Blog

Medicare Part D 2024

In this post, we will discuss some important information about Medicare Part D 2024.

Medicare Part D plans cover the cost of prescription drugs for Medicare enrollees.  Private insurance companies offer these plans to beneficiaries.   In order to remain complaint, all plan providers must follow CMS’ rules.

Prescription plan costs

There are a few costs associated with Medicare prescription plan coverage.  One of those costs include the monthly plan premium, this amount can range greatly depending on the plan and carrier.  Beneficiaries can opt to have the premium deducted from their monthly Social Security payment.  If the beneficiary has a greater than average income, they may be subject to an IRMAA, an adjusted premium amount based on income.  The premium may also be adjusted for those who have a lower-than-average income and qualify for Extra Help.

Other costs associated with Part D prescription are co-pays and coinsurance amounts paid at the pharmacy.  Many plans also include an annual deductible.  In 2024, the maximum annual deductible has increased from $505 in 2023 to $545 for 2024.

For those who neglect to sign up for a Medicare Part D plan on time, a late enrollment penalty is added to the monthly cost.  The penalty applies to anyone who goes without creditable Part D coverage for a period of 63 or more days.  CMS applies the penalty for as long as the beneficiary has Part D coverage.

Changes for Medicare Part D for 2024 

Because of the Inflation Reduction Act that was signed into law in 2022, there will be changes to the Medicare Part D program.   One important change has to do with the cost Medicare beneficiaries pay for prescription drugs.

 Click here to learn about prescription drug caps

Here are some of the changes in place for 2024:

In 2024, Medicare PDP members who reach the catastrophic phase ($8,000 in 2024) will not pay any additional out-of-pocket costs for the remainder of the year.  This means they are no longer subject to a 5% copay.

PDP plans are no longer able to raise their premiums over 6% per year starting in 2024.

Beneficiaries who use insulin will pay no more than $35 for a 1-month supply for covered insulin brands.  It is important to check your plan’s formulary to confirm which brands they include.  This pricing is in effect until the end of 2025.

Medicare covers many adult vaccines at no cost to Medicare beneficiaries.  this includes the Shingles vaccine as well as TDAP (tetanus vaccine), Covid, flu vaccine, Hepatitis A and many others.

More Medicare beneficiaries will qualify for Extra Help to pay for their health care needs in 2024. This is because beneficiaries with an income of up to 150% of the federal poverty level (up from 135% in 2023) may be qualified for the Part D Extra Help.  This program pays the Part D annual deductible, monthly premium and ensures beneficiaries pay a lower cost for generic and brand name drugs.

A few changes to prescription drug plans in 2025 and 2026

In 2025, one of the changes to the Part D program is a $2,000 out-of-pocket maximum in place for PDP beneficiaries.  CMS is also starting a prescription payment plan program.  The program is referred to as “smoothing” and begins Jan 1, 2025.  This program gives beneficiaries an opportunity the spread out the cost of prescription medications out over the year by using a payment plan.

Click here to learn more about the prescription payment program

In 2026 price negotiations will begin for expensive drugs that have no generic alternatives.

Learn the details of the price negotiation program

To view a comprehensive guide to all the ins and outs of Medicare for 2024, click this link and  download a copy of CMS Medicare and You handbook for 2024.    Information on Medicare Part D starts around page 79.

Watch a quick YouTube video on the drug cap proposed for 2025

Take a look at some of the other compliance updates CMS has in place or has proposed for agents :

Watch a quick YouTube video on the CMS proposed rule CMS 4205-P an how this could effect our business

Find out more about the 2024 CMS call recording requirements

Make sure you are up-to-date with the SOA rules – click here and learn more

Take a look at our video on TPMO rules for 2024

If you are unsure of the differences between an educational event and a sales event, click here.  You may also want to read our blog on “Things you can’t say when selling Medicare“.

If you already have a contract with Crowe and want to add a carrier, click here

Agents who want to join the team at Crowe, click here for online contracting

Please note: agents who offer Medicare Part D plans need to complete annual carrier certifications as well as AHIP before they can offer the plans.  AHIP is an annual certification that CMS requires.  It includes marketing and compliance guidelines as well as FWA laws.

If you don’t follow the Medicare marketing rules, you risk losing commissions, termination of your contracts, losing your license and receiving fines.

To view more images by this artist, click here

Wellcare prescription plans

Because the ability to access affordable prescription medications is crucial to maintaining good health, beneficiaries must be aware of all their options.  In order to help individuals make an informed decision, we will discuss some benefits of the WellCare prescription drug plans.

