I am not sure what this really means, but if the PBM has anything that resembles a “free hand” in setting up out-of-pocket costs for Medicare Part D programs, it will be the pt that gets financially screwed and the PBM industry will prosper financially. Barb has been Part D prgm since they started in 2006 and has a ZERO DEDUCTIBLE from the beginning. Over the last few years, ours and most Part D prgms have implemented $500+/yr deductibles and the annual deductible now exceeds the total of the monthly premiums. Over just a few years, our out-of-pocket for premiums and deductibles has OVER DOUBLED. With next year’s out-of-pocket limited to $2,000, could we see a dramatic increase in premiums, deductibles, prescription prices and the copay tier of many meds being moved up to higher tiers? Meaning that the PBM industry will be generating more profits from pts because the spread pricing between a lower tier and upper tier will go directly to the PBM’s bottom line. I just checked what our out-of-pocket for Rx copays and deductibles was for 2021 & 2022 was < $1000 each. It would probably be pretty easy for our Part D to raise our deductibles and tier level on all our Rxs to push our out-of-pocket an extra $500/yr for each of us… all that would drop to the PBM’s bottom line.
NCPA advocates for pharmacy in calls with CMS, HHS, White House
https://ncpa.org/newsroom/qam/2023/05/26/ncpa-advocates-pharmacy-calls-cms-hhs-white-house
Starting in 2025, Part D patients can elect to have cost-sharing “smoothed” out over the course of the benefit year under the Inflation Reduction Act and can elect to pay their cost-sharing in monthly installments. Out-of-pocket costs for Medicare Part D beneficiaries will be capped at $2,000 per year in plan year 2025. In subsequent years, the $2,000 threshold will be increased at the rate of growth for the Part D program. On May 24, NCPA’s Steve Postal attended an IRA workshop hosted by the Centers for Medicare & Medicaid Services and its contractor, Mathematica, and focused his comments on potential plan behavior that may add administrative burden to pharmacies. He also warned CMS to be wary of plan and PBM efforts to use education on smoothing to steer patients to PBM-affiliated pharmacies The following day, on May 25, NCPA’s Steve Postal and Anne Cassity spoke with the Department of Health and Human Services and White House officials about the IRA and the need for standardized educational materials published by HHS that alert patients to the copayment smoothing provision. They reiterated NCPA concerns that such educational efforts would add administrative burdens to pharmacists. Postal also asked HHS officials to report on the status of the HHS Bridge program that would provide COVID-19 vaccines from pharmacists to uninsured patients. HHS responded that it will be following up with more information on the copayment smoothing provision, as well as the HHS Bridge program.
Filed under: General Problems
I usually use GoodRx, it’s cheaper than any of my Part D copays. However, I’d guess mom and pop’s (if there’s any left?) probably won’t take GoodRx?
https://www.pharmaciststeve.com/the-ftc-fires-its-first-shot-at-www-goodrx-com-under-the-health-breach-notification-rule/
My little pharmacy does NOT take goodrx,,and this is exactly what it is,,a Ma&Pa PHARMACY,,,Closed on week-ends even,,,,maryw
The independent that we use – for the last 6 +/- yrs… closes at 6PM M-F & 3 PM on Saturday and ONCE in all those years, I had to go to an immediate care ( doc in a box )- late in the evening – chose to use a grocery store Rx dept. I would probably have survived, if I had waited until next morning to get the Rx filled. The Rx dept staff is consistent, now having to deal with a new staff member every other time going there. Wait time, is seldom > 5 minutes
Thats funny u mention new pharmacist.The one I deal w/was put IN the hospital,,but every time we go now,,there is always a different pharmacist on duty,,,new ones,,My old one for 30 years ,,,quit,,,after the cdc guildeline ,dea all this crap,,she said ,”Mary is this is what humanity is going to do the sick and dieing,she wanted no part of it,”,,,maryw
If you are dealing with one of the major chains, most of them have a “pool of floaters” and can vary from day to day… If it is a independent, they may be forced to use a temp service to have a pharmacist and again, often it will depend on who they have available to work on any particular day