Medicare part D Prescription Drug Plan (PDP)

Introduction

Replaces Medicare Card. Effective January 2006. Medicare Modernization Act (MMA) approved in December 2003, created a federal Medicare-sponsored drug plan for senior citizens, called Medicare Part D.

Patients will obtain drug coverage from a private Prescription Drug Plan or a Medicare Advantage Rx drug plan.

ALL Medicare patients are eligible regardless of income.

Most elderly patients will pay about $37 per month in 2006, plus a $250 deductible & a % of their drug costs. Low-income seniors will pay less.

Senior citizens must enroll in order to get drug coverage. Initial enrollment was from Nov 15, 2005 thru May 15, 2006. Patients who turn 65 after the initial enrollment will have 7 months to sign up, starting 3 months before their birthday. People who wait until AFTER their enrollment period will pay more.

Patients on Medicare & Medicaid will obtain their drug coverage only through Medicare. Medicaid recipients will be randomly assigned a drug plan, unless they choose one.

Medicare recipients can change only during annual open enrollment.

Nursing homes may not support the patient's drug plan.

Coverage may include a donut hole (coverage gap) in which out of pocket payment is needed to cover expenses exceeding a threshold but lower than a fixed higher amount. In 2009 the coverage gap in some instances amounted to about $4000/year out of pocket expenses. Once the upper threshold is exceeded, Medicare Part D covers 95% of additional medication costs

Selection criteria:

• premiums:
  • $2-85/month + a copay (through 2008)
  • average of $28/month for 2009.
• benefits:
  • standard plan has $250 annual deductable, then
  • 75% of next $2000
  • no coverage $2250-$5100
  • maxium out of pocket payment of $4700 for prescription costs up to $6680
  • 95% of cost > $6680
• formularies
• convenience

Notes

• Federal law prohibits Medicare from negotiating with pharmaceutical companies for lower prices
• the Inflation Reduction Act includes a provision that allows Medicare to negotiate the costs of prescription drugs
  • the 1st 10 drugs selected for Medicare price negotiation include:
• Eliquis (apixaban)
• Enbrel (etanercept)
• Entresto (sacubitril/valsartan)
• Farxiga (dapagliflozin
• Imbruvica (ibrutinib)
• Januvia (sitagliptin);
• Jardiance (empagliflozin)
• Stelara (ustekinumab)
• Xarelto (rivaroxaban)
• insulin-aspart including Fiasp, NovoLog
  • other insulins?
• Medicare will negotiate prices for up to 60 drugs covered under Medicare part B & Medicare part D over the next 4 years 2023-2027, & up to an additional 20 drugs each year following that

More general terms

• Medicare

Additional terms

• Medicare card