Something strange happened between the time Linda Griffith enrolled in a new Medicare prescription drug plan during the enrollment period last fall and when she tried to fill out her first prescription in January.
He chose a Humana drug plan for its low prices, with the help of his long-time insurance agent and Medicare Plan Finder, an online pricing tool for comparing a dizzying variety of options. But instead of the $ 70.09 he expected to pay for his dextroamphetamine, which was used to treat attention deficit / hyperactivity disorder, his pharmacist told him he owed $ 275.90.
“I didn’t take it because I thought something was wrong,” said Griffith, 73, a retired accountant for a construction company that lives in Weaverville, Northern California.
“For me, when you buy a plan, you have an implicit contract,” he said. “I say I’ll pay the premium on time for this plan. And they’ll make sure you get the drug for a certain amount.”
But it often doesn’t work that way. As soon as three weeks after the Medicare drug plan enrollment period ends on December 7, insurance plans can change what they charge members for drugs, and they can do so repeatedly. The cost of Griffith’s recipe pocket has varied every month and, as of March, she has already paid $ 433 more than she expected.
A recent analysis by the AARP, which is pushing Congress to pass legislation to control drug prices, compared the list prices of drug manufacturers between the end of December 2021 — shortly after the registration deadline. December 7 — and the end of January 2022, just one month after new Medicare drug plans began. The researchers found that the list prices of the 75 most commonly prescribed brand-name drugs for Medicare beneficiaries had risen by up to 8%.
Medicare officials acknowledge that manufacturer prices and out-of-pocket costs charged by an insurer can fluctuate. “Your plan may increase the co-payment or co-insurance you pay for a particular drug when the manufacturer raises its price or when a plan begins offering a generic form of a drug,” the Medicare website warns.
But no matter how high the prices are, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.
Drug makers often change the list price of drugs in January and occasionally back in July, “but they can raise prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. and a member of the Medicare Payments Advisory Board. This is true for any health insurance policy, not just Medicare drug plans.
Like the price of a car sticker, the list price of a drug is the starting point for negotiating discounts, in this case, between insurers or their pharmacy benefit managers and drug manufacturers. . If the list price goes up, the amount the plan member pays can also go up, he said.
Discounts received by insurers or their pharmacy benefit managers “usually do not translate into lower prices at the pharmacy counter,” he said. “Instead, these savings are used to reduce premiums or slow down premium growth for all beneficiaries.”
The Medicare Prescription Drug Benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have drug insurance coverage, advocates said, many still can’t afford it.
“We constantly hear from people who only have an absolute shock when they see not only the total cost of the drug, but also its cost-sharing,” Riccardi said.
The potential for surprises is growing. More insurers have eliminated co-payments (a dollar-fixed amount for a prescription) and instead charge members a percentage of the price of the drug, or co-insurance, said Chiquita Brooks-LaSure, a senior service center employee. Medicare and Medicaid, in a recent interview. with KHN. The drug benefit is designed to give insurers the “flexibility” to make those changes. “And that’s one of the reasons we’re asking Congress to give us the authority to negotiate drug prices,” he said.
CMS is also looking at ways to make drugs more affordable without waiting for Congress to act. “We’re always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Medicare Center, who joined Brooks-LaSure during the interview.
On April 22, CMS presented a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay their Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.
Grants make a difference. Low-income recipients who have separate drug coverage plans and receive grants are nearly twice as likely to take their drugs as those without financial assistance, according to a study co-authored by Dusetzina for Health Affairs in April.
When CMS approves plans to sell them to beneficiaries, the only part of the price of the drugs it approves is the amount or cost-sharing level applied to each drug. Some plans have up to six levels of drugs.
In addition to the level of drugs, what patients pay may also depend on the pharmacy, their deductible, their copayment or co-insurance, and whether they choose to abandon their insurance and pay in cash.
After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare, but she still couldn’t figure out why the cost was so high. . “I finally had to give in and pay for it because I need the drugs; I can’t function without them,” he said.
But she did not give up. He appealed to his insurance company for a downgrade, which was denied. The plan denied two more requests for price adjustments, despite the assistance of Pam Smith, a five-county program director in California under the Health Insurance Advice and Advocacy Program. They are now appealing directly to CMS.
“It’s important for us to work with our members who have questions about pocket costs that are higher than the member would expect,” said Lisa Dimond, a spokeswoman for Humana. He was unable to comment on Griffith’s situation due to privacy rules.
However, Griffith said he received a call from a Humana executive who said the company had received a media consultation. After talking about the problem, Griffith said, the woman said, “The [Medicare] Plan Finder is an external source and therefore not reliable information, “he told Griffith.
You don’t have to look far: CMS requires insurers to update their prices every two weeks.
“I want their money back and I want them to charge me the amount I agreed to pay for the drug,” Griffith said. “I think this needs to be fixed because other people will be fooled.”
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