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Latest news and updates about the Medicare and pharmacy industries.

2021 Medicare Changes

Posted on October 28, 2020 by Amplicare Team

Read on to see what major changes will apply to the 2021 plan year. We will update this post as more information becomes available.

Maximum copays for low-income full benefit dual eligible patients

  • 2020:
    • Full Benefit Dual Eligible: $1.30/ $3.90 copays
    • Full Benefit Dual Eligible or Full Extra Help: $3.60 / $8.95
  • 2021: 
    • Full Benefit Dual Eligible: $1.30 / $4.00
    • Full Benefit Dual Eligible or Full Extra Help: $3.70 / $9.20 

Standard minimum benefit changes

  • Maximum Deductible: The maximum deductible will increase by $20 to $435
  • Initial Coverage Limit: The initial coverage limit will increase by $110 to $4,130
  • Coverage Gap (brand-name drugs): Coverage for brand-name drugs will remain the same
    • 25% covered by patient, 5% by the plan, 70% by drug manufacturer
  • Coverage Gap (generics): Coverage for generics will increase by 12% for generics
    • 25% covered by patient, 75% by the plan
  • True-Out-of-Pocket (TrOOP) Threshold: The TrOOP threshold will increase by $200 from $6,550
  • Catastrophic Coverage (generics): 
    • Copays will increase slightly to 5% for drugs with a retail price over $74 and $3.70 for drugs with a retail price below $74 
  • Catastrophic Coverage (brand-name drugs)
    • Copays will increase slightly to 5% for drugs with a retail price over $184 and $9.20 for drugs with a retail below $184 

Beginning in 2021, the true out-of-pocket (TrOOP) threshold is increasing moderately from $6,350 to $6,550. This means patients will remain in the coverage gap ("donut hole") for a longer period of time before they transition to catastrophic coverage where their copays are minimal.

Get a printable infographic explaining the Medicare phases of coverage for 2021 — help educate your staff and your patients!

New Medicare Plans

  • SilverScript SmartRx is a new plan for 2021 with a monthly average premium of $7.38.
  • Indy Health SaverRx and Indy Health EliteRx are two new independent pharmacy friendly plans. They are available in Arkansas, Pennsylvania, West Virginia, Georgia, and Illinois. Health SaverRx is a benchmark plan ($0 premium for dual eligibles). Neither plan has DIR fees. 
  • Exemplar Health Basic (PDP) and Exemplar Health Enhanced (PDP) are new independent pharmacy friendly plans available in North Carolina and Texas. Both are benchmark plans ($0 premium for dual eligibles) and have no DIR fees. 
  • Troy Medicare: While not brand new (the plan was launched last year), the independent pharmacy friendly plan is available in four counties in North Carolina: Cabarrus, Iredell, Robeson, and Rowan. 

Network Changes

  • SilverScript Choice and SilverScript Plus are moving to the Aetna S2 Network.
  • Clear Spring plans moved from Elixir (Envision) to Express Scripts.
  • Express Scripts is the PBM for Prime Therapeutic plans.
  • Envision Insurance Company is rebranding to Elixir Insurance Company. The EnvisionRxPlus plan will be Elixir RxPlus. Note that CMS guidelines do not allow clients to be mapped into the new plan, therefore, all members will have to re-enroll in the Elixir RxPlus plan to retain their comparable low premium plan. Exceptions include members in NY, DC, MD, SC, and DE.

Ensure your patients have all the information they need this Medicare Open Enrollment. To learn more, watch our on-demand webinar "2021 Medicare Plan Network Changes" or schedule a consultation with one of our experts. 


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