2019 Medicare Changes

Open Enrollment is upon us! The Amplicare team analyzed the data surrounding next year’s plans and industry updates and have identified key changes that you and your patients will want to be aware of this Open Enrollment.

Industry Updates¹

• Enrollment periods for low-income, full-subsidy beneficiaries: Starting in 2019, dual-eligible patients (patients on both Medicare and Medicaid) will only be permitted to change their Medicare plan once every quarter from January to September. This is a big change from the previous regulation, allowing such patients to change plans once a month.  
• Maximum copays for low-income, full-subsidy beneficiaries: In 2019 maximum copays will increase for dual eligible patients by 5 cents, to $3.40, for generic/preferred, multi-source drugs. Maximum copays will increase by 15 cents, to $8.50, for all other drugs.

You can learn more about dual-eligibility by clicking this link.

Standard Minimum Benefit Changes²

• Maximum Deductible: The maximum deductible will increase by $10, to $415, in 2019.
• Initial Coverage Limit: The initial coverage limit will increase by $70, to $3,820, in 2019. When the initial coverage limit is reached, the patient will enter the Donut Hole.
• True-Out-of-Pocket (TrOOP) Threshold: The TrOOP threshold will increase by $100, to $5,100, in 2019. When this limit is reached, the patient will exit the Donut Hole.
• Donut Hole Coverage (brand-name drugs): Coverage during the Donut Hole for brand-name drugs will increase by 10%, to 75%, in 2019.
  • This means Medicare Part D enrollees will have to pay 25% of the total cost for their brand-name drugs purchased while in the Donut Hole. 
  • The 75% coverage includes a 70% “discount” paid by the brand-name drug manufacturer (an increase of 20%, compared to 2018), with the Medicare Part D plan covering the remaining 5% (a decrease of 10%, compared to 2018). 
  • The 70% paid by the drug manufacturer, combined with the 25% paid by the patient, counts towards the TrOOP threshold. 
• Donut Hole Coverage (generics): Coverage during the Donut Hole for generics will increase by 7%, to 63%.
  • This means Medicare Part D enrollees will have to pay 37% of the total cost for their generic drugs purchased while in the Donut Hole.
• Catastrophic Coverage: Copays may increase slightly to the greater of 5% or $3.40 for generic/preferred, multi-source drugs, and the greater of 5% or $8.50 for all other drugs in 2019.

Click here for a printable infographic explaining the Medicare phases of coverage for 2019 -- help educate your staff and your patients!

New Medicare Plans³

• Aetna Medicare Rx Value Plus PDP
  • Enhanced plan with a higher premium and no deductible.  
• Silverscript Allure PDP
  • Available in all states except Alaska.
  • Enhanced plan with higher premium than Silverscript Plus, no deductible. 
  • Same formulary as Silverscript Plus. 
  • Unlike Silverscript Plus, offers no gap coverage. 
  • This plan is being marketed as a good option for patients on higher tier brand medication due to “point-of-sale rebates, where a portion of pharmaceutical manufacturer rebates on certain Tier 3, Tier 4, and Tier 5 brand drugs are applied directly to the drug's price.”
  • It appears to have lower brand reimbursements at POS than Silverscript Plus.
• Wellcare Value Script PDP
  • New plan in most states -- was only available in Wisconsin, Louisiana, Arizona, Oregon, and Washington in 2018
  • Enhanced plan with a premium of $17 or less in all states where it is available. 
  • High deductible at $415, but Tier 1 and 2 drugs are excluded from the deductible, patient will immediately pay initial coverage copays for these tiers.
• Cigna Healthspring Rx Secure - Essential PDP
  • Enhanced plan with a lower premium but a restricted formulary. 
  • High deductible at $415, but excludes Tier 1 and 2 drugs.
• Mutual of Omaha Rx Plus (PDP)
  • PBM is ESI, BIN 610014. 
  • Standard plan, higher premium, broad formulary. 
  • $415 deductible, which applies to all tier drugs. 
  • Does not qualify as a “benchmark” plan in any state, due to the high premium.
• Mutual of Omaha Rx Value (PDP)
  • PBM is ESI, BIN 610014. 
  • “Skinny” enhanced plan -- lower premium, but a restricted formulary.  
  • Because part of the premium is supplemental, not the standard benefit, does not qualify as a benchmark plan despite the low monthly premium. 
  • High deductible at $415, excluding Tier 1 and Tier 2 drugs.
• Journey Rx Standard (PDP)
  • PBM is Caremark, BIN 004336. 
  • Basic plan, $415 deductible, benchmark plan in all 9 states where it is available. 
  • Available in California, Iowa, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. 
  • Same plan sponsor as Basic Blue plans (MII Life Insurance). 
• Journey Rx Value (PDP)
  • Caremark plan, BIN 004336.
  • “Skinny” Enhanced plan, low premium, $415 deductible. 
  • Available in California, Iowa, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. 
  • Same plan sponsor as Basic Blue plans (MII Life Insurance).
• CommunityCare Prescription Drug Plan (PDP)
  • PBM is Caremark, BIN 004336. 
  • New benchmark PDP for 2019 only available in Oklahoma. 
  • Basic plan with $28 monthly premium and a $415 deductible for non-LIS patients. 
  • $0 copays on Tier 1 drugs at preferred pharmacies.

