Caution. This email is EXTERNAL.

CMS continues to welcome and investigate the feedback you are raising to us about your questions and issues during Open Enrollment.  We encourage you to continue following the processes for sharing feedback, which helps get the most efficient information to you.  CMS provided some additional updates and tips below. Please share with your teams. 

Frequency of Prescription Fills

Some plans might cover a certain prescription drug if it is filled once a month, but not cover a 3-month supply filled once every 3 months.  If a beneficiary creates a drug list showing a prescription fill once every 3 months and the full price of the drug shows in the calculation for a drug that they think the plan covers, try changing the frequency of the fill.  You can also contact the plan directly to verify the coverage and pricing details and/or request a formulary exception. CMS added a new dynamic footnote to the Medicare Plan Finder to remind users to check the plan’s coverage on frequency of prescription fills: “This plan does not cover this drug at the selected frequency, so the price shown represents the full cash price.”

Example:

Part D Senior Savings Plans

1) Calculating True Out-of-Pocket (TrOOP) costs - Amounts paid by the plan aren’t eligible to be counted as TrOOP costs. Coverage Gap Discounts and payments made by the Medicare beneficiary are TrOOP eligible and counted toward the total.

2) Insulin Costs over $35 – Plans participating in the Senior Savings model aren’t required to cover or discount every type and form of insulin. At a minimum, a participating plan must cover at least one vial dosage form and one pen dosage form of each insulin type (e.g., rapid-acting, short-acting, intermediate-acting, and long-acting) at a $35 copay for a month’s supply in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. If higher costs are showing in the Medicare Plan Finder during those phases, it usually means that plan doesn’t cover or discount the exact form and type of insulin that a beneficiary entered in their drug list.  If a drug isn’t covered, a footnote will show in Medicare Plan Finder.

Example:

In addition, during the catastrophic phase, beneficiary copayments average $35.  However, those copayments may vary based on a number of factors so an individual may pay a copayment higher than $35 in that phase (but no more than 5% of the full cost of the drug).

3) Changing a Formulary -- Between the start of the Medicare Open Enrollment Period through 60 days after the start of the contract year, plans participating in the Senior Savings model may only remove a covered Part D drug from its formulary, or make changes in preferred or tiered cost-sharing status of a covered Part D drug, when the FDA deems a Part D drug unsafe, a manufacturer removes a Part D drug from the market, or a generic version of the brand drug is made available during this time period. Beneficiaries who are currently using any drugs that are being requested to be removed from formularies are exempt from the changes if they are approved by CMS. Plans are allowed to change the prices of their covered drugs, including insulin. 

Changes in Drug pricing

Prices of prescription drugs can fluctuate widely in the market, based on a number of different factors such as changes in production costs, demand for the drugs, or availability of generics or alternatives. Medicare Health and Drug Plans are allowed to change their pricing of drugs at any time of the year, even day-to-day during the Medicare Open Enrollment Period. However, plans can’t make formulary changes or tier-level changes during Open Enrollment. Drug pricing is updated every two weeks in the Medicare Plan Finder, and individual plans might update pricing on their own websites or at their call centers a different schedule, which could account for some inconsistencies in what displays to users at any point in time. Beneficiaries can always contact the plan to verify the latest pricing information.

Application of Mail Order Pricing to Deductible– CMS identified and updated some limited issues related to how mail order drug pricing was being calculated and applied to the deductible.  This update should clarify and resolve any reported concerns related to the deductible calculations.