Pharmacy Times

Medicare Part D Drug Plans: Counseling With a Moving Target

Author: Jeannette Y. Wick, RPh, MBA, FASCP

Patients are likely to be confused by the various Medicare prescription drug plans available to them as well as the year-to-year coverage changes, but the basics are reasonably straightforward.

Medicare Part D: Just when you thought you knew the ins-and-outs of this program, along came the Affordable Care Act (ACA) to usher in some subtle changes!
Created in 2003, Medicare Part D was designed to help the ever-growing number of Medicare beneficiaries deal with prescription drug costs. The basics, if you take the time to understand them, are reasonably straightforward:
Simple, yes? The situation only gets more complicated if the Medicare beneficiary is a dual eligible (covered by Medicare and Medicaid), has been approved for Special Help from Medicare, is in a retiree plan, or falls into any other category of exception. To navigate Medicare and Medicaid reimbursement processes for prescription medications as a pharmacist, you need an excellent software vendor who has a flexible program, updates software often, and provides exemplary customer service. More information is available at
Since we’ve passed the mid-year point, we—and our technology vendors—need to be looking forward to 2014, when some changes will go into effect. The deductible will fall to $310. Beneficiaries will enter the coverage gap when their spending combined with that of their prescription drug plan reaches $2850. This entry point is $120 lower than the 2013 threshold, so patients will hit the “donut hole” sooner. Many seniors will be surprised or confused, especially since the ACA is gradually closing the coverage gap so it disappears in 2020.
The coverage gap entry point is unrelated to the ACA. CMS determines it using a formula tied to per-capita total Part D drug expenses, which declined 4% last year. The ACA, however, determines the out-of-pocket maximum. It will decrease by $200 in 2014 to $4550. In sum, the coverage gap will shrink by $80.
But let’s return to a key concern for community pharmacists: Patients find Medicare Part D confusing. Recent well-publicized reports from CMS indicate that “prices are sometimes higher in certain preferred networks,” compared with traditional plans that offer patients greater choice, and because enrollment in such plans has increased, “the impact of higher preferred network prices on the program as a whole is likely to become increasingly significant.” Patients, understandably, may be confused by the choices they need to make and may turn to their pharmacists for help.
A patient’s choice of Medicare Part D plans depends on their location, and a suitable plan must be chosen based on the patient’s individual drug regimen. Medicare's official website features an online service called the Prescription Drug Plan Finder to help patients choose a plan. Despite the tool’s simplicity, many beneficiaries have trouble using it. Patients who are not computer savvy can also call Medicare at 1-800-MEDICARE (800-633-4227).
When beneficiaries ask for help, pharmacists should keep the following points in mind:
Consider joining CMS’s Pharmaceutical, Pharmacy, and Device Manufacturers Open Door Forums, which address practicing pharmacists’ concerns regarding serving Medicare and Medicaid beneficiaries. In addition, CMS’s Medicare Learning Network provides online training, education, and information for health care professionals.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.