Tag: Medicare PDP

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Part C Medicare Advantage Part D Prescription Drug

About the Medicare GLP-1 Bridge Program

Beginning July 1, 2026, a new federal initiative called the Medicare GLP-1 Bridge Program will allow individuals enrolled in a Part D plan to access certain highly sought-after weight-loss drugs for a flat copay of $50 a month.

According to the Centers for Medicare & Medicaid Services (CMS), this temporary demonstration program will run through December 31, 2027. The goal is to make these treatments more affordable while the government evaluates long-term coverage models.

Here are the essential details you need to know about who qualifies, what is covered, and how to get started.

1. Who Is Eligible?

You must be enrolled in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes drug coverage. (This excludes the MA-Only plans that do not include drug coverage.) However, because this is a medical demonstration, you cannot simply request the $50 rate at the pharmacy counter. Your doctor must submit a Prior Authorization showing you meet specific medical categories based on your Body Mass Index (BMI):

  • Tier 1: A BMI of 35 or higher (no other health conditions required).

  • Tier 2: A BMI of 30 to 34.9 plus at least one of these conditions: heart failure, uncontrolled high blood pressure, or chronic kidney disease.

  • Tier 3: A BMI of 27 to 29.9 plus at least one of these conditions: pre-diabetes, a history of a heart attack, a history of a stroke, or peripheral artery disease.

Note: The program specifically excludes patients who have Type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease, as those individuals are typically already eligible for GLP-1 coverage directly through standard Part D plans.

2. Which Medications Are Included?

The $50 monthly price is the result of a negotiated agreement between the federal government and certain drug manufacturers. The program strictly covers specific brand-name formulations prescribed specifically for weight management:

  • Wegovy® (both the standard injectable and the newer oral tablet versions).

  • Zepbound® (strictly limited to the KwikPen® formulation; standard single-dose vials or pens are not covered).

  • Foundayo® (Eli Lilly’s newly approved oral pill).

Medications like Ozempic® and Mounjaro® are not part of this $50 weight-loss program because they are FDA-approved to treat Type 2 diabetes and are already handled under standard Medicare Part D formularies.

3. The “Fine Print” Seniors Need to Know

Because the Bridge program operates entirely outside of the traditional Medicare Part D design, there are a few unique rules to keep in mind:

  • Out-of-Pocket Limits: The $50 monthly copay does not count toward your standard Part D deductible or your annual $2,100 out-of-pocket maximum.

  • Extra Help: Because the program includes a flat $50 copay for everyone who qualifies, the federal Low Income Subsidy (Extra Help) and New York State EPIC cost-sharing protections do not apply to this program.

  • Supply Limits: The program will only cover 28-day or 30-day supplies at a time.

How to Take Action

You do not need to sign up for a new insurance plan to participate. If you think you meet the BMI and health criteria, schedule an appointment with your doctor. Your physician will need to write the prescription with specific instructions for the Bridge program, and they will submit the required medical paperwork directly to the program’s central processor (managed by Humana) to approve your $50 rate. You may want to provide your provider with a copy of the CMS Prescriber Guide and the CMS Pharmacy Operational Framework. for their review.

Click below and watch our June 9 “Ask the Experts” interview where Chris, Kate and I answer some questions about the GLP-1 Bridge Program:

An interesting article comparing several GLP-1 medications: https://www.health.com/glp-1s-weight-loss-8674445

 

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Medicare Medicare A & B Medicare supplement Part C Medicare Advantage Part D Prescription Drug

About the 2026 Medicare Annual Enrollment

Annual Enrollment Period

The Medicare Annual Enrollment Period, from October 15th through December 7th, is when Medicare beneficiaries can enroll in or change their Medicare Advantage (Part C) or Medicare Prescription Drug (Part D) plan to take effect January 1.

