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 HHS Announces First Set of Drugs Selected for Medicare Price Negotiation

The drugs selected to undergo negotiations are:

• Eliquis, a blood thinner
• Xarelto, a blood thinner
• Januvia, a diabetes drug
• Jardiance, a diabetes drug
• Enbrel, a rheumatoid arthritis drug
• Imbruvica, a drug for blood cancers
• Farxiga, a drug for diabetes, heart failure and chronic kidney disease
• Entresto, a heart failure drug
• Stelara, a drug for psoriasis and Crohn's disease
• Fiasp and NovoLog, for diabetes

It is estimated that these medications account for roughly 20% of the total costs for Medicare during the review period. 

Perspective: While these changes are set to occur in future years, they may begin to impact pricing and modeling inside Part D and Part C plans sooner.  It is a good idea to review existing medication needs to confirm a consumers existing plan is still optimal for their needs. 

More information:

 https://www.whitehouse.gov/briefing-room/statements-releases/2023/08/29/fact-sheet-biden-harris-administration-announces-first-ten-drugs-selected-for-medicare-price-negotiation/

Network Negotiations

During the course of 2023 there have been a number of high profile negotiations between providers and insurance carriers.  

This often creates confusion and panic with consumers as they often receive letters from both parties reminding them that care options may abruptly change.   The change in networks may impact those enrolled in HMO or PPO plans.  These are Part C or advantage plans.   There are often options that can be explored to help insure needs are met.   If someone is enrolled in a medicare supplement plan they are under original medicare and networks aren't typically as applicable.

Perspective:  it is important for beneficiaries and consumers to confirm networks as they enroll in plans.  In the case a providers enter a negotiation that may impact care, explore whether how much of an impact it may have for the individual.  Explore options if necessary as their may be opportunities to enroll in a plan that provides the required coverage. 

What vaccines are covered by Medicare and how? 

Vaccines are often covered under Part B and without copayment but there are some covered under Part D (or Part C/ Advantage plans).  In review of the coverage:

Part B

Flu (influenza)

Pneumococcal 

Covid-19 

Hepatitis B

Part D

Tdap 

Shingles 

RSV(Respiratory syncytial virus)

Perspective:  As we enter the fall season many of these vaccines gain alot of focus.  RSV is recently approved for those over 60 and October is a common time to receive that vaccine.   The Part B vaccines will vary in coverage and cost depending on the enrolled plan.   Shingles and Tdap are currently offered with no cost share but it is encouraged to review the plan's formulary to determine. 

More information:

 The National Council on Aging (ncoa.org) 

There is a $35 cost-sharing cap on insulin products covered under prescription drug plans.  It is also important to note that the existing prescription plan deductibles will not apply to insulin products.  

Perspective: It is encouraged that consumers whom require insulin review their part d (PDP) or part c (advantage) plans to insure the products they prefer are on their plans formulary.  

More information:

https://www.cms.gov/priorities/innovation/innovation-models/part-d-savings-model

Routine dental care is not something covered under Medicare.   There are a few ways that consumers can obtain dental and/or vision insurance.   If someone is enrolled in a part c or advantage plan they often will have some added coverage for these needs inside the plan.   Coverage and networks will differ between carriers and products but it is worth reviewing.  

Those enrolled in original medicare with (or without) a supplement may wish to purchase a standalone plan for dental and / or vision.  There are many options locally and plan design flexibility.

Perspective: if you know someone who is concerned about this coverage.  a.) explore whether existing options may offer something that they may have overlooked.   This can be found in the Evidence of Coverage or Benefit Summary for their plan.   It is also encouraged to explore standalone options.  Goals can often be achieved at a competitive cost. 

Promote employee wellness and prevent healthcare costs from rising with our wellness programs. Encourage healthy habits, provide health education, and offer incentives for achieving health goals.

https://www.whitehouse.gov/briefing-room/statements-releases/2023/08/29/fact-sheet-biden-harris-administration-announces-first-ten-drugs-selected-for-medicare-price-negotiation/