Oct. 15 Deadline Nears for Medicare Part D Coverage Notices

Are you prepared for the Medicare Part D coverage notice deadline? Plan sponsors that offer prescription drug coverage must provide notices to Medicare-eligible individuals before October 15. Read on to learn more.

Plan sponsors that offer prescription drug coverage must provide notices of "creditable" or "non-creditable" coverage to Medicare-eligible individuals before each year's Medicare Part D annual enrollment period by Oct. 15.

Prescription drug coverage is creditable when it is at least actuarially equivalent to Medicare's standard Part D coverage and non-creditable when it does not provide, on average, as much coverage as Medicare's standard Part D plan.

The notice obligation is not limited to retirees and their dependents covered by the employers' plan, but also includes Medicare-eligible active employees and their dependents and Medicare-eligible COBRA participants and their dependents.


The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires group health plan sponsors that provide prescription drug coverage to disclose annually to individuals eligible for Medicare Part D whether the plan's coverage is creditable or non-creditable.

The Centers for Medicare & Medicaid Services (CMS) has provided a Creditable Coverage Simplified Determination method that plan sponsors can use to determine if a plan provides creditable coverage.

Disclosure of whether their prescription drug coverage is creditable allows individuals to make informed decisions about whether to remain in their current prescription drug plan or enroll in Medicare Part D during the Part D annual enrollment period.

Individuals who do not enroll in Medicare Part D during their initial enrollment period, and who subsequently go at least 63 consecutive days without creditable coverage (e.g., because they dropped their creditable coverage or have non-creditable coverage) generally will pay higher premiums if they enroll in a Medicare drug plan at a later date.

Who Must Receive the Notice?

The notice must be provided to all Medicare-eligible individuals who are covered under, or eligible for, the sponsor's prescription drug plan, regardless of whether the plan pays primary or secondary to Medicare. Thus, the notice obligation is not limited to retirees and their dependents but also includes Medicare-eligible active employees and their dependents and Medicare-eligible COBRA participants and their dependents.

Notice Requirements

The Medicare Part D annual enrollment period runs from Oct. 15 to Dec. 7. Each year, before the enrollment period begins (i.e., by Oct. 14), plan sponsors must notify Medicare-eligible individuals whether their prescription drug coverage is creditable or non-creditable. The Oct. 15 deadline applies to insured and self-funded plans, regardless of plan size, employer size or grandfathered status.

Part D eligible individuals must be given notices of the creditable or non-creditable status of their prescription drug coverage:

  • Before an individual's initial enrollment period for Part D.
  • Before the effective date of coverage for any Medicare-eligible individual who joins an employer plan.
  • Whenever prescription drug coverage ends or creditable coverage status changes.
  • Upon the individual's request.

According to CMS, the requirement to provide the notice prior to an individual's initial enrollment period will also be satisfied as long as the notice is provided to all plan participants each year before the beginning of the Medicare Part D annual enrollment period.

An EGWP exception

Employers that provide prescription drug coverage through a Medicare Part D Employer Group Waiver Plan (EGWP) are not required to provide the creditable coverage notice to individuals eligible for the EGWP.

The required notices may be provided in annual enrollment materials, separate mailings or electronically. Whether plan sponsors use the CMS model notices or other notices that meet prescribed standards, they must provide the required disclosures no later than Oct. 14, 2017.

Model notices that can be used to satisfy creditable/non-creditable coverage disclosure requirements are available in both English and Spanish on the CMS website.

Plan sponsors that choose not to use the model disclosure notices must provide notices that meet prescribed content standards. Notices of creditable/non-creditable coverage may be included in annual enrollment materials, sent in separate mailings or delivered electronically.

What if no prescription drug coverage is offered?

Because the notice informs individuals whether their prescription drug coverage is creditable or non-creditable, no notice is required when prescription drug coverage is not offered.

Plan sponsors may provide electronic notice to plan participants who have regular work-related computer access to the sponsor's electronic information system. However, plan sponsors that use this disclosure method must inform participants that they are responsible for providing notices to any Medicare-eligible dependents covered under the group health plan.

