Tag Archives: irmaa

CHANCES ARE YOUR MEDICARE ADVANTAGE AND DRUG PLAN PREMIUMS, COVERED DRUGS, OR GYM MEMBERSHIP WILL CHANGE

Posted on by
1

By D. Kenton Henry
Editor, Agent, Broker
HealthandMedicareInsurance.com
11 September 2024

Welcome, fellow boomers and others blessed to have lived long enough to find yourself here. I believe you recognize that the information in my blog posts can contribute to this leg of our journey being the longest and most rewarding. I’m right here with you and doing my best to make it so for all of us. Coming changes in 2025 Medicare plans are significant, so please read this and feel free to take notes. They could impact you and probably will.

We will begin with what your Medicare Part B premium to Medicare for Out-Patient Care will go to:
For those earning less than $105,000 your premium will go to $185.00 (up from $174.70)
For those in the highest income bracket, earning greater than $500,000 your premium will go to $628.90 (from $594.00)
For every income block in between, couples filing jointly, and what Part D premiums to Medicare will go to, please click on this link and scroll down: https://www.irmaacertifiedplanner.com/2025-irmaa-brackets/

An Annual Notice of Change (AOC) from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan is due you. It will arrive in the United States mail and, per Medicare rules, by September 30th. So, like the pretty woman in the image above, open it and read it. It outlines how much your premiums, deductibles, and co-pays will differ in the coming year. Will your drugs be covered, and will your current drug plan even be available? We don’t yet know. Mutual of Omaha notified agents and brokers that it is withdrawing altogether from the Part Drug plan market beginning January 1. If you are currently with them or have any other plan that is exiting the marketplace, follow the instructions in the next paragraph.

According to eHealth, a mere 36% of those surveyed claim the AOC to be “readily understandable.” The author of the attached article recommends you spend at least 30 minutes reviewing it. However, if you finish this article, you can cut that time considerably. If you have finished all and still feel you are among the remaining (up to) 64%—please call me @ 281-367-6565.

This article is a follow-up to my last blog post on September 3rd. “MAJOR CHANGES IN MEDICARE PART D DRUG PLANS ARE COMING OUR WAY (what we know. and one thing we don’t know).” To read it, please click on this link. (if necessary, copy and paste it in your browser’s URL box and hit enter):

https://healthandmedicareinsurance.com/2024/09/03/

Well, now we know more of the potential compromises mentioned or alluded to in that article. All of these are covered in detail in Feature Article 1 below.

The changes addressed here are largely because of the new $2,000 per year limit on Medicare Part D drug costs in 2025 (versus $8,000, plus 5% thereafter, in 2024). That leaves Medicare Part D insurance companies looking for ways to compensate for the additional costs shifting from you to them. Come January, you will meet a new deductible of up to $590 (from $545) for applicable drugs. Typically, your plan will apply this to brand-name drugs and not Tier 1 or Tier 2 generics.

Beyond that, the Gap, commonly referred to as the “donut hole” (in which you were previously responsible for 25% of your drug costs), has been eliminated entirely. You will have entered the “Initial Coverage” phase in which your elected drug plan will pay 65% of your applicable drug costs, and you will pay 25%. The Manufacturer (pharmaceutical company) will discount the remaining 10%. When you hit your maximum Out-of-Pocket (OOP) threshold of $2,000, you enter “Catastrophic Coverage”. At that point, your plan will pay 60%. Reinsurance (CMS, the Center for Medicare Services, i.e., the government) will pay 20%, and the Manufacturer will pay the remaining 20%. You will pay $0.

