Read on to see the major Medicare changes for the 2020 plan year pharmacists need to know. We’ll update this post as more information becomes available.
Maximum copays for low-income full benefit dual eligible patients
- Full Benefit Dual Eligible: $1.25/ $3.80 copays
- Full Benefit Dual Eligible or Full Extra Help: $3.40 / $8.50
- Full Benefit Dual Eligible: $1.30/ $3.90 copays
- Full Benefit Dual Eligible or Full Extra Help: $3.60 / $8.95
Standard minimum benefit changes
- Maximum Deductible: The maximum deductible will increase by $20 to $435
- Initial Coverage Limit: The initial coverage limit will increase by $100 to $4,020
- Coverage Gap (brand-name drugs): Coverage for brand-name drugs will remain the same
- 25% covered by patient, 5% by the plan, 70% by drug manufacturer
- Coverage Gap (generics): Coverage for generics will increase by 12% for generics
- 25% covered by patient, 75% by the plan
- True-Out-of-Pocket (TrOOP) Threshold: The TrOOP threshold will increase by $1,250 to $6,350
- Catastrophic Coverage: Copays will increase slightly to 5% / $3.60 for generics and 5% / $8.95 for brands (whichever is greater)
Technically the “donut hole” will be completely phased out for 2020. In 2020, patients will not pay more than 25% of their drug costs during the coverage gap/donut hole for both brand-name and generic medications.
However, beginning in 2020 the true out-of-pocket (TrOOP) threshold is increasing significantly to $6,350, which is over a $1,000 increase compared to 2019. This means patients will remain in the coverage gap/donut hole for a much longer period of time before they transition to catastrophic coverage where their copays are minimal.
Get a printable infographic explaining the Medicare phases of coverage for 2020 — help educate your staff and your patients!
New Medicare Plans
Clear Spring Health Value Rx (PDP) and Clear Spring Health Premier Rx (PDP) are two new Part D plans for 2020, sponsored by Group1001 (Group One Thousand One, LLC). These plans are available for patients in 41 states and the District of Columbia (AL, AK, AZ, AR, CA, DC, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, MD, MI, MN, MS, MO, MT, NE, NV, NJ, CA, ND, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WA, WV, WI, WY)
The plans using EnvisionRx as their PBM can be identified with BIN 012312.
- Clear Spring Health Value Rx (PDP) is a basic plan with a monthly premium between $25-$33 per month in most states and a deductible of $435. It is a benchmark plan ($0 premium for dual eligibles) in all states it is available, except for Texas and Ohio.
- Clear Spring Health Premier Rx (PDP) is an enhanced plan with a low monthly premium between $13-$17 per month in most states. It has a deductible of $435 but tier 1 and 2 drugs are exempt from the deductible and the patient will immediately begin paying initial coverage copays for them. Because it is an enhanced plan, it does not have benchmark status ($0 premiums for dual eligibles).
Humana Walmart Value Rx Plan (PDP) is a new plan available in all states for 2020. This should not be confused with the Walmart Value Rx Plan, which is being cross-walked to a new plan called Humana Premier Rx Plan (PDP) for 2020. This new Humana Walmart Value Rx Plan is an enhanced plan with a low monthly premium of $13.20 and a $435 deductible. Similar to the Clear Spring Health Premier Rx (PDP) above, tier 1 and 2 drugs are exempt from the deductible, and it is not a benchmark plan for duals.
WellCare Wellness Rx (PDP) is another new enhanced plan for 2020, available in all 50 states and DC. Monthly premiums range from $13-$16 with lower tier drugs/most generics exempt from the $435 deductible.
Plan Name Changes and Crosswalks
The following plan name changes will take effect in 2020:
- 2019 Aetna Medicare Rx Saver (PDP) is becoming WellCare Medicare Rx Saver (PDP).
- 2019 Aetna Medicare Rx Select (PDP) is becoming WellCare Medicare Rx Select (PDP).
- 2019 Aetna Medicare Rx Value Plus (PDP) is becoming Wellcare Medicare Rx Value Plus (PDP).
- 2019 Humana Preferred Rx Plan (PDP) is becoming Humana Basic Rx Plan (PDP).
- 2019 Humana Walmart Value Rx Plan (PDP) is becoming Humana Premier Rx Plan (PDP).
- All patients on Aetna Medicare Rx Value Plus (PDP) or WellCare Extra (PDP) will be on WellCare Medicare Rx Value Plus (PDP).
- All patients on Silverscript Allure (PDP) will be crosswalked to Silverscript Choice (PDP).
- All patients on Humana Enhanced (PDP) and Humana Walmart Rx Plan (PDP) in 2019 will be on Humana Premier Rx Plan (PDP).
- All Florida patients on BlueMedicare Value Rx (PDP) in 2019 will be crosswalked to BlueMedicare Premier Rx (PDP).
- All North Carolina and Louisiana patients on Basic Blue Rx Value (PDP) in 2019 will be crosswalked to Basic Blue Rx Standard (PDP).
Anthem BCBS plans (available in KY, IN, KS, VA, CA, CO, MO, OH, NH, ME, WI, GA, as well as under the name Empire in NY) have switched from Express Scripts to a new PBM called IngenioRx in partnership with CVS Caremark. IngenioRx Medicare BIN: 020115 PCN: IS RxGroup: WM2A
Silverscript Plus is switching to the CVS Caremark P1 network for 2020, which is historically an Aetna network, and has non-preferred/standard cost-sharing for independent pharmacies.