Electronic notice may also be provided to employees who do not have regular work-related computer access to the plan sponsor's electronic information system and to retirees or COBRA qualified beneficiaries, but only with a valid email address and their prior consent. Before individuals can effectively consent, they must be informed of the right to receive a paper copy, how to withdraw consent, how to update address information, and any hardware/software requirements to access and save the disclosure. In addition to emailing the notice to the individual, the sponsor must also post the notice (if not personalized) on its website.

Don't forget the disclosure to CMS

Plan sponsors that provide prescription drug coverage to Medicare-eligible individuals must also disclose to CMS annually whether the coverage is creditable or non-creditable. This disclosure must be made no more than 60 days after the beginning of each plan year—generally, by March 1. The CMS disclosure obligation applies to all plan sponsors that provide prescription drug coverage, even those that do not offer prescription drug coverage to retirees.

SOURCE: Chan, K.; Stover, R. (10 September 2018) "Oct. 15 Deadline Nears for Medicare Part D Coverage Notices" (Web Blog Post). Retrieved from https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/medicare-d-notice-deadline.aspx/

How to help alleviate specialty Rx costs

Originally posted September 9, 2014 by Melissa A. Winn on https://ebn.benefitnews.com.

Half of large employers say the cost of specialty pharmacy drugs is their second or third highest cost-driver, behind high-cost claims and special conditions, according to a recent survey by the National Business Group on Health. Brian Marcotte, NBGH’s president, calls the concern “significant,” considering specialty pharmacy currently impacts only about 2% of the population, but advancements in the manufacturing of these expensive drugs threaten to greatly increase the number of employees using them.

As employers consider their 2015 health plan designs, they “are very focused on specialty pharmacy drugs and the potential impact they have” on the company’s bottom-line, says Marcotte. Benefit advisers can add value by offering solutions to reign in the costs of these drugs, including programs to limit the quantity of the drugs dispensed at any one given time, the use of prior authorization to confirm the necessity of the treatment, and even the use of a freestanding specialty pharmacy.

“Benefit advisers should make sure employers are utilizing all of the specialty clinical programs offered by the medical and pharmacy vendors for their benefits,” says Brenda Gagnon, a pharmacy benefit adviser and president and CEO of the health care consulting firm B.M Gagnon Associates.

This is especially true in light of the fact the utilization of the drugs is bound to increase. “Current estimates for specialty medications are that they will cost an employer 50% to 60% of their total health benefits by 2016,” says Gagnon.

That’s true not only because the high cost of developing and manufacturing the drugs is reflected in their high price tag, but also Gagnon says, because “drug manufacturers have put more effort into finding more than one drug therapy for the drug.”

For example, she notes, AbbVie’s Humira is used for rheumatoid arthritis, Crohn’s disease, colitis and psoriasis.

Research and development costs are “passed onto the employer when an employee is taking a specialty medication,” Gagnon adds, saying the cost of the drugs can be anywhere from $1,200 to $12,000 a month, depending on the disease.

Utilization controls

An employer client has no control over the high price tag on these drugs, says Michael Zucarelli, national pharmacy practice leader for the employee benefit and financial firm CBIZ.

Where benefit advisers can help employers tame their client’s drug spend, however, is through health plan options designed to manage these drugs’ utilization, he says.

First and foremost, plans should have some sort of appropriate use protocol or prior authorization. Such a procedure would ensure claims are reviewed to make sure the drugs are safe and effective for the employee, as well as safeguard the plan financially, suggests Zucarelli.

In addition, employers have an opportunity to manage drug use as the number of specialty drugs available to treat any one disease expands, creating competition within the drug classes.

Employers “can now become a little more creative in how they set up their plan. They may prefer one or a couple of treatments over another,” he says.

This can be designed as a formulary in which a less expensive drug option would be covered at 100% and the more expensive option would require the employee to pay 100% of the cost share, he says. Otherwise, it can be set up as a step-therapy program, in which the more expensive drug cannot even be used until the less expensive option has been tried and failed.

“We’re seeing plan sponsors look at that as an option and more are adopting it,” says Zucarelli, adding that he typically advises employers to institute a step-therapy program as soon as possible, while it affects only a small number of plan members.

Advisers can also work with employers on channel management, Zucarelli suggests, saying employers should have a consultant, pharmacy benefit manager, or medical plan carrier evaluate where the drug spend is to gain visibility and look at opportunities for site-of-care management.

“Maybe a patient is getting a particular specialty drug in a hospital infusion suite and that may not be the most convenient or cost-effective treatment,” he suggests.

