2019 The Big changes in Medicare Part D
For 2019, the announced changes from CMS (Centers for Medicare) with regards to Part D are significant.
The deductible phase (Phase 1) and benefit levels are $415, up from $405 in 2018. (This may or may not apply to appropriate carrier plans – please note, each carrier will have specific deductibles, so review with members accordingly).
The Initial Coverage Phase (ICP) is being increased from $3,750 in 2018 to $3,820 in 2019. The TrOOP (True Out-of-Pocket) is being increased from $5,000 in 2018 to $5,100 in 2019. This begins the Coverage Gap phase or “Donut Hole.”
The Coverage Gap Phase or “Donut Hole”
The Coverage Gap Phase or “Donut Hole”is tricky, however, let’s break down the formula:
- Part D enrollees will receive a 75% Donut Hole discount on the total cost of their brand-name drugs purchased while in the Donut Hole. The discount includes, a 70% discount paid by the brand-name manufacturer and a 5% discount paid by the Medicare Part D plan. The 70% paid by the drug manufacturer combined with the 25% the member pays, counts towards the TrOOP or Donut Hole exit point. Example: If a member reaches the Donut Hole and purchases a brand-name medication with a retail cost of $100, they will pay $25 for the medication, and receive $95 credit toward meeting their TrOOP spending limit.
- Part D beneficiaries who reach the Donut Hole will also pay a maximum of 37% co-pay on generic drugs purchased while in the Coverage Gap (receiving a 63% discount). For example: If a member reaches the Donut Hole in 2019, and their generic medication has a retail cost of $100, they will pay $37, which will count towards their TrOOP or Donut Hole exit point.
The Catastrophic Coverage Phase Benefit Medicare
The Catastrophic Coverage Phase Benefit will increase from $3.35 in 2018 to $3.40 in 2019 for generic drugs. Brand name drugs will increase from $8.35 in 2018 to $8.50 in 2019. In this phase, Medicare pays 80% of the cost, plans will pay 15%, and the member will pay the greater of 5% coinsurance or the new co-pay amounts mentioned above for all other drugs. Here’s how that works:
- For generic drugs with a retail price of $68 or under, the member pays $3.40. If the generic drug price with a retail price of $68 and greater, the 5% coinsurance applies.
- For name-brand drugs, beneficiaries would pay $8.50 for those drugs with a retail price under $170 and 5% coinsurance for those with a retail price over $170.
For Full Part D Subsidy members or those who are over 100% of the Federal Poverty Level (FPL), the co-pays for generic cost for prescriptions will be $3.40 in 2019.
That’s up $0.05 from 2018 where is was $3.35. Brand name prescription drug co-pays will be $8.50 in 2019; up from $8.35 in 2018.
Members who are up to or at 100% of FPL will still have generic prescription drug co-pays of $1.25 in 2019. However, the co-pay for brand-name drugs will rise to $8.50 in 2019 from $8.35 in 2018.
For members with a Partial Part D Subsidy, their deductible will rise from $83.00 in 2018 to $85.00 in 2019. They maintain a 15% coinsurance and pay $3.40 for generics and $8.50 for brand-name drugs (increases are the same as above).
CMS also announced that the transition supply rule is changing for 2019.
The long-term care setting is going from 90 days to 30 days along with the “30-day transition supply” to “an approved month’s supply” so that it will now be equivalent to the approved month’s supply for the applicable plan bid.
Thus, Part D sponsors will be required to provide an approved month’s supply in both the long-term care and outpatient settings.
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