Medicare Advantage and standalone Part D plans would need to set a monthly cap on patient copays for drugs by Jan. 1, 2025, under drug price legislation that is in the works.1,2
Out-of-pocket prescription drug costs can be a significant burden for Medicare beneficiaries, and Democrats are hoping this legislation will help ease that load. Plans should take note as the bill works its way through Congress, and make sure they are prepared to comply if it passes.
Plans would need to give enrollees the option to pay their copays for covered drugs in capped monthly amounts, and members would be able to enroll in this option at any time during the plan year. MA plans may collect unpaid amounts if a member fails to pay.
Additionally, the bill would set an annual out-of-pocket cap of $2,000 for Part D costs beginning in 2024, as well as a $35 cap for insulin product copays in Part D.1
MA plans would be required to notify pharmacies that members may enroll in the cap if that member is about to pay out-of-pocket costs.1
The legislation, likely to be included in a $1.75 trillion spending bill that could see a vote in Congress in the coming weeks, would also allow Medicare to negotiate prices for certain drugs.1
Beginning in 2023, Medicare would be able to negotiate the prices for 10 single-source drugs, with those prices going into effect in 2025.3 Drugs eligible for negotiation would be small-molecule drugs that have been on the market for nine years and biologics that have been on the market for 13 years.4 The negotiated prices will be locked in unless a competitor enters the market.3
If these efforts result in lower drug prices for Medicare beneficiaries, they could, in turn, promote a healthier member base for MA plans.
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- King, R. Part D, Medicare Advantage drug plans must install cost-sharing cap by 2025 in new drug price bill. Fierce Healthcare. Nov. 4, 2021. https://www.fiercehealthcare.com/payer/part-d-and-medicare-advantage-drug-plans-must-install-cost-sharing-cap-by-2025-new-drug-price
- Text of H.R. 5376, Build Back Better Act. Nov. 3, 2021. https://rules.house.gov/sites/democrats.rules.house.gov/files/BILLS-117HR5376RH-RCP117-18.pdf
- Owens, C., Herman, B. Medicare drug negotiations may not be as limited as we thought. Axios. Nov. 5, 2021. https://www.axios.com/democrats-medicare-prescription-drug-negotiations-bf94bd22-3aad-42c1-a9f1-12c9183814c0.html
- Sullivan, P. House leaders make last-minute change on drug pricing after dispute. The Hill. Nov. 4, 2021. https://thehill.com/policy/healthcare/580203-house-leaders-make-last-minute-change-on-drug-pricing-after-dispute