicare Part D coverage and costs

    2024: Medicare Part D coverage and costs

    Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, Medicare covers the prescription drugs you get from the pharmacy under Medicare Part D. The vast majority of people with Medicare, 50.5 million in 2023, are enrolled in a Part D drug plan. Here’s what you need to know about Medicare Part D coverage and costs in 2024 and why you should take a close look at your options for next year during this annual open enrollment period.

    Don’t assume that your current Part D drug plan will cover your drugs in 2024, even if it does in 2023. Rather, assume that your costs will go up a lot if you didn’t check which Part D plan was likely to save you the most money based on your drug needs, during the Medicare open enrollment period (October 15-December 7). Each year, these Part D private insurance plans can change dramatically. Kaiser Family Foundation offers key facts about Part D plans in 2023.

    As a general rule, close to three in four people enrolled in traditional Medicare and a Part D plan will pay higher costs the following year, if they do not look at their options and switch plans.

    In 2024, there are 709 prescription drug plans available nationally, according to the Kaiser Family Foundation. If you are in traditional Medicare, you will be able to choose from among 15 to 24 Part D plans in your state. 16 national Part D prescription drug plans, with monthly premiums ranging from $6 to $111. The average premium is $43.

    Premiums: Premiums are typically higher for Part D plans offering enhanced benefits, lower cost-sharing and/or low or no deductibles. Standard Part D plans have a base monthly premium in 2024 of $34.70, but it could be higher or lower depending upon multiple factors. Part D “enhanced” plans that charge no or a low deductible have a base monthly premium of $55.50 in 2024.

    If your annual income is $103,000 or higher, you pay a supplemental premium of between $12.90 and $81 a month.

    Standard deductible: The standard and highest possible deductible—the amount you must pay before your coverage begins—is $545, up from $505 in 2023.

    If you have traditional Medicare: You typically will be able to choose among 24 Part D drug plans. Depending upon the state you live in, your options range between 19 and 28.

    If you are in a Medicare Advantage plan: You typically will have a choice  of around 35 Part D drug plans.

    Cost-sharing: For non-preferred brand-name drugs, coinsurance could be as high as 40-50 percent and as low as $0 for preferred generics, depending upon the Part D plan you choose. You also are likely to pay 15-25 percent coinsurance for preferred brand drugs.

    Typically you’ll pay about $1 for preferred generics and $5 for generics. You’ll pay around $44 copay for preferred brands, 45 percent coinsurance for non-preferred drugs, and 25 percent coinsurance for specialty drugs.

    Maximum out-of-pocket: The most you will pay out of pocket for drugs you purchase through Part D is $3,300 in 2024, even though the out-of-pocket spending limit is rising to $8,000 or $12,447 in total drug costs). But the $8,000 includes the value of the manufacturer discount on the price of brand-name drugs during the coverage gap phase of the benefit. If you only use brand-name drugs, you will only have to pay around $3,300 out of pocket.

    Also, keep in mind that in 2025, your maximum out-of-pocket cost for drugs covered through Part D will be $2,000 because of the Inflation Reduction Act.

    Costs in each coverage phase: After you have paid your deductible, you are in the initial coverage phase, where you generally will pay around 25 percent of the cost of both brand-name and generic drugs until your drug costs total $5,030. You will then be in the coverage gap phase, where you will be responsible for about 25 percent of the cost of your drugs. Once your out-of-pocket drug costs, including the deductible, but not your Part D premium, total  $8,000 in the coverage gap phase (in fact, around $3,300 plus manufacturer discounts,) you will be in the catastrophic coverage phase. At that point, you will pay nothing more for your covered drugs.

    If you qualify for a low-income subsidy (LIS) or Extra Help: You will have lower out-of-pocket costs, depending upon the Part D plan you choose and the drugs you use. You should pay $4.50 for each generic drug that is covered and $11.20 for each brand-name covered drug. Around 13 million people with Medicare qualify for extra help with their prescription drug costs. There are 198 Part D drug plans for which you will not pay a premium. You can also choose a “non-benchmark” plan and pay a portion of the monthly premium.

    You should get Extra Help automatically if you have full Medicaid benefits or are receiving SSI benefits. If not, you can apply for Extra Help through the Social Security Administration. To qualify, generally, an individual’s countable income needs to be below $21,870 and your assets need to be below $16,600.

    If you need insulin: The Inflation Reduction Act limits your monthly copayment to no more than $35 in all phases of Part D coverage. However, that limit applies only to insulin in a plan’s formulary, not all insulin products.

    If you need a vaccine: Vaccine costs are covered in full for vaccines that are on the Part D formulary.

    Here’s more from Just Care: