Yesterday, the Kaiser Family Foundation released survey results that showed that only 25% of adults over 65 knew about the Medicare prescription drug benefit (Part D) out-of-pocket cap starting in January 2024. Coincidentally, I also spent a chunk of yesterday explaining the $0 patient cost-sharing in catastrophic to two different groups yesterday. Both of whom knew a fair bit about the Part D benefit but didn’t understand the change for 2024.
Starting in 2024, there is no cost-sharing for patients once they enter the catastrophic phase of the benefit so the maximum out-of-pocket Part D spending for patients is $8,000. This is for brand and generic products. Currently beneficiaries that hit the catastrophic phase pay 5% for the remainder of the plan year which can be hundreds of dollars a month.
What counts towards this $8,000 is any Part D copays/coinsurance that the patient pays for brands or generics plus, if they are taking a brand product, any manufacturer contribution in the coverage gap.
Example: A patient taking an expensive product (like a $14,000/month oncology product) would go right through the coverage phases and have $3,333 spending in one month and have no Part D copays/coinsurance for the rest of the year on other prescription fills.
$545 deductible
+
$1,121 in the initial coverage phase
+
$1,667 in the coverage gap
$3,333 patient total + $4,667 manufacturer contribution = $8,000
It is possible that a beneficiary taking only generic products would spend more than $3,333 OOP, but typically generics are lower cost and most beneficiaries with this type of utilization are likely taking both brand and generic medicines.
Communicating these changes is not necessarily easy, but it is important. While the majority of patients do not reach this level of spending, 1.3 million or so do and they need to know and so do the stakeholders that work with them. And, given my experiences yesterday, it takes a bit of work.
The Kaiser study shows that there is not the level of engagement needed to educate beneficiaries about the changes from the Inflation Reduction Act (IRA) and that includes $0 vaccines and $35 insulins and caps on OOP. I’m not suggesting we need to go all in about 2025 (yet) or 2026 negotiation efforts, we can start smaller. But there is an opportunity to rally the advocacy efforts and share some good news with patients and who couldn’t use some good news right about now?