As the 2017 Open Enrollment begins, it is important for both patients and pharmacists to understand the changes taking place with Medicare this year.
In 2017, a number of Medicare Part D plans and Medicare Advantage plans are merging with or being consolidated into other Medicare plans. Medicare enrollees who are currently enrolled in one of the 2016 plans being merged will receive an Annual Notice of Change (ANOC) letter, which will explain the new plan assignment. Any questions relating to plan mergers or consolidations should be addressed directly with your plan sponsor to fully understand these changes.
This year, many pharmacies chose to opt out of contracts with Humana. By opting out, patients enrolled in Humana plans can no longer fill scripts at a pharmacy that is not contracted with the plan. It is important to reach out to any patients at your pharmacy currently enrolled in a Humana plan and help them find a plan your pharmacy can accept if they’d like to continue filling there.
Improvements to Medicare are made on a yearly basis, one being reducing expenses for seniors and moving to close the Part D donut hole by 2020. iMedicare has developed a handy infographic to break down the changes to the benefits for 2017.
For Medicare Part D there are 4 phases of coverage: deductible, initial coverage, donut hole, and catastrophic. The deductible is the amount you must pay for health care or prescriptions, before Original Medicare, your Medicare drug plan, your Medicare Health Plan, or your other insurance begins to pay.
The Part D deductible is the amount you must pay each year for your prescriptions before your Medicare Prescription Drug Plan begins to pay its share of your covered drugs. Some plans have deductibles and others do not. For 2017, the maximum deductible, which the patient is 100% responsible for, is the first $400 of drug costs. This means that the enrollee must pay $400 worth of prescriptions before their Medicare plan will pay any of their prescription drug costs.
After patients reach $400 in prescription drug expenses, they have reached the initial coverage phase. Initial coverage begins after you have met your yearly deductible. During initial coverage, patients pay a tier copayment (a set amount you pay) or tier coinsurance (a percentage of the total cost) for each covered drug.
Then the enrollee reaches the coverage gap, also known as the donut hole. In the donut hole, patients pay 40% of the cost of brand name drugs, while the plan covers the remaining 60% of the cost. It is important to note that the Brand Cost in this phase is split between the Manufacturer and the Plan. The patient is also responsible for 51% of the cost of their generic prescriptions, while the plan covers 49%. This phase ends when the patient’s out-of-pocket cost reaches $4,950, or when their total drug costs reach $8,071.16 in 2017. However, for brand name drugs, 95% of the full price—what the patient pays plus the 50% manufacturer discount payment—will count as out-of-pocket costs.
Once the patient reaches the plan’s out of pocket limit during the coverage gap, they move into catastrophic coverage. During this final phases, patients only pay a small coinsurance amount or a copayment for the rest of the year. In 2017, patients pay the greater of 5% coinsurance or $3.30 copays for generics and the greater of 5% coinsurance or $8.25 copays for brand medication.
It is important that patients and pharmacists alike to get to know the adjustments to Medicare for 2017 in order to avoid headaches and financial concerns. The best way to determine what plan would fit best for a patient and how their medications put them in each phase would be to run several plan comparisons during Open Enrollment.