Colleen Massey, MS
Janelle Herren, MSE, PharmD, RPh
Donna Bartlett, PharmD, BCGP, RPh
Policy and advocacy
At the end of this case, students will be able to:
- Describe Medicare Part D and the role of the pharmacist in assisting beneficiaries
- Identify medications and immunizations covered by Medicare Part D
- Recall factors that may contribute to Medicare beneficiaries selecting non-optimal plans
- Identify resources and tools that pharmacists can utilize to help patients with plan selection
Originally, individuals enrolled in Medicare did not have access to outpatient prescription coverage through the program. Seeing the need for coverage, Congress passed legislation for the inclusion of a drug benefit within the Medicare program, known as the Medicare Prescription Drug Improvement and Modernization Act of 2003.1 As a result of this, outpatient prescription coverage, known as Medicare Part D, became available to beneficiaries in 2006.
Enrolling in Medicare Part D is voluntary and beneficiaries, who most often pay a monthly premium, can obtain their coverage through either stand-alone prescription or Medicare Advantage plans. Both options are provided by private companies that contract with the Centers for Medicare and Medicaid Services (CMS). The Medicare Part D plan must provide a minimum benefit based upon a standard benefit design, which has four distinct phases where beneficiaries pay different costs for their medications. In 2021, this standard benefit had a $445 deductible, an initial coverage phase, a coverage gap (which begins when the full cost of the medication reaches $4,130), and catastrophic coverage (starting when a beneficiary’s out-of-pocket expenses for medications reach $6,550).2 Many enhanced plans exist in addition to the standard plans, and in 2021 beneficiaries had, on average, 60 different plans to choose from.3 Additionally, medications placed on different tiers on the plan’s formulary may have different associated costs than others. Specific medications may be full cost or require a copayment or coinsurance depending on the plan structure, deductibles, and phase of coverage. This variation in cost can be confusing to beneficiaries and result in poor medication adherence. For example, patients may think their medication will always be expensive if they are currently in a deductible phase, not realizing that they may be liable for a lower cost once they enter the initial coverage phase.
Insurance plans contain costs and provide safety stops by utilizing coverage restrictions. These restrictions include quantity limits, step therapy, and prior authorizations. All Medicare Part D plans must cover at least two chemically distinct drugs in each drug category to ensure that people can obtain the drugs that they are prescribed, but plans can choose which specific drugs they will offer. However, CMS has identified six categories of drugs, commonly referred to as the “six protected classes” and requires Medicare Part D plans to cover “all or substantially all” of the drugs in those classes.4 In addition, there are several classes of drugs that Medicare Part D plans do not cover.5 Finally, in addition to drugs, Medicare Part D plans also cover all commercially available vaccines that are not covered under Part B.6
The variation among plans, the number of plans, and the changing medication costs across the phases of the benefit lead many beneficiaries to select sub-optimal plans. In a review of plan choices, it was found that beneficiaries spent more than they needed for coverage.7 Additionally, many do not switch plans despite changes to their benefits that could affect the coverage and cost of their medications.8 This may be a result of the complexity of the benefit and the tool designed to assist beneficiaries with finding the best coverage.9 Pharmacists are well-positioned to help with this complex process and provide guidance to beneficiaries.
CC: “I’m having a hard time breathing and I don’t have an inhaler at home to use.”
Patient: JP is a 68-year-old male (72 in, 98.1 kg) who is a regular patient at your clinic for his COPD and diabetes care.
HPI: JP was diagnosed with COPD three years ago. He had a cold two weeks ago and his pulmonary symptoms have gradually worsened over that time. Today he is coughing and wheezing as he sits in the waiting room. His symptoms include shortness of breath, chest tightness and wheezing, and a persistent productive cough.
PMH: COPD (x 3 years); T2DM (x 6 years); HTN (x 10 years); major depressive disorder; osteoarthritis of the hands; shingles (single episode two years ago; has not received Shingrix®)
- Mother: deceased (breast cancer)
- Father: deceased (stroke)
- Brother: alive (72 years); HTN, COPD
- Drinks socially (3-4 beers on the weekends)
- Denies smoking and illicit substance use
- Spiriva® Handihaler® one capsule daily
- Ventolin® HFA two puffs four times daily PRN
- Lisinopril/HCTZ 20/12.5 mg one tablet daily
- Sertraline 50 mg one tablet daily
- Lantus Solostar® 100 u/mL 30 units subcutaneously daily at bedtime
- Viagra ® 50 mg one tablet one hour prior to sexual activity
- BP 148/82 mmHg
- HgbA1c 8.4%
SDH: JP has been married for 35 years and is a retired electrician. He has traditional Medicare and a Medicare Part D plan that his son helped him to choose two years ago. His retirement income is limited; he states he can only afford generic medications and can often only pay for his inhalers and his insulin every other month. He has tried different inhalers that are often too expensive for him. His doctor prescribed the Spiriva® Handihaler® about six months ago, but he admits that he struggles to use the capsules in the device due to his arthritis.
1. What factors should be considered when finding a plan for this patient?
2. Through what type of Medicare plans are beneficiaries able to access Medicare Part D benefits?
3. What information and strategies could you discuss with JP to help him better afford his medications like his insulin and inhalers? Are any of JP’s drugs NOT covered by his Medicare Part D plan?
4. The Medicare website is a helpful resource to help individuals find the most cost-effective coverage. JP needs help with finding a new plan. He fills his medications at the retail pharmacy CVS, has a zip code of 01608, and does not qualify for any assistance with the cost of his medications. Utilizing the Medicare Plan Finder to compare the available options, what stand-alone Medicare Part D plan has the lowest annual cost including the plan premium and medication costs?
