Another edition will come out mid October when 2023 plan information is available. So much MISinformation about the IRA (Inflation Reduction Act) in the public realm that is either incorrect or misleading, hopefully this will clarify.

The CMS No Surprise Act became effective 1/1/2022. In a nutshell, this is what it means to you  . .

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.

Notice the Act does not cover Medicare ADVANTAGE plans. You can still get surprise bills from non-par providers as well as claims submitted and DENIED by your Medicare Advantage carrier.

Many Advantage plans issued in Georgia (2022) limit your MOOP (maximum out of pocket) to $6700 per calendar year. This cap applies ONLY TO in network, approved claims. Out of network claims (from non-par providers) can increase your MOOP cap by several thousand dollars.

As mentioned in my last newsletter, effective 1/1/2023 . . . no copay for vaccines recommended by ACIP . . . this includes Pneumonia and Shingles vax. Some reports I have seen listed the date for this change as 2024. That is incorrect.

Prescriptions are not required for pneumonia or shingles vaccine.

Insulin - Effective 1/1/2023, insulin will be available with a $35 copay . . . check your PDP formulary to see which brand and type of insulin is covered. If you have a Medicare qualified CGM pump, the $35 copay is effective 7/1/2023.

Heads up - MOST of the changes (other than insulin and vaccinations) will not impact drug pricing until later years.

https://www.kff.org/medicare/issue-brief/how-will-the-prescription-drug-provisions-in-the-inflation-reduction-act-affect-medicare-beneficiaries/

Note, the $2000 OOP cap on Part D drugs does not kick in until 2025. Negotiated pricing for “certain high priced” drugs does not happen until 2026 and later. Also note that the current legislation does not apply to ALL drugs, only selected drugs. The IRA applies to 10 drugs in 2026, 15 drugs in 2027 & 2028, and 20 drugs in 2029 and later.

In the FWIW column, I recently saw a graph that accompanied an article extolling the virtues of the IRA and how this law will save “billions” for seniors on Medicare.

The graph shows how the cost of medicine has tripled since 2005, a year BEFORE Part D was available.

From a historical perspective, when health care (including Rx) is covered by insurance, underlying prices rise faster than general inflation rates. The economic explanation is this. When the consumer pays LESS out of pocket (due to insurance reimbursement), medical providers and manufacturers take that as an opportunity to implement price increases.

With regard to drugs, many consumers actually paid LESS for drugs, especially higher priced medications, prior to Part D implementation. There were more PAP (Patient Assistance Programs) before 2006 than after.

PAP provides DISCOUNTS for high priced drugs to a large number of seniors who are middle income and NOT COVERED by a Medicare Part D plan. Once Part D was available the number of people who qualified for discount coupons dropped. Part D will disqualify you from getting deep discounts on many medications.

Medicare Part D increased drug prices and eliminated many manufacturer discounts!

One report listed the top 5 drugs where Medicare spends the most money. While they are expensive, they are not the drugs with the highest price tag . . . merely ones that receive the most money from CMS.

To clarify, the most expensive drugs are rarely used, often as a last resort and generally only for a few months until the patient expires.

By comparison, the top 5 drugs that receive the most funding from Medicare are listed below. Price estimate is for one dosage (mg/number of pills) based on 2022 PDP pricing, using CVS pharmacy.

ELIQUIS 5mg/60 -  $141, SilverScript PLUS

REVLIMID 10mg/21 - $5,114, Elixir RxSecure

XARELTO 20MG/30 - $141, SilverScript PLUS

JANUVIA 100mg/30 - $141, SilverScript PLUS

TRULICITY 1.5mg pen (4 pack) - $141, SilverScript PLUS

Above pricing from Medicare.gov . . . which is notorious for being wrong, especially this time of year.

Using a more reliable drug plan finder (with weekly formulary updates) and got different results.

ELIQUIS - $47

REVLIMID - $6496

XARELTO - $47

JANUVIA - $47

TRULICITY - $47

All of the above (except Revlimid) are considered tier 3 with SilverScript PLUS, no deductible plan. Revlimid is tier 5.

What Revlimid Is Used For:

Treatment of Multiple Myeloma

Treatment of transfusion-dependent myelodysplastic syndrome (MDS) patients with deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.

Treatment of Mantle Cell Lymphoma (MCL)

Note: If a drug has been approved for one use, physicians may elect to use this same drug for other problems if they believe it may be helpful.

https://chemocare.com/chemotherapy/drug-info/revlimid.aspx

You have reached the end of this newsletter . . . almost . . .

The mid October letter SHOULD be less technical and have SOME specifics about 2023 drug plans.

I expect a LOT of changes for 2023 . . . higher plan premiums, higher co-pays and possibly fewer drug plans.

Many carriers will not be able to meet the deadlines for DC mandated changes and will possibly pull their plan off the market for next year unless modifications to IRA are made in the next few weeks.

Health insurance companies must revise Medicare Advantage and Part D materials to reflect the new law prior to the upcoming open enrollment period, which begins Oct. 15 and ends Dec. 7. Insurers must notify enrollees about the insulin and vaccine policies by Sept. 30 and distribute revised benefit summaries and update their websites by Oct. 15, CMS directs in the memorandum.

https://www.modernhealthcare.com/medicare/medicare-plans-must-update-materials-comply-new-law?

This is looking like a train wreck of the magnitude made possible by bureaucrats who have no understanding about how the real world operates.

Beam me up, Scotty!

Perhaps now you know why I call this the SAUSAGE edition . . .

The expression is, you don’t ever want to see how sausage (and laws) are made . . .

Please share this newsletter with your friends (if you dare). The next newsletter should come in MID October with more details about what to expect for 2023 drug plans.

Take care,

Bob

https://www.youtube.com/c/GeorgiaMedicarePlans

https://www.facebook.com/GeorgiaMedicarePlans/