Value-based Medication Management: New Ways to Help Patients with Medication Costs
Medication costs are an increasing problem for both patients and the health care system. From 2009 to 2018, the average price of a brand-name prescription more than doubled to over $350.1 Fortunately, there are some developments that can help lower your patients’ out-of-pocket medication costs and improve medication spend in value-based contracts.
Vaccines recommended by the Advisory Committee on Immunization Practices are now available with no deductible or cost-sharing.
Understanding Medicare Updates
The 2022 Inflation Reduction Act (IRA) includes several measures to help decrease medication costs for Medicare patients.2 Become familiar with how these changes can help your patients:
- As of January 2023, Medicare Part D insulin costs will be capped at $35/month. This is for all coverage phases (including the “donut hole” coverage gap), and any deductibles do not need to be met first:
- This applies to any formulary insulin product, including combination GLP1-RA/insulin products (Soliqua, Xultophy).
- The patient cost will be the same at both preferred and non-preferred pharmacies.
- Insulin administered via pump has historically been covered under Medicare Part B. Starting July 1, 2023, insulin for pumps will also be capped at $35/month.
- Vaccines recommended by the Advisory Committee on Immunization Practices are now available with no deductible or cost-sharing:
- This applies to adult vaccines covered under either Part B or Part D. Be aware
that administering Part D vaccines at a provider office may result in additional patient costs. - Part B covers influenza, pneumococcal, hepatitis B and any other vaccines used to treat injuries and exposures.
- Part D covers other vaccines used to prevent illnesses.
- Other changes to come that may help reduce costs include:
- Expanded eligibility for the low-income subsidy program (also known as LIS or Extra Help) starting in 2024.
- Decreased caps on out-of-pocket Part D costs for patients, leading to a $2,000 annual cap starting in 2025.
- Increased ability for Medicare to negotiate prescription drug costs and potential rebates for Medicare if medication price increases outpace inflation.
- Where to learn more:
- How the IRA affects Medicare: Inflation Reduction Act and Medicare | CMS
- FAQ on insulin cost-savings changes under the IRA: Frequently Asked
Questions about Medicare Insulin Cost-Sharing Changes in the Prescription
Drug Law (cms.gov).
Vaccines recommended by the Advisory Committee on Immunization Practices are now available with no deductible or cost-sharing.
Helping Patients Maximize Pharmacy Benefits
Both commercial and Medicare prescription insurance benefits are now offering more incentives to improve adherence and decrease costs. Help your patients get the most out of their pharmacy benefits using these tips:
- Does your patient have a preferred pharmacy?
- Out-of-network pharmacies can have elevated prices when compared to preferred pharmacies.
- Does their insurance offer mail order pharmacy services? Not only is it convenient for patients, it may also be lower cost than other pharmacies.
- Does your patient have a 90- or 100-day supply of medications?
- Utilizing extended day supplies for maintenance medications can reduce trips to the pharmacy and help with adherence.
- Some Medicare Advantage insurance companies will cover up to 100 days of medications in one fill at the same cost as a 90-day supply.
- Also consider providing 4 refills on prescriptions with extended day supplies. Not only does it help with adherence, it can cut down on patient calls to your clinic. Learn more about extended prescription duration in this American Medical Association article.
- Has your patient talked with their insurance?
- There may be other cost-savings benefits they don’t know about. Some companies offer free over-the-counter medications, general medication cost assistance programs, gift cards for groceries, or discounts on transportation.
- By calling the phone number on the back of their insurance card and asking for help with saving money, they can find out how to get the most of out of their pharmacy benefits.
References:
- Congressional Budget Office. (2022). Prescription Drugs: Spending,
Use, and Prices. https://www.cbo.gov/publication/57050. - Centers for Medicare & Medicaid Services. (2023, January 10).
Inflation Reduction Act and Medicare
https://www.cms.gov/inflation-reduction-act-and-medicare.