This, of course, sounds very well and good! And for those utilizing large quantities of drugs, or expensive drugs, this will indeed be of great benefit. But in what ways may the drug plans “compensate” for the additional costs they will bear? Much of such was referenced or alluded to above. However, please permit me to drill down on potential measures drug plans may take to offset their increased share of your drug cost. *(I am a Medicare Insurance product broker and not a C.P.A. As such, I will not address the impact on the taxpayer of their increased share of Medicare drug costs in this forum. wink. wink 😉

The drill down:

In addition to the higher deductible, higher premiums may be in store. But it could have been a lot worse. CMS did health insurance companies a favor with a “premium-stabilization” plan. In 2025, they will give them a subsidy in exchange for not “slapping members with exorbitant premium hikes. So, “what might have been a 40%, 50%, or higher premium increase may only be as high as 25%. Either way, it will be a sticker shock when some see how their premiums changed.” *(a paraphrase a quote in Feature Article 1)

The Kaiser Family Foundation says the average cost of a stand-alone Part D drug plan is $43. I have seen previews of premiums which will be $0, but others, have risen. In addition to your premium, co-pays for your drugs could go substantially higher. If your drug plan is obligated to charge you less for (or cover more of) a particular drug, are they simply going to charge you more for others?

And what about “Value Added Benefits” (VAB) available in some Medicare Advantage Plans? These include vision, hearing, and dental services. Other examples include acupuncture, bathroom safety devices, and wigs for hair loss. And what about your gym membership? Embedded dental insurance has been dramatically cut back or removed completely.

VAB are not covered by Original Medicare. Medicare Advantage has been able (often along with a $0 premium) to offer these things as an additional incentive to encourage enrollment in their plans. However, because you left Original Medicare and “assigned” the administration of your benefits and claims to the Advantage company when you enrolled, your plan can choose to provide these ancillary benefits that Original Medicare does not. Or they can choose to cover them no longer. This discretion is on their part because the provision of VAB benefits is not codified in law or per CMS regulation. Resultingly, they are not guaranteed. They are optional benefits that the plans have the right to withdraw at any time. I hope you can continue to “workout” at the gym, at your plan’s expense, in 2025 and beyond. But be prepared to purchase a home gym kit if you learn your membership is downgraded or your Advantage plan disappears entirely.

With no obligation, please feel free to contact me for clarification of these relevant issues and additional guidance in navigating the Medicare system and the changes referred to here. I’m in Medicare with you. I am a “Boomer” who has spent the better part of his life in the medical insurance market. For years, I have assisted individuals, families, and businesses in identifying and enrolling in health insurance plans that came as close as I could get them to fully meeting their medical insurance wants and needs.

To sum things up, I work for my clients. I work for you. Not the insurance company. I study, take their tests, and “certify” to represent their products each calendar year. I just completed certifying with approximately 14 companies in preparation for marketing their products in 2025. They do not pay to renew my licenses or my Errors and Omissions insurance, nor do they cover my office insurance and expenses. Neither they, nor anyone else, pay me wages or a salary. And that is great! I knew and understood those terms when I went out on my own. And that is precisely why I did it. I did not want to be beholden to the insurance company.

After becoming independent, the list of companies I was contracted with grew to over 40 during the 1990s. That number has changed as many of those companies went the way of the steam engine with “Obamacare” and all the red tape and regulations that come with it and remaining in the industry. But I persist. I remain positioned to provide you with virtually every available Medicare and health insurance product in your region.

In conclusion:

 If you’re reading this, chances are you remember Jim Rockford (a private detective, portrayed by the actor the late James Garner) in his TV show, The Rockford Files (you can hear the opening music now, can’t you?). In the prelude to each episode, you see his cassette recording answering machine and hear the message, “This is Jim Rockford. At the tone, leave a message …”. 

Should you get mine, please do the same. Or you may simply text me.

Donald Kenton Henry

Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com
Https://TheWoodlandsTXHealthInsurance.com
Https://Allplanhealthinsurance.com
Please follow me @ Https://HealthandMedicareInsurance.com

Leave a comment

********************************************************************************************

FEATURE ARTICLE 1

FORTUNE
Richard Eisenberg
Updated Mon, Aug 26, 2024

Why this year’s Medicare Annual Notice of Change will be vital reading for beneficiaries

In this article:

If you’re on Medicare, you’ll be getting one or two Annual Notice of Change letters in your mail or email this September about your 2025 coverage and costs. You may be tempted to ignore what looks like junk, as nearly a third of recipients do, according to an eHealth survey.

