The 'Cost Reduction' feature in 2015 Medicare Part D plans
Based on results from the CMS Government Medicare Plan D evaluator
tool, prescription drug costs for identical prescriptions varied
more than $10,700 between available plans. Estimated costs for a
patient's drug plan insurance premium and drug costs ranged from
$3,474 to $14,221 for 2015. Additionally, mail order prescription
fulfillment was the most expensive option in all but one of the
plans.
This article details our findings, explains the operation of the
Medicare Plan D Finder website and provides general guidance on the
advice patients should seek from pharmacists regarding drug
regimens and drug costs which may impact drug adherence.
It is best to enroll by Dec. 7, but there are limited enrollment
options beginning Dec. 8. Most of these address involuntary events:
a person turns 65, loses coverage because of a change in
employment, the plan itself loses the contract with Medicare and
the like. One of the more significant reasons to change is that the
patient wasn't told a private plan wasn't as good as a Medicare
plan. Finally, a patient is able to switch to a five-star plan
once between Dec. 8 and Nov. 30. Not all ZIP codes have
five-star plans.
We used the Medicare Plan Finder for Part D1 to
evaluate our plans. The drug list consists of six of the top 10
most-prescribed drugs, based on data collected from July 2013 -
June 20142. It is not uncommon for Medicare patients to
take six or more prescriptions, and since costs increase with the
number of drugs, the selection of an appropriate insurance plan
becomes essential. The selected drugs cover common
conditions:
- High cholesterol/triglycerides (Crestor Tab 40mg)
- High blood pressure/heart failure (Diovan Tab 160 mg)
- Pain, depression and anxiety (Duloxetine HCL Cap 60 mg)
- Thyroid replacement therapy (Levothyroxine Sodium Tab 100
mcg)
- Nerve pain and fibromyalgia (Lyrica Cap 75 mg)
- Heartburn, GERD (Nexium Cap 20 mg)3
The Part D plan evaluation begins with the selection of a ZIP
code. We located our study in a Boston suburb, with a large number
of pharmacies relative to its size. The finder next requests that
the beneficiary select a pharmacy (a "preferred pharmacy"). We
determined that pharmacy selection influences price, and
consequently we ran the plan evaluator separately for each
participating pharmacy we chose. While it is possible to select
more than one preferred pharmacy, when we did select two, the plan
gave the lowest price plan for only one of the pharmacies. In other
words, the results for the second pharmacy were not reported, so we
did not have a valid comparison until we ran the evaluator for each
pharmacy independently.
We selected the category "Lowest Estimated Annual Retail Drug
Cost" in the evaluator, and then selected "all plans" for results.
We studied four separate preferred pharmacies, including a national
retail chain, a community pharmacy and a pharmacy located in a
retail setting. Because actual results vary by drug list, ZIP code
and pharmacy, we report only de-identified information. Cost
calculations include insurance premiums and deductibles, if any, as
well as the cost for drugs which were not covered by
insurance.
There are caveats in using the evaluator. First, all of the drug
costs listed are estimated; actual drug prices may vary throughout
the year. This variation may not impact patients, if the drug plan
uses co-pays which are fixed amounts and not co-insurance where
patients pay percentages of drug cost. More importantly, an
insurance company is not required to cover the drug throughout the
insurance year; a drug can be removed from coverage (that is,
removed from the formulary) with sixty days' notice to a patient.
This typically gives the patient one last covered refill and a
higher cost for subsequent refills. Lastly, a patient may not need
a particular drug for 12 months, or may be switched to a different
drug to address a condition.
This cost analysis did not include any rewards card or loyalty
programs which may be offered by retail pharmacies, nor does it
include any financial assistance, such as pharmaceutical assistance
programs (For example, see Figure 2 for the description of the
pharmaceutical assistance available for Crestor).
The plan evaluator includes a cost reduction feature that alerts
patients if a generic drug or a therapeutic equivalent is
available. For example, Nexium is a Tier 4 (high cost brand-name
drug), with an estimated annual cost of $3,410. The evaluator
suggests three lower cost alternatives to Nexium: Dexilant (Tier 3,
brand-name) at $3,264/annual, omeprazole (Tier 1, preferred
generic) at $3,280/annual and pantoprazole (Tier 2, generic) at
$3,285/annual. After revising the drug list to remove Nexium and
include omeprazole, the evaluator generated a different insurance
plan as having the lowest annual cost. The total cost for the plan
with omeprazole is $3,267, the lowest annual cost result we
obtained for retail pharmacy and the mail order option was the
lowest price, of all options, at $3,202. With a prescription, the
Medicare Part D patient cost for a year's supply of omeprazole is
about $45. However, omeprazole is available over the counter (OTC)
without prescription, at a cost of about $200 per year. One
important question for the healthcare professional is whether a
12-month regimen of any of these heartburn medications is
appropriate. According to the OTC package labeling, omeprazole
should not be used for more than the recommended treatment period
of 14 days. Patients should contact their physician if the product
is still needed after the 14-day course, or if more than one course
of treatment is needed more than every four
months4.
