Medicare Part D Enrollment Tools


Educate Your Patients to Avoid Confusion & Disruption

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Medicare Part D open enrollment for 2020 starts October 15, and it's time prepare for plan change season and the stress and confusion it brings.

As in past enrollment periods, some of your Part D patients are likely to receive confusing or incomplete information about which pharmacies they can use in a particular plan's Part D network. Some of these communications mislead patients into thinking that if your pharmacy is not preferred in a plan, they cannot fill prescriptions there.

Rather than scrambling to counter confusing and misleading communications that may come late in the enrollment period, start educating your patients now and offer to answer questions and assist in plan comparisons.

American Pharmacies has prepared a customizable letter that you can send to select patients who need help with their plan choices or have questions about whether they should use a preferred or non-preferred network pharmacy. The letter is in Microsoft Word format and can be individualized with your own pharmacy logo, name and address/phone number. We also are providing a Part D bag clipper and a half-page flier that you can print to hand out to patients or use as a bag stuffer. Use the links at the top of this article to download.

Part D Resources
For You & Your Patients

Go to our Resources Page for a downloadable patient letter, bag stuffers & clippers, and links to helpful online tools.

Plan Changes Affecting Enrollees in 2021

  • Initial Deductible: Increases by $10 to $445 in 2021.
  • Initial Coverage Limit (ICL): Increases from $4,020 in 2020 to $4,130.
  • Out-of-Pocket Threshold: Increases from $6,350 to $6,550.
  • Coverage Gap (Donut Hole): Begins once a beneficiary reaches the Medicare Part D plan's initial coverage limit ($4,130 in 2021) and ends when out-of-pocket expenses total $6,550. CMS estimates that $10,048.39 in medications must be purchased in 2021 before exiting the Donut Hole. 
  • 2021 Donut Hole Discount: Part D enrollees will receive a 75% Donut Hole discount on brand-name drugs purchased while in the Donut Hole: a 70% discount paid by the drug manufacturer and a 5% discount paid by the Part D plan. The 70% paid by the drug manufacturer combined with the 25% the enrollee pays toward the Donut Hole exit point.
    Example: A beneficiary who reaches the Donut Hole and purchases a brand drug that costs $100 will pay $25 for the medication and receive $95 credit toward the 2020 out-of-pocket limit.
  • Medicare Part D beneficiaries who reach the Donut Hole will also pay a maximum 25% co-pay on generic drugs purchased while in the Coverage Gap (a 75% discount). The co-pay counts toward the Donut Hole exit point.
  • Minimum Cost-sharing During Catastrophic Coverage: Beneficiaries will be charged $3.70 for generic or preferred multisource drugs with a retail price under $74 and 5% for those with a retail price of $74 or more. For brand drugs, beneficiaries will pay $8.95 for those costing under $184 and 5% for those with a retail price over $184 or more.
  • Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy (LIS) Eligible Enrollees: Increases to $3.70 for generic or preferred drug that is a multi-source drug and $8.95 for all other drugs in 2020.
Uploaded via media manager.Pay Close Attention to Plan "Marketing" 
CMS in 2018 narrowed its definition of the term "marketing" in Part D to mean materials and activities intended to influence enrollees' plan choice decisions. Only materials meeting this definition now receive close CMS review, while the agency has relaxed its oversight of "communications" and "communication materials."
Be on the lookout during open enrollment for communications from Part D plan sponsors and PBMs that aren't overt marketing, but attempt to influence enrollees' plan choices through misleading "notifications" about network pharmacies and co-payments. Be sure to alert American Pharmacies if any of your patients receives such communications.   

The True Impact of Preferred Networks

In this time of restricted Part D networks and growing DIR fees, it does not make economic sense to participate as a preferred provider in every Part D plan. The negative margins that you would experience as a preferred provider in some Part D plans simply cannot be overcome through increased script volume.

AmerisourceBergen's Elevate Provider Network has proven that profitability is possible in Part D plans through careful plan analysis and by not seeking preferred provider status in plans that essentially guarantee negative margins. In understanding Elevate's decision to avoid preferred provider participation in certain Part D plans, you should remember:

  • LIS (low-income subsidy) patients pay the same co-pay regardless of whether or not you are a preferred provider. Full-benefit, dual-eligible LIS patients (those on Medicaid) will have a zero copay in any Part D plan. Other LIS patients will have the same fixed co-payments in all plans.
  • In some areas, LIS patients represent more than half of a plan's patient count. If a high percentage of your busiess is Medicaid, the impact from not being a preferred network pharmacy will be greatly minimized.
  • Remember that patients who leave your pharmacy over a small co-pay differential are not likely to be your most profitable patients or the ones purchasing your front-end merchandise.

Cultivating Patient Loyalty

The fact that your pharmacy is not preferred with a given Part D plan does not mean your patients need to find another pharmacy or another plan. Patients choose their Part D plan based on many variables, only one of which is cost and convenience of the plan's network pharmacies. Patients typically look closely at:

  • Monthly premium;
  • Annual deductible;
  • Co-pays;
  • Coverage during the donut hole;
  • Formulary; and
  • The plan's pharmacy network.

Uploaded via media manager.Your patients come to your pharmacy for a reason... Identify the values they perceive in you and reinforce them every way you can. One of the best ways you can do that is by being a helpful and empathetic resource for their Part D decisions.