Who to trust on RX comparisons

[DS4]

I am turning into not being a big fan of cutting pills in half

Amazon product ASIN B001KYVO78

 

[somarco]

Without going back and researching, the $2k cap, if ever implemented, will probably have a yearly "inflation adjustment".

 

[gregj]

if ever implemented.

what's the adoption barrier?

seems pretty tame budget-impact-wise, and popular on balance

 

[kgmom219]

My short reply is "I don't know"

My longer answer is I don't imagine it would be an explicit, formulaic combination - more some kind of actuarial acknowledgment that in '25 the Rx share of plans' spending suddenly jumps up.

Feels like somewhere there's probably some data that suggests what share of beneficiaries currently take a dollar volume of meds that would push them above a $2k cap, which would permit some spitballing on the distribution of the $ we're talking about. I've been too lazy to look but it's probably somewhere associated with the measure that implemented that cap...who knows, the forecast may be much lower than I'm currently imagining....

EDIT: sure enough, the forecast impact is lower than I was imagining. This 8/18/22 Kaiser Family Foundation piece provides some details (about 1/2 way down).

I already told Juliana and Tricia at KFF that I hope they are right but think they are wrong.

We are already seeing it at Aetna. There's a base plan with a great premium and formulary for T1's. And in most areas that means they will get the low income people. (And note that they stopped paying commission on it, too)

The premiums won't increase due to the IRA, but what they can (and will) do is tighten up the formularies. Most of the carriers offer at least 2 or 3 Part D plans. They will have a base plan with an incredibly low premium combined with a very tight, closed formulary. Then the 2nd or 3rd option will be a $100 premium with low or $0 deductible and a decent formulary. All those people we are seeing on Eliquis or Xarelto? They'll be paying $100 a month premium in 2025.

 

[somarco]

All those people we are seeing on Eliquis or Xarelto? They'll be paying $100 a month premium in 2025.

Unless they order from Canada or qualify for a PAP.

I am finding more PAP's expanding their qualifying requirements and no longer exclude those with a Medicare PDP. There is an attestation form as part of the application where you agree to not try and use your PDP plus the PAP.

Many of the PAP's send your meds to your doc, although some will deliver to your home.

I haven't used NeedyMeds.org in years but starting to refer folks to them more than in the past. So far I have clients approved for help with Vemliddy, Januvia and Xarelto.

 

[LostDollar]

I am finding more PAP's expanding their qualifying requirements and no longer exclude those with a Medicare PDP. There is an attestation form as part of the application where you agree to not try and use your PDP plus the PAP.

@fed up posted in another thread about a PAP for trulicity. Just looking on Lilly's website,
they appear to accept patients with Part D plans if the patients meet Lilly's income guidelines. they appear to have three categories of medicines with different FPL income limits for each category.

The Lilly website also shows this link where people who are not eligible for Lilly's assistance program can look to see if they can obtain some help elsewhere. I can't evaluate or keep track of this stuff so I'll put the link here so others can keep track of it if it is useful.

[EXTERNAL LINK] - Medicine Assistance Tool

 

[gregj]

note that they stopped paying commission on it, too)

the detectable uptick in non-commissioned plans, for whatever reasons, probably deserves its own thread ....

I think you're right about Rx plan designs likely moving to greater low-high 'separation' & narrower formularies. GoodRx, Mark Cuban, Singlecare et al also seem interested in continuing to elbow MAPD & PDP plans aside at the pharmacy register.

 

[DS4]

the detectable uptick in non-commissioned plans, for whatever reasons, probably deserves its own thread ..

I predict, going forward, more and more plans will be non-commissionable

 

[somarco]

I predict, going forward, more and more plans will be non-commissionable

And no more "deductible exempt" meds

 

[steveadlman]

In my state (Alabama), drug coverage with Advantage plans has a much lower deductible and lower copays. It seems the stand-alone PDP's are subsidizing drug coverage with MAPD's.