Patients should never make therapeutic decisions without first
consulting a medical professional about the drugs prescribed,
despite the suggestions from the evaluator. Pharmacists are
well-qualified to provide information essential to the patient for
Medicare Part D evaluation. However, a pharmacist may not promote a
particular insurance plan to a patient.
The first step in using the evaluator is to obtain from your
pharmacist a drug list which correctly identifies the prescription
medications and dosing. Under the HIPAA regulations, 45 CFR §
164.524 and § 164.510(b), patients have "a right to access, to
inspect and obtain a copy of protected health information about the
individual in a designated record set" with few exceptions.
Pharmacists are permitted to disclose information to family members
or other individuals responsible for the care of the patient so
long as the patient does not object to the pharmacy sharing the
information with that person. Also, a pharmacy must provide a
print-out of the patient's prescription drug spending, for tax
records at any time. These records should provide accurate spelling
and dosing for the drugs, which makes using the evaluator feasible
for non-medical personnel.
Additionally, a pharmacist is required by Massachusetts
regulations to both conduct a drug utilization review (DUR) and to
discuss issues that "in the pharmacist's professional judgment, are
deemed to be significant for the health and safety of the patient"
247 CMR § 9.07. To paraphrase the regulation, a DUR may include a
review of the patient record and each new prescription presented
for dispensing, for the purpose of promoting therapeutic
appropriateness, by making a reasonable effort to identify the
following: "over-utilization or under-utilization; therapeutic
duplication; drug-disease contraindication; drug-drug interaction;
incorrect drug dosage or duration of drug treatment; drug-allergy
interactions; clinical abuse or misuse; and any significant change
in drug, dose or directions. When the pharmacist determines any of
the foregoing, the pharmacist shall take appropriate measures to
ensure the proper care of the patient which may include
consultation with the prescribing practitioner and/or direct
consultation with the patient."
To illustrate the value of a pharmacist's drug utilization review,
we present a fictional example. A 67-year-old woman presents to the
pharmacy on several prescription medications. She has been seen by
three specialists over the past year, in addition to her primary
care physician with whom she visits regularly. She doesn't
understand why she is taking so many medications and is displeased
with the associated financial burden. Brand name copays appear to
be a significant contributing factor to the overall cost of the
regimen. After thoroughly reviewing the list of medications, the
pharmacist notes the patient is taking brand name Crestor 5 mg
daily for high cholesterol. Crestor belongs to a class of
medications known as "statins." Although this agent is not
available generically, there are alternative agents within the
statin class that may be considered. However, several important
questions should be answered before providing a patient
recommendation. Is the medication necessary? Will the medication be
needed chronically? If the response to these questions is "yes,"
the next step is to assess whether or not the patient has been
consistently taking the prescribed medication. If so, what has been
the response? The pharmacist will also run an interaction check to
determine whether the medication interacts with other medications
prescribed. The interaction check should then be replicated using
the proposed alternative as well. Finally, it is important to
determine whether other medications have been used for the same
indication in the past? If so, what was the patient response? We
have not been given enough information in this example to
responsibly recommend an alternative therapy.
However, this example illustrates the level of training and
expertise necessary to ensure any changes to a regimen are done
safely as well as the potential harm in selecting a therapeutic
alternative suggested by the Plan Evaluator. We note that
substitution of a generic drug for a brand name drug is generally
required and is not considered a "therapeutic alternative."
We close with some suggestions on actually using the evaluator
plan. For our study, we did not enroll a patient. Because of the
significant price differences, we recommend first time users
explore the website, without entering a SSN. After entering the
drug list, save the list and record the site-generated number and
date. This will save considerable time going forward. Finally,
inexperienced users can spend between eight to 10 hours duplicating
our studies. With practice, and a saved drug list, we were able to
reduce the time to less than two hours.
In conclusion, our pilot study demonstrates that the Medicare Part
D plan finder is an effective tool in determining a patient's cost
of prescription drugs. The plan finder not only estimates insurance
costs, but also suggests drugs to switch in order to save money.
However, a drug utilization review by a pharmacist or other health
care professional is necessary before a patient should consider
changing one drug for another.
The authors thank David Johnson, executive vice president,
Massachusetts Pharmacists Association.
- Found at www.medicare.gov/find-a-plan/questions/home.aspx
- Drug list from www.webmd.com/new/20140805/top-10-drugs
- The authors note that this list reflects a total number of
prescription drugs higher than that taken by the average Medicade
patient, but also that the number of drugs prescribed per patient
is inconsistent throughout the country (see Prescription Drug Use
Among Medicare Patients Highly Inconsistent, accessed at www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/10/prescription-drug-use-among-medicare-patients-highly-inconsisten.html).
This list is refelctive of conditions suffered by a substantial
number of Medicare patients.
- Product Information: PRILOSEC OTC(R) -- omeprazole magnesium
delayed release tablets. Procter & Gamble, Cincinnati, OH.