Don’t.

“So often, a person who is quite happy with their plan and doesn’t bother to look at their Annual Notice of Change then gets a nasty surprise in January” when the plan’s new costs and coverage kick in, says Danielle Roberts, author of 10 Costly Medicare Mistakes You Can’t Afford to Make and founding partner of Boomer Benefits, which sells Medicare policies.

What is an Annual Notice of Change?

An Annual Notice of Change from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan lays out how much your premiums, deductibles, and co-pays will differ in the year ahead and whether the plan will even be offered. (Medigap plans don’t send these notices because they don’t change much year to year.)

An Annual Notice of Change from your Part D plan also says whether your prescriptions will be covered and, if so, how much you’ll pay. A Medicare Advantage Notice of Change will tell you if your doctors and hospitals will remain in the plan’s network.

While this information is always essential to make smart choices during Medicare’s eight-week open enrollment period (Oct. 15 – Dec. 7), experts say reading your Annual Notice of Change is especially important in 2024.

“There is an excellent chance that something is changing on your plan,” says Roberts. “This year, more than ever, we can expect big changes in the plans.”

Surprising effect of the $2,000 prescription drug cap

That’s largely due to a major Medicare change coming in 2025: the new $2,000 cap on out-of-pocket costs for prescriptions covered by a Part D plan.

Since Part D health insurers will be on the hook for more prescription costs due to the cap, they’ll be looking for ways to compensate.

That could mean higher premiums (currently $43 a month for stand-alone plans, on average, according to KFF), deductibles, and co-pays—possibly substantially higher than in 2024.

“I have been very, very concerned about what the $2,000 cap was going to do to Part D premiums,” says Roberts.

The prescription drug change in 2025 could also lead to your Part D plan no longer covering certain medications you take or raising prices of ones it will.

Medicare Advantage plans—some facing profit squeezes currently—often include Part D coverage, so they may respond to the $2,000 cap by trimming or eliminating benefits to keep their popular $0 premiums intact, experts expect.

As a result, your Medicare Advantage benefits that original Medicare can’t offer—such as dental, vision, hearing, and gym memberships—could be less attractive than in 2024, or possibly gone entirely.

“It really will be important to understand what’s changing in the coming year in my current plan and does the plan still fit?” says eHealth CEO Fran Soistman. “Does it still provide the value that it did when I elected to go in it in the first place?”

Reading and understanding the Notice of Change

Your Annual Notice of Change will tell you—if you can understand it.

Only 36% of Medicare beneficiaries surveyed by eHealth said their Annual Notice of Change letter is “readily understandable.”

Figure on spending about 30 minutes closely reading your Annual Notice of Change to see exactly what will be different in 2025 and whether you’ll want to switch plans or coverage next year as a result.

During open enrollment, you can switch from your current Part D plan to another, from your Medicare Advantage plan to another, from Medicare Advantage to original Medicare as well as from original Medicare to a Medicare Advantage plan.

But don’t feel compelled to switch plans just because your Annual Notice of Change says your premium will go up a little or a benefit will be trimmed slightly.

“If there’s a modest benefit decrease or premium increase, but they’re satisfied with what the carrier is providing, people shouldn’t make a change,” Soistman says.

However, he added, if a medication you take will no longer be covered or your physician or hospital won’t be in network, that’s an important change that may persuade you to switch coverage.

The Medicare Plan Finder on Medicare’s site will let you compare Part D and Medicare Advantage plans for 2025.

And, as Philip Moeller writes in the forthcoming revised edition of his book, Get What’s Yours for Medicare, if your Medicare Advantage plan won’t include your favorite doctor or hospital in its network in the year ahead, it’s legally obligated to work with you to identify other physicians or hospitals in its network that you’d like.