Important; CMS has guidelines in place to regulate the types of medications that prescription drug plan providers must cover.  This includes a minimum standard of benefits for providers to follow. The formulary for each plan Each plan meets the requirements as required by law. Because each plan differs, the cost and drugs included in the formulary can vary.

Find out about the Medicare drug price negotiations

Although Wellcare offers three different plan choices, it is important to review each plan formulary and make sure it provides coverage to fit the prescription needs for anyone considering enrollment.

The three Wellcare PDP plans for 2024

Some features of the Wellcare prescription plans

Wellcare has no or low premium plans available to provide coverage for individuals who qualify for Extra Help.  These plans are available in all states and offer low or no copays when enrollees purchase prescriptions from preferred pharmacies.

Some Wellcare plans include no deductible, so plans cover prescriptions on day one.

Wellcare has a nationwide network of preferred pharmacies that includes thousands of national, regional and local pharmacy chains. It also includes grocers and independent pharmacies as well.  These relationships help plan members save money on prescription drugs.

Use this link to the Wellcare preferred pharmacy tool and find a local in-network pharmacy.

Find a preferred pharmacy tool to find a local pharmacy.

The member service representatives are available either online at wellcare.com/PDP or by phone at 866-822-1339 (TTY – 711) during the hours of 8am – 8pm EST Monday – Friday. They can provide answers to members coverage or medication questions.

If you want to view the plan formulary (complete list of drugs each plan covers), visit Wellcare’s website or contact their member services department.

Aetna SilverScript

For Medicare beneficiaries who are on Original Medicare or Original Medicare and a Medicare Supplement plan, it is a good idea to add a Medicare prescription drug plan to cover your prescriptions. One prescription drug plan that provides coverage to many beneficiaries is the Aetna SilverScript Plan.  In this post, we will go over some of the benefits these plans provide.

Aetna SilverScript Overview

Aetna SilverScript is a Medicare prescription drug plan provider.  It is part of the Aetna family of medical insurance plans. These plans are designed to work with Original Medicare or Medicare supplement plans and cannot be sold to anyone who is currently enrolled in a Medicare Advantage plan and wants to remain on that plan.

Eligibility for prescription plan enrollment

In order for a beneficiary to eligible for enrollment in any PDP plan, they must be enrolled in either Medicare Part A or both Medicare Part A & Part B.  Beneficiaries must also live in the service area of the plan they want to enroll in.

There are specific times you must use to enroll in a Medicare prescription drug plan (Part D).

1. During your initial enrollment period (IEP).
2. Enroll during the Annual Election period (AEP).
3. If you have a Medicare Advantage plan, you can enroll during the Medicare Advantage Open Enrollment Period (MAOEP).
4. When you qualify for a special election period (SEP).

Learn more about Medicare’s enrollment periods

Aetna SilverScript plans

In 2024, Aetna is offering 3 different plan choices:

1. First, the SilverScript Smart Saver plan – This plan has an average monthly premium of $11.19, Please note, this cost is an average.  Actual cost depends on the service area. This plan offers a $0 copay for a 30-day supply of Tier 1 drugs.   There are almost 600 drugs that fall into Tier 1 and Tier 2 on this plan, drugs on tier 2 have a copay amount of $5.  The SilverScript Smart Saver plan also provides members a low deductible of $280 for Tier 2 through Tier 5 drugs.
2. Second, the SilverScript Choice plan – Members of this plan pay an average monthly premium of $46.59.  Please note, this cost is an average and the actual cost depends on the service area.  There is a $545 deductible applied to all tiers of this plan.  The copay amount for Tier 1 drugs is $2 while the Tier 2 copay amount is $7.  Beneficiaries who qualify for Extra Help do not have to pay a plan premium.
3. Third, the SilverScript Plus plan – The premium for this plan averages $103.51 although the actual amount varies depending on the service area.  This is a top-notch plan that offers members a $0 deductible for both Tier 1 and Tier 2 drugs.  On this plan, there is a $0 copay for many prescription vitamins, minerals and some other types of drugs. members also receive additional gap coverage.

Watch a video on Drug plan changes for 2024

Features of Aetna SilverScript PDP plans

Variety of Plans

Aetna offers a wide range of prescription drug coverage options.  This allows beneficiaries to choose a plan that aligns with their personal needs and budget.  Each plan covers different medications at varying costs.