Some Important Tips to Consider if you are now enrolled in a Medicare Advantage (Part C) Plan:
  • You can leave your Medicare Advantage plan and enroll in another Medicare Advantage plan offered in your county. [We offer several]
  • Even if you decide to stay with your current Medicare Advantage plan, make sure your doctors and preferred hospitals are still in your network, especially if your plan is a HMO. 
  • You can leave Medicare Advantage and return to Original Medicare and purchase a Medicare Supplement (aka Medigap) policy. For New York State residents, acceptance is guaranteed and the continuous coverage transfer means no pre-existing condition limitations apply.
Some Important Tips to Consider if you HAVE ORIGINAL MEDICARE AND a Medicare SUPPLEMENT Plan:
  • The Annual Enrollment Period applies to your Part D drug plan only.
  • New York State residents can change their Medicare Supplement plan at any time of the year and without medical underwriting. An example could be changing from one company to another or changing from one plan (Plan F, Plan G, Plan N or High Deductible) to another. 
  • You can leave your Medicare Supplement (Medigap) plan and join a Medicare Advantage plan during the Annual Enrollment Period. There is no underwriting to move to a Medicare Advantage plan. You will be automatically accepted as long as your permanent address is within the coverage area.
  • Unless your prescription drugs are covered through the Veterans Administration, most individuals with Original Medicare and a Medicare Supplement plan also add a Medicare Part D prescription drug plan. We recommend updating your medication list and confirming – through your personal account at medicare.gov – which Part D drug plans will cover your prescriptions at the lowest annual out of pocket costs – that includes premium, deductible and prescription copay costs.

Our team of licensed, independent and certified agent advisors, from Long Island to the North Country, offer a no-obligation complimentary consultation to help you compare Medicare plans in your coverage area.

So, reach out to local agent by phone, an online note or book an appointment directly to his or her calendar and learn more about your Medicare plan options.

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Medicare Part D Prescription Drug

The New Law and Medicare Part D

The US House and Senate has passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year, increased to $2,100 in 2026.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

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Categories
Medicare

Get Questions Answered at “Medicare 101” Webinar

Are you going to be eligible for Medicare in the near future? Have you been enrolled in Medicare for awhile and want to better understand what it offers? Do you have a family member you help with Medicare issues?

If you answered yes, then “Medicare 101” is for you. This no sales-pitch educational webinar, led by multi-state licensed and Medicare Plan Specialist Dan Alcorn, will be held 9:30 am on the following days:

Monday – September 28, 2020 Register Here
Tuesday – October 6, 2020 Register Here
Sunday – October 18, 2020 Register Here
Monday – November 2, 2020 Register Here
Saturday – November 14, 2020 Register Here
Friday – November 20, 2020 Register Here

We’ll explore Medicare Parts A, B, C and D, the difference between a Medicare Supplement and Medicare Advantage plan, and more. After registration, you will receive the login instructions by e-mail. (The presentation is via GoToMeeting, a video conferencing platform. No video camera is necessary.)

For the GoToMeeting link and access code, register online at:
https://dgalcorn.com/dans-public-presentation-schedule/medicare-101/

Categories
Case Studies Part D Prescription Drug

New York State EPIC and Mary – a case study

“… a huge thanks for cluing us in to the EPIC ..program.”
“…we now estimate yearly savings to be $7,000+/-” 
“…we’d never heard of this program until one of your newsletter emails..”

When Mary became eligible for Medicare I helped her enroll in the Medicare Supplement Plan G she selected as secondary to Original Medicare.

Then we searched and found a Part D prescription drug plan that included her specialty medication in its covered drugs, known as the “formulary.” Although the specialty drug was categorized at the highest cost sharing, tier 5, its being included saved the added step and hassle of requesting a “formulary exception.” 

John and Mary’s joint income is below $100,000 so she became eligible for the New York State EPIC program. 

As John’s note to me states, once Mary’s pharmacy cumulative copayments reached her EPIC 2020 deductible level, that tier 5 specialty drug copay was reduced to $20. John estimates this saves the household about $7,000 annually.

