Seniors, Medicare plan providers, and caregivers can expect a few changes in the 2019 Medicare Part D program. Below are a few highlights from the final
2019 Call Letter
and a 1,156
page Medicare Part D (unpublished) Final Rule
released on April 02, 2018 by the Centers for Medicare and Medicaid Services (CMS).
(1) The finalized standard 2019 Medicare Part D plan parameters increase slightly over 2018 Medicare Part D plan coverage (except for the total estimated retail drug spending needed to exit the Donut Hole).
CMS published the finalized defined standard Medicare Part D plan
parameters that will form the basis of the 2019 Medicare drug plans. You
here to see our analysis
of the 2019 standard defined plan changes and how Medicare
Part D coverage has changed over the years.
(2) You may exit the 2019 Donut Hole
faster than you expected.
One key point of the CMS Call Letter is that, based on the Bipartisan Budget Act of
enacted February 2018, the brand-name Donut Hole discount
will increase to 75% in 2019 - and the pharmaceutical
industry will be responsible for 70% of this 75% Donut Hole discount, with your
Medicare Part D plan covering the remaining 5%.
So if your monthly retail drug costs are over $318
, you will reach the 2019 Donut Hole, pay 25% of retail brand-name drug prices, and get 95% of
the brand-name retail drug cost credited to your out-of-pocket spending limit
(or TrOOP). And this means:
You may exit
the 2019 Donut Hole faster than you expected and enter Catastrophic
. Based on historical drug
purchasing, CMS estimates that if you have monthly retail drug costs over $678
you will exit the 2019 Donut Hole.
(3) The 2019 generic drug Donut Hole discount has not changed.
As a reminder, the generic Donut Hole discount was not affected or “closed”
by the Bipartisan Budget Act of 2018. The 2019 generic Donut Hole discount is 63% of retail – you will pay 37% of the generic drug cost and the amount you spend will count toward exiting the
Donut Hole. In 2020, the generic Donut Hole discount will increase to 75%.
(4) You will not receive your 2019 ANOC letter and
your Medicare Part D plan’s Evidence of Coverage at the same time.
In late-September or early October, your Medicare plan will send you a 2019
Annual Notice of Change letter (ANOC) detailing how your current 2018 Medicare
plan is changing in 2019. However, CMS is separating the delivery of the ANOC letter and the delivery of your Evidence of Coverage (EOC) document so that the two documents arrive at different
You may recall that your ANOC is a relatively short, 10+ page document that summarizes upcoming plan changes and your EOC document is a rather long, 140+ page document that details your
2019 Medicare plan coverage. As noted by CMS, the “ANOC must be delivered 15 days prior to the [Annual Election Period (AEP)] and will be received
by enrollees ahead of the EOC, thus allowing enrollees to focus on materials
that drive decision-making during the AEP.” You should expect your 2019 EOC to
be delivered on the first day of the Annual Election Period (October 15th
(5) Your 2019 Medicare Part D plan will actively fight opioid addiction.
In 2019, your Medicare Part D plan will implement a drug management program
to monitor and limit at-risk Medicare beneficiaries’ access to frequently
abused drugs (such as opioids and benzodiazepines). Medicare Part D plans will be permitted to
have a “lock-in” feature “to limit an at-risk beneficiary’s access to
frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies).”
will also limit “the availability of the
special enrollment period (SEP) for dually or other low income subsidy (LIS)
eligible beneficiaries who are identified as at-risk or potentially at-risk for
prescription drug abuse under such drug management programs
. At-risk determinations, which include prescriber and pharmacy lock-in, will be subject to the existing beneficiary appeals
process.” [emphasis added]
(6) Starting in 2019, the Special
Enrollment Period (SEP) for Dual-Eligible and Extra Help recipients will be
limited to one plan change per quarter during the first 9 months of the year.
In 2019, Medicare beneficiaries who are dual-eligible (Medicare/Medicaid) or
eligible for the Medicare Part D Extra Help program will no longer have a continuous
month-to-month Special Enrollment Period (SEP)
. Instead, the Dual-Eligible or Extra Help SEP “ may be used only once per calendar quarter during the first
nine months of the year
(7) The Medicare Advantage Open Enrollment Period returns in 2019.
In 2019, we will no longer have the Medicare Advantage Disenrollment Period
that started January 1st
and continued through February 14th
. Instead, we will return to the Medicare
Advantage Open Enrollment Period (OEP) starting on January 1st
continuing through March 31st
The OEP will allow people “enrolled in an MA plan, including newly MA-eligible individuals, to make a one-time election to go to another [Medicare
Advantage] plan” - or to leave their Medicare Advantage plan, join a stand-alone
Medicare Part D plan, and return to Original Medicare Part A and Part B. "For example, an individual enrolled in an MA-PD plan may use the OEP to switch to: (1) another MA-PD plan; (2) an MA-only plan; or (3) Original Medicare with or without a PDP. The OEP will also allow an individual enrolled in an MA-only plan to switch to-- (1) another MA-only plan; (2) an MA-PD plan; or (3) Original Medicare with or without a PDP. However, this enrollment period does not allow for Part D changes for individuals enrolled in Original Medicare, including those with enrollment in stand-alone PDPs."
CMS expects approximately 558,000 Medicare beneficiaries will use the OEP to make an enrollment change.
You can read more about the 2019 Medicare Part D plan year outlook at: Q1Medicare.com/2019
You can also sign-up for our Medicare Part D Reminder Service
and we will send an email as information becomes
available on the 2019 Medicare Part D program and plans. Your email will not be shared with anyone and you can unsubscribe at any time.