A new program to help avoid big premium hikes

To help prevent drastic Part D premium increases, the government’s Centers for Medicare and Medicaid Services recently threw a bone to health insurers with a premium-stabilization plan.

Medicare will provide a special subsidy to those insurers for 2025 in exchange for avoiding slapping members with exorbitant premium hikes.

“It should take what might have been a 40%, 50%, or higher premium increase down to probably 25%,” says Soistman. “It’s still going to be a bit of sticker shock when some people see how their premiums changed.”

Roberts says, “I’m still somewhat concerned about premiums, but I feel a little better after the stabilization program announcement.”

Getting help if your Medicare plan will change

After reading your Annual Notice of Change, you may want to get help deciding on the right Medicare plans for 2025 and to understand the implications of coming changes to your plans.

You can ask a Medicare broker or agent for assistance; there’s a directory at the National Association of Benefits and Insurance Professionals site. The sooner you do, the better, since agents and brokers will be swamped near the end of open enrollment.

“At Boomer Benefits, we have to stop taking new requests after Thanksgiving,” says Roberts.

If one of your prescriptions won’t be covered by your Part D plan in 2025, call your doctor to see if another covered medication would be okay or if you should find a new plan that includes it, Roberts advises.

For information about Part D and Medicare Advantage plans without purchase recommendations, try your State Health Insurance Assistance Program or visit Medicare’s site or call Medicare’s toll-free number.

More time for open enrollment?

Soistman believes all the changes coming to Part D and Medicare Advantage plans for 2025 will push back the arrival of the Annual Notice of Change documents to the last two weeks of September.

If so, this will give people with the plans less time than normal to read the notices before open enrollment.

The eHealth agency has asked the Centers for Medicare and Medicaid Services to extend open enrollment by about five days to give beneficiaries, insurers, and Medicare brokers more time. Boomer Benefits favors the extension, too.

So far, the government hasn’t responded to eHealth’s proposal.

Could the 2025 open enrollment become Medicare’s equivalent of the Department of Education’s FAFSA financial-aid form fiasco of chaos and confusion?

“I don’t think it will be quite as drastic. I think it is going to be a year of change, though,” says Soistman. “And change is hard for people.”
*********
Please follow me follow D. Kenton Henry @ Https://HealthandMedicareInsurance.com

MAJOR CHANGES IN MEDICARE PART D DRUG PLANS ARE COMING OUR WAY (what we know. and one thing we don’t know)

Posted on by
Reply

Date: September 3, 2024

Editor, Broker, Agent – D. Kenton Henry             TheWoodlandsTXHealthInsurance.com; HealthandMedicareInsurance.com

Each year, our Medicare Part D Drug Plan and Medicare Advantage Plan owe us our Annual Notice of Change (ANOC). Your plan is obligated to have it to us by September 30th. Resist the temptation to ignore it, AS MAJOR CHANGES ARE COMING OUR WAY! Your ANOC will arrive by U.S. mail along with dozens of solicitations for our Medicare insurance business. So, watch for it and review it carefully.

These changes are credited to the Biden “Inflation Reduction Act.” On the surface, they will undoubtedly benefit many seniors using prescription drugs. What remains to be seen are the consequences beneath the surface. The first is … at what cost (premium)? Your current plan’s 2025 premium will be in your ANOC. But we will have to wait until October 1 to know what the alternative plans will cost. This begs the question—because of the additional cost of these mandated improvements in benefits—will all these 30 different plans and their companies even remain in the marketplace? And what if yours doesn’t?