Extensive Network of Pharmacies

All Aetna SilverScript plans offer an extensive network of pharmacies.  This gives beneficiaries the flexibility and convenience to choose where they fill their prescriptions.

Mail-Order Options

The Aetna SilverScript plans provide the option for mail-order prescriptions, allowing beneficiaries to receive a 90-day supply of their medications conveniently delivered to their door.

Members of Aetna SilverScript PDP plans can visit AetnaMedicare.com to access and print plan materials, pay their plan premiums, check coverage of their drugs or locate a local, preferred pharmacy.

Aetna also provides members a secure site, Caremark.com, to find prescription prices, see possible prescription savings options, sign up for mail delivery, check order status and more.

Click here to learn why you should use a Medicare agent

To see if these plans are right for you, check with a licensed Medicare agent who can ensure your coverage needs are properly met by either these plans or another one.

If you would like to view more images by this artist, click here

Medicare drug price negotiations

Because of the high cost of some prescription drugs for Medicare beneficiaries, the CMS has announced the first 10 drugs that will be subject for Medicare drug price negotiations.  The negotiations are part of the Inflation Reduction Act.  Up until recently, Medicare has been able to negotiate prices for medical care beneficiaries receive but this did not include the costs of medications.  This is about to change when the negotiated prices go into effect as of 2026.

Watch a quick video on the Medicare Part D changes 

Medicare will negotiate with drugmakers over the cost for the some of the most expensive medications and does not apply to drugs that have a generic alternative.  The first 10 medications chosen for negotiations are:

1. Eliquis (a blood thinner)
2. Enbrel (for rheumatoid arthritis)
3. Entresto (for heart failure)
4. Farxiga (for diabetes, heart failure & chronic kidney disease)
5. Fiasp & Novalog (for diabetes)
6. Imbruvica (for blood cancers)
7. Januvia (for diabetes)
8. Jardiance (for diabetes)
9. Stelara (for psoriasis & Chron’s disease)
10. Xarelto (a blood thinner)

According to the CMS, the 10 drugs above accounted for 20% of the Medicare Part D spending ($50.5 billion) during the period from June 2022 through the end of May 2023.  Part D of Medicare covers prescriptions taken by beneficiaries at home.  It does not cover medications administered by medical providers in medical facilities for treatment of things like cancer or other health conditions.  In these situations, Medicare Part B covers the necessary drugs.

Click here to read the drug price negotiation fact sheet 

Medicare beneficiaries spend billions of dollars for prescription drugs

Because of the high cost of some essential medications, beneficiaries sometimes have to either limit basic needs or go without the drugs that help maintain their quality of life.  All the while, drug manufacturers rake in record setting profits.

These 10 drugs are just the beginning

This list of 10 drugs is just the starting point.  In 2027 Medicare hopes to add 15 more drugs and even more in the years that follow.  This list will grow each year as long as the drug manufacturers are unsuccessful in their attempts to stop the drug cost negotiations.

Find out about the Medicare prescription payment program.

What will drug manufacturers do

If the drug companies do not agree to the negotiations, they face possible tax penalties.  Drug manufacturers can avoid the tax penalty if they remove their drug from the Medicare market.  However, if they do that, they will take lifesaving drugs from Medicare beneficiaries as well as lose a large part of their market share.

Some large drug companies are seeking legal counsel to stop the drug price negotiations.  They argue that the loss in income will affect their ability to fund necessary research and development and that in turn will reduce their ability to produce new medical treatments.

Click here to view more images by this artist

Medicare prescription payment plan

The Medicare prescription payment plan is also referred to as “smoothing“. This is a way to help Medicare beneficiaries pay for the high cost of prescription medications.  The Medicare prescription payment plan is one small part of the inflation reduction act of 2022.

Watch a quick YouTube video on potential changes to commissions in 2025

When will the program start

In 2025, Medicare Part D (PDP) plan enrollees have a chance to opt for a prescription payment program.  The plan will help beneficiaries pay out-of-pocket costs for prescriptions.  Everyone in a PDP plan has a chance to enroll in the payment program, it is not based on income.  Enrollees have the option to enroll before the plan year starts or during any month of the year.   Please note, the payment plan does not include plan premium payments.

Here are some of the details

Participation in the Medicare prescription payment plan is optional.  PDP plan enrollees must choose to be part of the program.  Once an enrollee joins the program, and has out-of-pocket prescription costs, they receive a monthly bill to cover those costs.  Any out-of-pocket costs for prescriptions are included even during the deductible phase of PDP coverage.  There is no minimum out-of-pocket amount required before anyone can join.  Participants receive a monthly bill as long as they remain part of the program.