5. How does JP benefit from the identification of Medicare’s six protected classes?
6. Would JP’s Shingrix® vaccine be covered under his Medicare Part D plan or his Medicare Part B? Would JP have to pay out of pocket costs to receive this vaccine?
Patients who cannot access medications due to cost or the inherent complexity of their Medicare Part D plan may be at risk for health complications and serial hospitalizations due to non-adherence.4 There are safeguards built into the Medicare Part D plans to ensure medication accessibility and equity for Medicare beneficiaries, including tiered costs, special insulin tiers, and protected medication classes. However, many patients are unaware of these benefits or struggle with health literacy challenges that prevent them from maximizing the benefits of these plans.9
Pharmacists, with their broad knowledge of drug classes and insurance complexities, are key health care advocates who can assist Medicare patients with these challenges. While helping patients to navigate the Medicare plan choices and understand the structure and benefits of the plans, pharmacists can help to improve medication access, reduce overall medication costs, and improve health outcomes for their patients.4 Pharmacists may also incorporate other assistance programs to help improve access and reduce medication costs even for those who have chosen an appropriate Medicare plan; for example, if a patient is eligible for a state pharmacy assistance program (SPAP), the costs associated with Medicare Part D may be lower. Pharmacists should become familiar with general eligibility requirements for state insurance assistance, Extra Help through Social Security, manufacturer assistance programs, discount programs like GoodRx, and Medicaid dual eligibility.
Patient Approaches and Opportunities
As one of the most accessible healthcare providers, pharmacists can be invaluable resources for their Medicare patients. Even simple recommendations can save Medicare patients significant costs during the year, including reminding patients to review their plans annually to ensure their current medications are on the plan’s formulary, assisting with identifying coverage restrictions, and reminding patients to budget accordingly for renewed deductibles that come every January.5
Additionally, pharmacists can recommend generic drugs, biosimilars, and appropriate therapeutic alternatives that may be in lower cost tiers to further reduce patients’ costs. Requesting 90-day refills from prescribers can improve adherence and reduce copays. Pharmacists can also use this opportunity to ensure a patient’s chosen pharmacy will accept their preferred plan and potentially reduce copays. This strategy may encourage Medicare patients to use a single pharmacy for their prescriptions which can improve their adherence and overall health outcomes.4
Medication therapy management (MTM), or comprehensive medication review (CMR), is an additional component of Medicare Part D that can be administered by pharmacists to benefit patients. Each insurance plan has criteria for MTM eligibility and may require the beneficiary to have three specific disease states, eight medications, and drug costs that reach the coverage gap to be eligible for MTM services.6 If patients do not have the required disease states or have reduced drug costs due to prescription cost assistance programs, they may not meet the criteria, even if they are taking multiple medications to treat multiple conditions. However, MTM services are excellent opportunities to improve adherence, identify therapeutic alternatives, reduce polypharmacy, and lower costs for Medicare patients.4
Related chapters of interest:
- Communicating health information: hidden barriers and practical approaches
- Equity for all: providing accessible healthcare for patients living with disabilities
- Let your pharmacist be your guide: navigating barriers to pharmaceutical access
- Medicaid. State overviews.
- Medicare. Find health and drug plans.
- Medicare. Find out if your state has a state pharmaceutical assistance program.
- Medicare. Assistance with Medicare Part D drug costs (manufacturer prescription assistance programs).
- Medicare. Six ways to get help with prescription drug costs.
- Medicare Rights Center, MedicareInteractive.org. Medicare coverage overview.
- Social Security Administration. Extra help with Medicare prescription drug plan costs.
- NeedyMeds. Find help with the cost of medicine.
- Health Affairs. The Part D senior savings model: reducing out-of-pocket costs for insulin in Medicare Part D.
- Journal articles:
- Huffman KF, Upchurch G. The health of older Americans: a primer on Medicare and a local perspective. J Am Geriatr Soc 2018;66(1):25-32.
- Hastert JD. H.R.1 – 108th Congress (2003-2004): Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Published December 8, 2003. . Accessed March 11, 2021.
- Center for Medicare and Medicaid Services. Announcement 7 of Calendar Year (CY) 2021 Medicare Advantage (MA) capitation rates and Part C and Part D payment policies. Published April 2020. . Accessed January 5, 2021.
- Cubanski J, Damico D. Medicare Part D: a first look at Medicare prescription drug plans in 2021. Published October 29, 2020. . Accessed January 5, 2021.
- Zagaria M. Drug costs in Medicare dollars and cost-related nonadherence. US Pharm 2019:44(60):8-11. . Accessed March 14, 2021.
- Gilchrist A. 4 ways pharmacists can be superheroes for Medicare patients. Pharmacy Times. Published July 26, 2013. . Accessed March 14, 2021.
- Center for Medicare and Medicaid Services. 2019 Medicare Part D medication therapy management (MTM) programs fact sheet summary of 2019 MTM programs. Updated September 25, 2019. . Accessed December 30, 2020.
- Zhou C, Zhang Y. The vast majority of Medicare Part D beneficiaries still don’t choose the cheapest plans that meet their medication needs. Health Affairs 2012;31(10):2259-65.
- Jacobson G, Damico A. No itch to switch: few Medicare beneficiaries switch plans during the open enrollment period. Published December 2, 2019. . Accessed January 13, 2021.
- Jacobson G, Swoope C, Perry M. How are seniors choosing and changing health insurance plans? Published May 13, 2014. . Accessed January 13, 2021.