Let’s address the upcoming changes in benefits:
We will begin with what your Medicare Part B premium to Medicare for Out-Patient Care will go to:
For those earning less than $105,000 your premium will go to $185.00 (up from $174.70)
For those in the highest income bracket, earning greater than $500,000 your premium will go to $628.90 (from $594.00)
For every income block in between, couples filing jointly, and what Part D premiums to Medicare will go to, please click on this link and scroll down: https://www.irmaacertifiedplanner.com/2025-irmaa-brackets/

Relative to Medicare Part D Prescription Drug plans, as is the case in 2024, there is no beneficiary cost sharing above the annual OOP threshold. That will be $2,000 in 2025. That’s down from $8,000 in 2024! The coverage gap phase (also known as the “donut hole”) will be eliminated, which will result in standard Part D coverage consisting of a three-phase benefit: a deductible phase, an initial coverage phase, and a catastrophic phase. The annual Part D Drug Plan deductible caps at $590, up from $545 this year.

Here is how the changes take effect for the coming calendar years.

  • 2025: The Inflation Reduction Act will lower out-of-pocket costs for Medicare Part D enrollees to a maximum of $2,000 per year. The Coverage Gap Discount Program will end and be replaced by the Manufacturer Discount Program. The standard Part D benefit design will also change to include three phases: deductible, initial coverage, and catastrophic coverage. The law will also require Part D plans to offer enrollees the option to pay for prescription drugs in capped monthly payments instead of all at once. 
  • 2027: Medicare will negotiate costs for 15 Part D drugs. 
  • 2028: Medicare will negotiate costs for 15 Part B and Part D drugs. 
  • 2029: Medicare will negotiate costs for 20 Part B and Part D drugs. 
  • Every year after 2028: Medicare will negotiate costs for 20 Part B and Part D drugs. 

IN REVIEW:

In 2025, Medicare Part D, the federal program that helps Medicare beneficiaries pay for prescription drugs, will undergo significant changes aimed at reducing out-of-pocket costs for seniors and improving access to necessary medications. These changes are part of the ongoing implementation of the Inflation Reduction Act (IRA) of 2022, which introduced sweeping reforms to the healthcare system, particularly in prescription drug pricing.

Key Changes in 2025

1. Introduction of a $2,000 Out-of-Pocket Cap

One of the most anticipated changes is the introduction of a $2,000 annual cap on out-of-pocket costs for prescription drugs under Medicare Part D. This cap will significantly ease the financial burden for many seniors who, in previous years, faced unlimited out-of-pocket expenses once they passed through the “donut hole” coverage gap.

This new cap means that once a beneficiary’s spending on covered drugs reaches $2,000 in a year, Medicare will cover the remaining costs, ensuring that seniors are not overwhelmed by high medication expenses.

2. Expanded Access to Low-Income Subsidies

Starting in 2025, eligibility for the Low-Income Subsidy (LIS), also known as “Extra Help,” will be expanded. Previously, this subsidy was available only to individuals with incomes up to 150% of the federal poverty level. In 2025, the threshold will be increased to 200% of the federal poverty level, allowing more seniors to qualify for additional financial assistance. This expansion is expected to help millions of low-income seniors reduce their prescription drug costs even further.

3. Price Negotiations for High-Cost Drugs

Another major change is the implementation of Medicare’s ability to negotiate drug prices directly with pharmaceutical companies. Starting in 2025, Medicare will begin negotiating the prices of 20 high-cost drugs that are covered under Part D. This is a historic shift in policy, as Medicare has previously been prohibited from negotiating drug prices.

The drugs selected for negotiation will be among the most expensive and widely used by Medicare beneficiaries. The goal is to bring down the cost of these medications, resulting in lower premiums and out-of-pocket costs for beneficiaries.

4. Elimination of the Coverage Gap (Donut Hole)

The infamous “donut hole” in Medicare Part D coverage will be fully eliminated in 2025. This gap in coverage previously required beneficiaries to pay a higher percentage of their drug costs after their spending reached a certain limit until they qualified for catastrophic coverage. With the donut hole’s elimination, seniors will no longer experience a sudden increase in out-of-pocket costs, making drug costs more predictable and manageable throughout the year.

