As the summer comes to a close, many pharmacies are seeing more and more patients enter the ‘donut hole’. During the donut hole – also known as the Medicare Part D Coverage Gap – patients pay a larger share of their medication cost. After the total cost of patients’ 2017 medications reaches $3,700, their copays become 40% the cost of brands and 51% of generics. With the copay increase, patients may feel they are unable to afford their prescriptions and desperately need your insight and counsel. Patients who struggle with being able to afford their prescriptions are less likely to be adherent. Adherence not only affects your pharmacy’s reimbursements, but your patients’ health. So we assembled some helpful steps to make sure your patients never feel like they have to go without their medication!
Inform your patients about the existing discounts that they can access outside of their Medicare Part D plans. The Center for Medicare and Medicaid Services (CMS) says if you have Part D you still have a choice. A CMS spokesperson said that “a Medicare beneficiary does have a right to purchase a drug outside of a prescription drug plan at his or her discretion.” Meaning that your patients aren’t limited to their plan’s specific formulary, and can be a bigger part of the decision making process when it comes to their prescription drug needs. If a patient enters the donut hole and it is unlikely they will enter catastrophic coverage, this can be a good option.
Explain to your patients how the different phases of their Medicare Part D coverage works. Should they enter the donut hole they may be able to reach the out-of-pocket amount ($4,950) that would place them in the catastrophic phase. This phase would significantly decrease their cost, making it much easier to afford their prescriptions! In fact, to take advantage of the lower copays during catastrophic coverage, some pharmacies will convert a 30 day brand supply to 90 days at the end of the year. Perhaps you can look at the monthly cost breakdown for the remainder of the year, and help the patient plan accordingly.
Be on the lookout for changes in drug cost throughout the year. While insurance plans cannot change most aspects of a formulary throughout the year, they can change the full cost of drugs; so, copays that are a percentage of full cost can fluctuate. This is usually due to a change in AWP for brand drugs, or a plan updating their MAC list. You can use the Formulary Lookup tool in iMedicare to see a drug’s full cost across plans, and identify affordable therapeutic alternatives covered on your patient’s current plan.
Discuss the possibility of your patient qualifying for Extra Help through Social Security. If they meet certain criteria, their plan premiums and deductibles will be significantly reduced. They may be eligible to pay no more than $3.30 for each generic prescription and $8.25 for brand. iMedicare has a link to the application form on the Edit Patient Profile screen.
Recommend generics where they are available to replace expensive name-brand medications. If there are no generics available you may be able to recommend an alternative from the same class that costs less. iMedicare provides you with full access to the Part D formularies, including copays, so you can tell patients up-front what their costs will be.
And last but not least you can assist them in finding a less expensive plan based on their drug list. Using iMedicare’s Plan Comparison tool, you can easily identify plan options that will keep your patients in your pharmacy. Invite your patients to come in and have a conversation with you during this year’s Open Enrollment (October 15th-December 7th). Or use your iMedicare Opportunities to see which patients you can help throughout the year.
At the end of the day, patient care is the most important aspect of everything that we do. Taking the time to engage with your patients and work with them will keep them coming back for years to come.