Cap Medicare Part D so Seniors Can Afford Their Medications
Last updated: April 2023
Many patients on biologics have a difficult time paying for their medication copays. This is true for my son and me who both have psoriasis and psoriatic arthritis. Between the two of us, the out-of-pocket costs for our quarterly injections are almost $4,000.
This is in addition to doctors’ visits, tests, and other health care expenses. We both use copay assistance from the drug manufacturer to afford these out-of-pocket costs.
The importance of copays
Without this copay assistance, we would not be able to live a comfortable, but modest, lifestyle. Having to find more than $10,000 every year to afford the biologics that keep us healthy and our disease in check is just unimaginable.
That’s why my heart breaks when I hear so many seniors on Medicare Part D cannot afford their medications. Those on Medicare Part D are not afforded most copay assistance, like us. On top of that, Medicare Part D is one of the only health plans without an annual out-of-pocket maximum, so costs become unpredictable.
According to a 2020 National Psoriasis Foundation survey, 45% of psoriatic disease patients who take a biologic and are on Medicare worried about being able to afford their treatments in the last 12 months. On April 20-21, 2021, NPF advocates met virtually with lawmakers and their staff on Capitol Hill to request changes in Medicare Part D so seniors can afford their medications. I was proud to be one of them.
How does Medicare Part D work?
Medicare Part D is the prescription drug benefit of Medicare. Part D has different phases:
- Deductible: Patient pays 100%, up to $445
- Initial coverage: Patient pays 25%, up to $4,130 (total drug spending – amount the patient and plan have paid)
- Coverage gap: Patient pays 25%, up to $6,550
- Catastrophic coverage: Patient pays no more than 5% after reaching $6,550.
Even in the last catastrophic phase, patients still must pay 5% of their drug costs for the remainder of the year.
What are some of the challenges of Part D?
As more specialty drugs, like biologics, become available, 25% coinsurance in the initial coverage and coverage gap phases becomes increasingly unaffordable. According to the Kaiser Family Foundation, the number of patients who reached catastrophic coverage in 2017 was more than double the number in 2007.
Part D is one of the only health plans without an out-of-pocket cap. In addition, federal anti-kickback laws make it difficult to obtain manufacturer copay assistance plans.
Congressional Proposals and Smoothing
There is bipartisan support in both the House and Senate to cap Medicare Part D out-of-pocket costs, with proposals ranging from $2,000 to $3,100. While the NPF does not propose a certain threshold, it does support any proposal that would provide much-needed relief to seniors.
In addition to an out-of-pocket cap, the NPF is supporting proposals that also provide a smoothing mechanism. This would allow out-of-pocket costs to be spread out over the entire year. Rather than paying high out-of-pocket costs, say $3,100, for medications at the beginning of the year to meet the phase cost-sharing requirements, the copay could be spread out over 12 months to make budgeting and monthly $258.33 installments easier to manage.
Learn more about Medicare Part D out-of-pocket caps and the smoothing mechanism and ask your representative and senators to take action.
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