5. Enhanced Catastrophic Coverage

In conjunction with the out-of-pocket cap, changes to catastrophic coverage will also take effect. Once a beneficiary’s drug spending surpasses the $2,000 threshold, they will enter catastrophic coverage, where Medicare will cover 100% of the drug costs for the remainder of the year. Previously, beneficiaries were still required to pay 5% of their drug costs even in the catastrophic phase.

Impact on Beneficiaries

These changes are expected to have a profound impact on Medicare beneficiaries, especially those with chronic conditions who rely on expensive medications. The $2,000 out-of-pocket cap, in particular, is seen as a game-changer, as it will provide financial relief to millions of seniors who previously faced unlimited costs for their medications.

The expansion of the Low-Income Subsidy will also bring much-needed assistance to a broader range of seniors, ensuring that those with limited financial resources can afford their prescriptions.

To further assist Medicare recipients with large prescription drug costs until such time as they have reached their $2,000 annual maximum out-of-pocket, Medicare is implementing the MEDICARE PRESCRIPTION PAYMENT PLAN (M3P), also known as the “Smoothing” because it allows Medicare Part D beneficiaries to pay their of Out-of-Pocket Prescription Drug Costs Over the course of the Year.”

Elements of M3P:

  • Monthly Installments: Starting in 2025, beneficiaries will have the option to spread out their out-of-pocket costs over the course of the year, rather than paying large sums at once when they fill prescriptions. This “smoothing” option is designed to make it easier for beneficiaries to manage their drug costs.
  • All Part D members will be eligible to opt into the program for 1/1/2025, regardless of low-income status.
  • Once opted into the program, members pay $0 at the pharmacy.
  • The drug plan will pay the pharmacy the cost of the drug in full along inclusive of the member’s cost share. The Medicare recipient will then pay their drug cost in monthly installments, billed by the plan, over the course of the year, using the Center for Medicare Services (CMS) prescribed payment methodology.  

As alluded to previously, these improvements in benefits will not be without consequences. While the 2025 changes to Medicare Part D are widely welcomed, they are not without controversy. In addition to potential increases in Part D and Medicare Advantage Part D premiums, some critics argue that the drug price negotiation process could lead to reduced access to certain medications if pharmaceutical companies decide to withdraw drugs from the Medicare program rather than negotiate lower prices. There are also concerns about the long-term sustainability of these reforms and their potential impact on the pharmaceutical industry’s ability to innovate.

Conclusion:

As 2025 approaches, Medicare beneficiaries should begin to familiarize themselves with these upcoming changes and how they may affect their prescription drug coverage. The enhancements to Medicare Part D reflect a broader effort to make healthcare more affordable and accessible for seniors, addressing long-standing issues in the system. While the full impact of these reforms will unfold over time, the changes in 2025 mark a significant step forward in improving the financial security and well-being of millions of Medicare beneficiaries.

For changes in covered and non-covered drugs, see Feature Article 1 below.

Please contact me directly with any questions or concerns as the details of changes to your current plan become available. I can help you review all the 2025 options available to you in the marketplace and would welcome you as a client. Remember, we can enroll in a new Part D Drug Plan for 2025 beginning 10/15/2024.

Donald Kenton Henry, Jr

Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com
Https://HealthandMedicareInsurance.com
Https://Allplanhealthinsurance.com

FEATURE ARTICLE 1:

Study Finds Drug Coverage Changes in Medicare Part D Plans

August 22, 2024

By Denise Myshko

Avalere’s Kylie Stengel talks about the regional shifts in formularies and utilization management in Medicare Part D prescription drug plans.

The number of both the standalone prescription drug plans (PDP) and the low-income subsidy (LIS) benchmark plans in Medicare Part D decreased between 2023 and 2024, according to a new review from Avalere.

Of the 801 prescription drug plans offered in 2023 across the United States, 95 were no longer offered in 2024, which is a decrease of 12%. Additionally, almost half of Medicare beneficiaries enrolled in the low-income benchmark plans were in plans that lost benchmark status, meaning enrollees had to choose a new plan or pay a premium in 2024.

