With the annual Medicare enrollment period about to begin, we want to make you aware of some updates we’re planning for our Medicare Advantage plans for 2025 — some of which we anticipate will result in an increased number of calls and questions from patients in need of prescription updates and medication reviews.
Industrywide changes resulting from the IRA
Certain provisions of the Inflation Reduction Act (IRA) will result in a number of changes across the health care industry beginning Jan. 1, 2025. These changes will impact all members of a Medicare Part D prescription drug plan, including our applicable Point32Health members.
Because of the substantial and wide-reaching effect of these provisions, we want to highlight the most significant updates you and your patients can anticipate in connection with the IRA, as well as some consequent changes Point32Health is making to our Pharmacy formulary tiering for 2025.
The provisions of the IRA apply to all Medicare Advantage and Medicare Part D prescription drug plans. The most notable changes our members will see in 2025 in relation to these industrywide provisions include:
- Lower maximum out-of-pocket limit (MOOP) – For 2025, the MOOP will be lowered from $3,300 to $2,000, meaning that $2,000 is the highest amount a member may be obligated to pay for all their prescription drugs in 2025 before entering catastrophic coverage, during which Point32Health would pay the remainder of their prescription drug costs.
- Implementation of the Medicare Prescription Payment Plan – Members will have the opportunity to opt into the Medicare Prescription Payment Plan, which is a new payment option that will allow them to better manage their out-of-pocket Part D prescription drug costs by splitting bills into regular monthly installments across the calendar year, as an alternative to paying the full amount up front. This is expected to improve access to drugs, and may also contribute to increased utilization due to the removal of a cost barrier preventing some members from starting a new treatment or adhering to an existing treatment. The program is free to join and there is no accrued interest on outstanding payments.
- The prescription drug coverage gap (“donut hole”) is going away – Currently, Medicare Part D prescription drug plans have a coverage gap known as the “donut hole,” which means that once a member and their plan have spent a certain amount for covered drugs for the plan year, their coverage is temporarily limited. This will be eliminated for 2025.
Point32Health Pharmacy formulary and benefit changes
In an effort to ensure that our plan premiums remain affordable, Point32Health is implementing certain changes as a result of the IRA for the 2025 plan year.
Firstly, we’ll be making a number of changes to our Pharmacy formulary, which will cause some drugs to have higher cost shares as a result of moving to higher tiers, and some drugs to no longer be covered. (For drugs that are no longer covered, there may be a therapeutically equivalent medication available that will meet the member’s needs.)
Formulary changes occur every year, but the volume of these changes will be markedly higher for 2025 than in previous years. While the majority of these changes will not have a substantial effect, members and providers should be prepared for the fact that certain tier changes will result in significantly higher costs for some drugs.
Additionally, we’re making changes to our benefit structures for 2025, which will include drugs on Tier 3 and Tier 4 moving from fixed copays to a coinsurance payment structure, meaning that the member will pay a percentage of the actual cost of the drug. Coinsurance payments for some drugs will be similar or lower in cost compared to the current copays, but it’s important to note that costs for some Tier 3 and Tier 4 drugs — particularly high-cost brands — will be significantly higher on the coinsurance model.
Key points to keep in mind
Depending on the drugs they take, your Point32Health Medicare Advantage patients may experience varying degrees of prescription drug coverage disruption and financial impacts. Some key points to note include:
- Providers who prescribe Part D medications to Point32Health members should prepare to receive an increased number of calls and questions from patients in need of prescription updates and medication reviews.
- The IRA provisions apply to all health plans with Medicare members, and we anticipate that many other plans will be making similar updates to their plan designs and formularies.
- Point32Health is communicating with our members through several different channels to ensure that they are aware of the coming changes, including sending letters to members most impacted by these changes.
- For many members, depending on which prescription drugs they take, much of the negative impact associated with tiering and benefit structure changes may be mitigated by the IRA’s reduced MOOP and the introduction of the new Medicare Prescription Payment Plan.
- Providers should instruct members to prepare financially for the updates coming in 2025:
- We also recommend that eligible patients consider enrolling in the Medicare Prescription Payment Plan if it may be right for them. They can do this during the AEP, once their Jan. 1, 2025 eligibility and enrollment is confirmed, or anytime throughout the 2025 benefit year. Patients looking for help in determining whether this payment option is a good fit for them should call Point32Health Member Services at the number on the back of their ID card.
- Recommend that members refill prescriptions prior to Jan. 1, 2025 for drugs that will be increasing in cost.
Harvard Pilgrim StrideSM (HMO/HMO-POS) Medicare Advantage plan being discontinued
In addition, we want to share an important update on our Harvard Pilgrim StrideSM (HMO/HMO-POS) Medicare Advantage plan. We are constantly examining our business to ensure we offer our members affordable, high-quality health plans and products in the market. As a result of a comprehensive review of the New Hampshire Medicare Advantage market, we recently made the decision to discontinue our StrideSM (HMO/HMO-POS) Medicare Advantage plan in New Hampshire, effective Jan. 1, 2025. As of that date, the product will no longer be available.
Please continue to provide services to StrideSM (HMO/HMO-POS) Medicare Advantage members through the end of the year and submit claims as you do today. We will process claims through the claims timely submission time frame for Stride, which is 365 days post date of service.
We will continue to offer our other New Hampshire products, including our Harvard Pilgrim Commercial plans and our individual Medicare Supplement plan.
While members will continue to have access to their Stride benefits and services through the end of the year, we are encouraging the approximately 10,000 affected members to seek out alternative options available in the market. We are mailing letters to these members to inform them of the discontinuance and how to search for an alternative plan offering during the Annual Enrollment Period (AEP).
Look to next month’s issue of Insights and Updates for Providers for a follow-up communication providing more in-depth detail regarding benefit updates, specific drugs that will be critically impacted, and more.
Annmarie Dadoly,
Senior Manager, Provider Communications
Joseph O’Riordan,
Editor
Susan Panos, Ellen Gustavson, Ryan Francis, Stephen Wong,
Writers
Kristin Edmonston,
Production Coordinator
Kristina Cicelova,
Graphic Designer