Gagnon agrees employers can use a third-party consultant company like Artemtetrx, which uses data analytics to evaluate claims data and identify high drug spend and opportunities for cost management across clinical management, reimbursement management, site of care management and plan design.

When an employer client raises a question about a high-dollar claim, Zucarelli says the plan’s PBM or carrier could also be asked to do a case review and insure the patient is taking the high-cost drug for an appropriate use.

“Unfortunately, once an employee is on a certain drug, it’s hard to get them off of it or switch it,” he says, adding that that’s why he suggests employers get a lot of these tactics in place now, before the use of the drugs increases, which is inevitable.

“Getting these management techniques in place now is going to further minimize disruption,” he adds.


Five tips for saving on prescription drugs

Original article https://www.benefitspro.com

By Kathryn Mayer

No two pharmacies are alike.

According to an analysis by Consumer Reports, prescription drugs vary widely in price depending on where you shop. Failing to comparison shop could result in overpaying by as much as $100 a month or even more, depending on the drug.

The consumer group says shoppers need to compare prices. Here are five other tips on how to save money on prescriptions, according to Consumer Reports.

Request the lowest price. Consumer Reports analysis reveals shoppers weren’t always given the best, lowest price. Make sure you ask.

Go generic. Generics are copies of brand-name medications whose patents have expired. The Food and Drug Administration requires generics contain the same active ingredients in the same strength as the brands they copy. In addition, a generic must be “bioequivalent” to its corresponding brand, meaning that it delivers the same amount of active ingredients into a person’s bloodstream in the same amount of time as the original brand.

Leave the city. Some grocery store and independent drugstores had higher prices in urban areas than rural areas, according to Consumer Reports. For example, CR shoppers priced a 30-day supply of generic Actos at a pharmacy in Raleigh, N.C., for $203, while another pharmacy in a rural area of the state sold it for just $37.

Get a refill for 90 days, not 30 days. Most pharmacies offer discounts on a three-month supply.

Look for additional discounts. All chain and big-box drugstores now offer discount generic-drug programs, with some selling hundreds of generic drugs for $4 a month or $10 for a three-month supply. Just make sure your drug is on the list. Offers vary and check the fine print.


Companies Look to Pharmacy Benefits for Savings

Employers increasingly are putting prescription drugs -- specifically their plan designs and providers -- under the microscope in hopes of spotting more health care savings.

Following a trend among health care plans, more prescription drug plans are shifting to a "value-based" model, according to Lauren Flynn Kelly, a blogger with AIS Health. In a recent post, Kelly highlighted one particular eight-tier formula that assigned clinical and financial values to drugs on each tier and included only a few lower-cost generics on its first tier.

Ritu Malhotra of The Segal Co. noted that this type of plan design promotes the use of generics -- particularly the lower-cost generic options.

"I think the value part of the value-based plan design is that those drugs are effective and much more cost-effective and could potentially result in a savings on the medical side if patients are more adherent," Malhotra notes in the AIS Health post.

Patient adherence is a primary goal of value-based plans, Kelly wrote. Unfortunately for employers, it's an area where the statistics remain grim. A recent poll by Express Scripts Inc. found that non-adherence cost the nation about $317.4 billion in 2011 in treatment -- that's not counting lost productivity and other costs that can occur when patients don't follow their prescribed drug regimen, according to a report in Employee Benefit News.

While adherence remains a constant obstacle, recent moves in the pharmacy benefit marketplace may create alternative opportunities for lower costs and stronger benefits, an online Workforce report suggests.

Express Scripts' $29 billion purchase of Medco Health Solutions could shake up the pharmacy benefit management (PBM) landscape, potentially creating a polarization between big PBMs that offer the best costs and smaller PBMs that can offer more services, F. Randy Vogenberg of the Institute for Integrated Healthcare told Workforce.

Linda Cahn, founder of Pharmacy Benefits Consultants, suggests that the merger may prompt some employers to start shopping for better deals.

"I think people are aware that changing PBMs can save them large amounts of money, and they are also aware that marketplace developments create further incentives to conduct [request for proposals]," Cahn told Workforce.

Most employers, however, likely won't make any sudden moves with their PBMs at renewal time later this year.

"Change creates controversy, and employers are not looking for controversy," Vogenberg said.