“We did see a reduction in the number of PDP offerings in general, but this is really a significant decrease in specifically the LIS benchmark plan offerings,” Kylie Stengel, associate principal at Avalere said in an interview. “We do believe that is due to the changing market conditions under the Inflation Reduction Act, although not all of the IRA changes are in effect as of yet. These changes together have changed how plans thought about their offerings for 2024.”

The Inflation Reduction Act’s $35 cap on insulin out-of-pocket costs went into effect in January 2023. Next year will see two important elements of the Inflation Reduction Act being implemented: a $2,000 cap on out-of-pocket costs under Part D and the Prescription Payment Plan, sometimes called the “smoothing” program, where beneficiaries with Medicare Part D drug coverage will have the option to pay out-of-pocket costs in monthly payments spread out over the year.

Medicare Part D provides prescription drug coverage to supplement traditional Medicare or Medicare Advantage plans. In 2023, more than 50 million of the 65 million Medicare beneficiaries were enrolled in Part D plans.

Seniors with low incomes are eligible for prescription drug coverage from plans that meet a certain benchmark for no additional premium costs. The benchmark is the maximum premium that the Medicare program will pay for drug plan coverage.

“The benchmark is an enrollment weighted average in each region,” Stengel said. “CMS takes the average of all bids from both PDP and Medicare Advantage plans and sets a premium amount by region.”

In its analysis, Avalere assessed data from the Part D Public Use Files for 2023 and 2024 from the Centers for Medicare and Medicaid Services. This data contains information about formulary, cost sharing, and utilization management for Medicare prescription drug plans.

Avalere researchers looked at coverage changes and focused on 24 of the most used, single-source branded drugs in five therapeutic categories: anticoagulants; asthma/chronic obstructive pulmonary disease (COPD) autoimmune; multiple sclerosis and pulmonary hypertension. Avalere, however, is not releasing the names of the drugs they analyzed.

Researchers conducted two sets of comparisons. In the prescription drug plans, they looked at. Changes in formularies from 2023 and 2024 and the differences for plans that exited the market. They also assessed the low-income benchmark plans for whether they maintained benchmark status and the differences in formularies in plans that lost and plans that maintained benchmark status.

“When you look under the hood, when you look at specific therapeutic areas and regions, there is a lot of variability,” Stengel said. “When you’re looking across all drugs at a national level, you might not see a lot of change.”

One of the biggest areas to see change was the coverage of drugs to treat patients with pulmonary hypertension. In 2023, 39% of plans covered the drugs for pulmonary hypertension. In 2024, just 30% of plans did.

Avalere also found regional differences in coverage for some therapeutic areas. For example, coverage of drugs to treat patients with multiple sclerosis was lower among plans that remained in the market in 2024 in 11 regions but higher in 13 regions.

Avalere found that cost-sharing changes were limited for autoimmune, multiple sclerosis, and pulmonary hypertension drugs. However, use of coinsurance for anticoagulants and drugs that treat patients with asthma/COPD increased substantially for all prescription drug plan comparisons.

For the low income subsidy benchmark plans, there were regional differences on the utilization management used for the anticoagulant drugs. In five regions, there was a 20-percentage-point or more difference in utilization management among plans that lost benchmark status compared with plans that maintained benchmark status.

“It’s hard to know what factors are driving this; we didn’t do an assessment in terms of why there might have been a decrease in coverage for some of these therapeutic areas. But pulmonary hypertension is an area with a lot of higher cost drugs so we thought might expect there to more changes,” Stengel said. “Plans might be reacting to the elimination of patient cost-sharing to reduce their financial risk.”

But she said it may be too early to predict plan offerings for 2025. “I think we can expect potentially there to be less enhanced plans in the market just because the overall the basic benefit is a richer compared with previous years.”

Leave a comment