Medicare Part D Co-Pays
With the new year, there may be changes to co-pays. Please remember that many Medicare Part D plans have deductibles that will need to be met in the 2015 calendar year. These deductibles may range from $50 TO $320 depending on the plan. This will not impact residents with Medicaid.
Preferred Drug List
North Carolina Medicaid has made many changes to their Preferred Drug List. They have also made changes in how they calculate reimbursement to pharmacies. You may see an increase of communication from the pharmacy to your facility or doctor due to changes in policies and reimbursement. These communication sheets are sent to update you on the status of medications. Communication is also sent to the physician so they may complete the Prior Authorization forms or change the medication to a formulary drug. We will make every reasonable attempt to send a small supply of the medication during the processing of the paperwork. Please know there may be circumstances when a med may not be short supplied or may be delayed in being filled, based on the cost of the medication and if cost would be a hardship to the resident. We will communicate with your staff as any issues arise.
Changes in Coverage Gap Policy
The coverage gap (doughnut hole) calculations have changed for 2015. The total drug cost required to reach the coverage gap is now $2960. This is an increase from 2014’s requirement. This change means it will take longer for residents to move into the coverage gap, a positive change for the resident. Once in the coverage gap, the resident will be responsible for a lower percentage of the drug cost than in years past. Brand drugs will have a 45% of drug cost copay and generic drugs will have a 65% of drug cost copay. The calculation of out-of-pocket costs able to contribute to the coverage gap has changed as well. Prior to 2015, only true out-of pocket expenses (deductibles and copays) were used to factor in coverage gap calculations. Now 97.5% of insurance cost for the drug is calculated as an out-of-pocket expense. Once total out-of-pocket expenses reach $4700, copays drop to approximately 5% of drug cost for the remainder of the year.