Of course I was thrilled to hear my mention of EPIC helped John and Mary like this. I encourage every client to confirm your New York EPIC eligibility and enroll. I have included the EPIC enrollment form below and am available to assist with any eligibility or enrollment process questions. 

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Part D Prescription Drug Uncategorized

Part D Late Enrollment Penalty

Q: “Dan, I just received a letter stating I will have to pay a Part D late enrollment penalty next year for not having a drug plan during the months of February through December, 2017. What’s this all about?”

A: “Sam, after you turned 65 in October 2016 you had individual coverage with prescription drug benefits through January 2017. Now you’re enrolling in a Medicare Advantage plan with Part D coverage, effective January 2018. For those 11 months, February through December, that you went without drug coverage Medicare will impose a penalty for the late enrollment.”

Again, why do I owe a late enrollment penalty?

If, for any continuous period of 63 days or more after your Initial Enrollment Period is over you go without one of the following, you will have a penalty added to your Medicare Part D premium:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (HMO or PPO) with prescription drug coverage.
  • Creditable prescription drug coverage (a drug plan that pays at least as much as the Medicare standard – most often provided through an employer or the individual insurance exchange.)

 

How does Medicare calculate the late enrollment penalty?

The penalty is based on multiplying two factors.

  1. Medicare calculates 1% of the “national base beneficiary premium” ($35.63 in 2017; $35.02 in 2018) which for 2018 will be $.35
  2. Medicare determines the number of full, uncovered months you didn’t have Part D or creditable coverage. In the above instance, that was 11 months.
  3. The $.35 is then multiplied by the number of months. In our example of 11, that equals $3.85
  4. The monthly penalty is rounded to the nearest $.10 (the example would then be rounded to $3.90) and added to your monthly Part D premium.

Will the late enrollment penalty change?

Yes, annually.  When Medicare determines the national base beneficiary premium has changed, as in $35.63 in 2017 to $35.02 in 2018, the late enrollment penalty amount will be recalculated.

Do I pay the late enrollment penalty through Social Security?

No.  The penalty, rounded to the nearest $.10 is added to your Part D premium and collected by your private insurance company

 

Source: https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

Categories
Case Studies Part D Prescription Drug

“Having this EPIC plan was a miracle; an absolute miracle.”

Only a fraction of the nearly 3 million New York State residents aged 65 and older are enrolled in the state’s pharmaceutical assistance program known as New York EPIC.

When I meet with New York Medicare Part D clients, I ask if their individual income is below the $75,000 threshold, $100,000 if married. If so, I advise enrolling in EPIC even if they don’t take any or have only inexpensive medication.  Because, as Schenectady County, New York resident Beth says, “You never know.”

Beth shares her story. The $20,000 per dose medication.

In this 16 minute interview Beth shares her story of how she originally enrolled in EPIC and didn’t use it. She explains how her doctor prescribed a specialty medication. And how that medication was not included on her Medicare Part D plan formulary, its list of covered medications. And when she learned the drug would require a special exception approval from her Medicare Part D plan and costs $20,000 per dose, she was relieved to hear that EPIC would help. Listen in as Beth explains how affordable this $20,000 medication became after EPIC’s help.

Beth: “To me, having this EPIC plan was miracle, an absolute miracle. Because I wouldn’t have been able to get that drug and I would still remain very ill.”

If you reside in New York State, are age 65 or above, and have questions about how EPIC and your Medicare Part D plan can work together, please call (518) 346-2115.

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Case Studies Part D Prescription Drug

Medicare Extra Help: “The savings are a godsend…”

Medicare Supplement Testimonial

Medicare Extra Help

I was delighted to assist this New York based beneficiary who is on a limited income and was not aware of the Medicare Savings Program available through a New York State program for Medicare Part B premium or that Social Security offers “Extra Help” with Part D premium and prescription drug co-pay.

Call 518-346-2115 for a confidential review of your Medicare Part B or Part D costs.

Extra Help for Medicare Part B and Medicare Part D
Extra Help for Medicare Part B and Medicare Part D