Name Changes and Discontinued Plans³ 

• Symphonix Value Rx PDP
  • All patients currently enrolled in this plan will be automatically transferred to AARP MedicareRx Saver Plus (PDP) in 2019 if they don’t enroll in a new plan.
• First Health Value Plus and First Health Premier Plus PDPs
  • All patients currently enrolled in these plans will be automatically transferred to Aetna Medicare Rx Value PDP in 2019 if they don’t enroll in a new plan.
• Care Improvement Plus MA-PDPs and SNPs are becoming UnitedHealthCare plans.

Regional Plan Changes³

Michigan

• All patients currently enrolled in Prescription Blue Option A PDP will be automatically transferred to Prescription Blue Select PDP in 2019 if they don’t enroll in a new plan.
• All patients currently enrolled in Prescription Blue Option B PDP will be automatically transferred to Prescription Blue Premium PDP in 2019 if they don’t enroll in a new plan.
• All patients currently enrolled in Basic Blue Rx PDP will be automatically transferred to Journey Rx Standard PDP in 2019 if they don’t enroll in a new plan.

Alabama and Tennessee

• All patients currently on BlueRx Option I will be transferred to BlueRx Essential PDP in 2019 if they don’t enroll in a new plan.
• All patients currently on BlueRx Option II will be transferred to BlueRx Enhanced Plus PDP in 2019 if they don’t enroll in a new plan.
• There is another new plan for 2019 in AL and TN called BlueRx Enhanced PDP. 

Kansas

• All patients currently on Blue MedicareRx Premier PDP will be transferred to Blue MedicareRx Value PDP in 2019 if they don’t enroll in a new plan.

Virginia, Colorado, Ohio, Indiana, Wisconsin, New Hampshire, Maine, Kentucky BCBS

• All patients currently on Anthem Blue MedicareRx Premier PDP will be transferred to Anthem Blue MedicareRx Standard PDP in 2019 if they don’t enroll in a new plan.
  • The PBM is ESI, BIN 003858, PCN MD.

 Missouri BCBS

• All patients currently on Blue MedicareRx Premier PDP will be transferred to Blue MedicareRx Value PDP in 2019 if they don’t enroll in a new plan.
  • The PBM is ESI, BIN 003858, PCN MD.

California BCBS

• All patients currently on Anthem Blue Cross MedicareRx Gold PDP will be transferred to Anthem Blue Cross MedicareRx Standard PDP in 2019 if they don’t enroll in a new plan.

Georgia BCBS 

• All patients currently on BCBSGa Blue MedicareRx Premier will be transferred to Anthem Blue MedicareRx Standard PDP in 2019 if they don’t enroll in a new plan.
• All patients currently on BCBSGa Blue MedicareRx Standard PDP will be transferred to Anthem Blue MedicareRx Standard PDP in 2019 if they don’t enroll in a new plan.
• All patients currently on BCBSGa Blue MedicareRx Plus PDP will be transferred to Anthem Blue MedicareRx Plus PDP in 2019 if they don’t enroll in a new plan
• For all plans above, PBM is ESI, BIN 003858, PCN MD.

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¹ https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-policy-changes-and-updates-medicare-advantage-and-prescription-drug-benefit-program

² https://q1medicare.com/PartD-The-2019-Medicare-Part-D-Outlook.php

³ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Plan-Crosswalks-Items/2019-Part-CandD-Plan-Crosswalk.html