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10 Questions Pharmacies Need to Ask About Medicare Part D Every Year

10 Questions Pharmacies Need to Ask About Medicare Part D Every Year by Elements magazine |

August 15, 2018

Inside: Medicare covers the majority of independent pharmacy patients. Learn what questions to ask to make the most of Medicare Part D each year.

The month of October is just as scary and full of surprises as Halloween to many of your patients.

Why? Open enrollment for Medicare Part D starts. If there’s one thing you know for sure, it’s that patients will have questions about Medicare Part D. Navigating the ever-changing benefits plans can feel as intimidating as navigating through a haunted house.

Sixty percent of Medicare beneficiaries find choosing a Medicare Part D plan too confusing, according to an Express Scripts analysis.

For many patients, their independent pharmacy is the most accessible link to the world of Medicare. Use this perfect opportunity to show patients that they can count on their independent pharmacy to help.

Prepare your pharmacy to educate patients about the latest in Medicare Part D. You’ll help them feel confident about enrolling and confident that your pharmacy cares about them. Helping patients understand the Medicare Part D plan options will build trust and cultivate long-lasting relationships.

Your pharmacy also needs to know the latest about Medicare Part D because the policies affect your profits. With more than half of independent pharmacies’ prescription revenue coming from Medicare Part D plans, you can’t afford to be in the dark on yearly changes.

Here’s a list of the most important questions your pharmacy should ask each year before Medicare Part D enrollment begins.

1. What are the changes in this year’s Standard Benefit Model?

The Centers for Medicare and Medicaid Services (CMS) release updated standard benefit parameters each year and set minimum standards for the year’s Medicare Part D prescription drug plan coverage.

It’s important to know all these changes each year, as even the smallest change can affect your pharmacy and your patients.

For example, in 2018, CMS allowed the substitution of certain low-cost generic drugs on plan formularies at any point during the year. Knowing that information allows you to help patients keep an eye out for lower cost drugs.

RELATED: 3 Ways to Help Patients Make Smart Medicare Part D Decisions

2. What are this year’s exceptions to the Medicare Part D drug plan parameters?

Each year CMS allows Medicare Part D providers to deviate from the defined standard benefits in certain ways.

For example, a provider might be able to offer prescription drug plans with more enhanced features, such as:


CMS outlines these exceptions on its website.

3. When can I see the coming year’s Medicare Part D plans?

Medicare’s releases plan information in late September or early October. Sign up for the free reminder service to receive an email as more information becomes available about the plans.

4. Are there any Medicare Part D Drug plan policy changes I need to be aware of?

Medicare Part D policies change every year.

For example, the coming year’s plans might have altered which drugs they cover. One plan might cover more generics and another more brands. Knowing what’s covered under each plan will help you counsel your patients on their best options and make the right drug recommendations.

Other changes to look for include:


Also look for new terminology or revised definitions. For example, in 2018, CMS changed the meaning of “any willing pharmacy.” This definition matters because it determines whether a pharmacy can participate in the Medicare Part D preferred network.

5. Are there any changes to Star Ratings?

Star Ratings could potentially influence your pharmacy’s reimbursements and your patients’ plan quality.

They affect your pharmacy’s ability to retain patients and obtain reimbursement for your services. Independent pharmacies need to keep up with changes to Star Ratings each year. Also, take the time to educate all staff members on Star Ratings and the processes that affect them.

Star Ratings help consumers compare Medicare Advantage plans based on factors of quality, cost, and coverage. Although CMS doesn’t assign Star Ratings to independent pharmacies, the services you provide to patients can affect the results of health plans’ Star Ratings. Health plans can issue their own ratings to pharmacies and measure a pharmacy’s performance by reviewing claims.

6. How much are this year’s penalties for late enrollment?

Even with Medicare, if you snooze you lose.

Patients pay a higher monthly premium if they don’t enroll in a Medicare Part D prescription drug plan when they’re first eligible. Or, they have to go without creditable prescription drug coverage for more than 63 days.

In certain situations, patients can appeal their late enrollment penalty.

CMS doesn’t apply a late enrollment penalty to people who qualify for the Medicare Part D financial Extra-Help program. Or, if they have another form of creditable prescription drug coverage, such as VA or employer coverage.

The penalties for late enrollment can change each year. lists the new penalty information.

7. What are this year’s income-related Medicare adjustment amounts?

In Medicare Part D, patients who make more money pay more for their plan. Patients who make less money pay less.

This Medicare Part D Income-Related Monthly Adjustment Amount (IRMAA) bases its calculations on a patient’s modified adjusted gross income. It parallels the additional payments she makes to her Medicare Part B premium.

It also limits the maximum amount a patient can pay per year. For example, in 2018, CMS reduced the maximum amount that low-income beneficiaries pay for biosimilars.

IRMAA can change each year and is calculated using the recently released standard Medicare Part D base premium.

8. Are there any changes to the Medicare Advantage plans?

Private companies approved by Medicare offer Medicare Advantage plans. Patients enrolled in Medicare Advantage plans receive Part A and Part B Medicare benefits, but not Medicare Part D. Most Medicare Advantage plans offer their own prescription drug coverage.

Changes to Medicare Part D don’t necessarily apply to Medicare Advantage plans and vice versa. So, you’ll need to check for changes in Medicare Advantage plans that might not apply to Medicare Part D.

9. What existing plans are changing?

CMS offers a variety of plans in Medicare Part D. And in 2018, CMS removed an important restriction that limited the number of plans offered.

This change means your patients have more options. And, your independent pharmacy has more year-to-year changes to keep track of.

10. Will there be new plans for 2019?

On any given year, Medicare might introduce a new Medicare Part D plan.

Once the plans become available to view, you can analyze their differences and answer patients’ questions.

Learn each of the new plans so you can better help patients navigate the confusing land of Medicare enrollments.

To conduct an analysis, use the CMS Plan Finder. Or, iMedicare, a tool designed for independent pharmacies that allows you to compare Medicare plans in seconds.


Use this article as your resource each year as October rolls around to help patients and your pharmacy get the most out of Medicare Part D.


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