How is the monthly payment amount decided

There will be an annual cap of $2,000 on out-of-pocket costs in 2025.  The amount each beneficiary pays for their monthly plan depends on a few different factors.  It is not as easy as dividing $2,000 over the course of 12 months.

Learn more about the Part D drug cap

1. The Medicare prescription payment plan will deduct the out-of-pocket amount beneficiaries have already paid before enrollment in the program.
2. Any remaining costs are then divided by the number of months left in the year.

CMS will create a payment calculator so Part D beneficiaries can decide if enrolling in the payment plan is a good idea or not.

CMS is still working out the details of this program

We do not know exactly how the prescription payment program will work yet because the details have not been finalized by CMS yet.  We will post additional details as they are available to the public.

Please note:  This program is set to start in 2025, the same year the annual drug cap will be set at $2,000.  In other words, no Part D enrollee will pay more than $2,000 out-of-pocket for their prescriptions.

To view more images by this artist, click here

Choosing Medicare Drug Coverage

There are many things to consider when choosing Medicare drug coverage (Medicare Part D).  This is a very important decision that can cost you quite a bit if you are not careful.

Steps to help you choose the best Medicare drug coverage to fit your needs:

Decide what your medication needs are.

Make a list of all your current medications.  It is important to include the dose and how often you take them.  It is also important to consider which pharmacy you will use. Each plan has a list of preferred pharmacies that offer you a lower cost share when you use them.  You may also need to consider medications your doctor may add to your list in the near future.

Review your current coverage.

If you are new to Medicare and decide to go with Original Medicare (Part A and Part B), you need to purchase a stand-alone prescription drug plan (Part D).   Alternatively, you might opt for a Medicare Advantage plan (Part C) that includes prescription drug coverage.  These plans are referred to as MAPD plans.

If you already have either a Part D plan or an MAPD plan, you should review your plan’s Annual Notice of Change (ANOC) or Evidence of Coverage (EOC) document each year.  These resources will provide valuable notice of any changes in coverage, costs, or formulary for the upcoming year.

Know the Medicare enrollment periods.

It is important that you understand when you can enroll in a PDP plan.  For most people there are 2 main enrollment periods.  The initial Enrollment Period (IEP) occurs when you first become eligible for Medicare. It typically starts three months before your 65th birthday, includes your birth month, and extends for three months afterward.  Each year, The Annual Enrollment Period (AEP) Starts Oct 15 and runs until Dec 7 .  During this time, you can make changes to your Medicare coverage.

There are also some SEPs (Special Election Periods) where you can make changes to your plan.  Click here to learn more about SEPs.  

Please note; certain individuals who have a qualifying disability also have the option to enroll in a Medicare Part D (PDP) plan.

Compare the plan’s total cost.

Because there are many factors that make up the total cost for a Medicare plan, it is important to consider the plan premium, the cost of your medications, deductibles, copayments and co-insurance.  You also need to be aware of the coverage gap and catastrophic coverage thresholds, as these may affect your total out-of-pocket costs.

There are a couple ways to compare plan costs.  One of the best ways is to locate a licensed Medicare agent who is certified to offer plans from a variety of local carriers.  Agents should have access to online quoting tools that can show you plan comparisons. Comparisons include a cost breakdown of each prescription as well as plan premiums and other coverage information.  Agents are a great free resource.  They can help advise you on how coverage works and which plan will suit your personal needs.

Click here to view our YouTube video of Sunfire vs. Connecture Medicare quoting sites

You can also do a plan quote on your own by visiting medicare.gov and using the plan finder.  This is a free resource although, it does not offer a consultation like an agent can.

Consider each plan’s star rating.

Each year, Medicare provides star ratings for both PDP plans and MA/MAPD plans.  These ratings are based on many factors  and have a scale from 1 to 5 stars.  A rating of 1 is the lowest and 5 is the highest ranking.  Each plan is rated on the quality of the plan which is decided by customer satisfaction of care and customer service provided.

Remember:

Over time, both medication needs and health status changes; it is important to review your Medicare drug coverage each year during AEP.  This will help you prepare for the year ahead and keep costly surprises to a minimum, although none of us has a crystal ball.

Click here to fill out an online contract with Crowe and Associates

To view more images by this artist; click here.