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Q1Group 2019 PDP Analysis: Will your 2018 Medicare Part D prescription drug plan begin using preferred pharmacy pricing in 2019?


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Q1Group 2019 PDP Analysis: Will your 2018 Medicare Part D prescription drug plan begin using preferred pharmacy pricing in 2019?
Published on 2018-10-20 15:54:51
Category: Annual Medicare Plan Changes


Each Medicare Part D plan has a national pharmacy network that includes 50,000 to 60,000+ pharmacies and both "preferred" and "standard" pharmacies are included in a Medicare prescription drug plan’s pharmacy network.

However, preferred network pharmacies usually have lower cost-sharing as compared to standard network pharmacies — meaning, you may pay less for your prescriptions at a preferred pharmacy as compared to a standard pharmacy (you can see some 2019 examples below).

How do you know if your Medicare Part D plan uses preferred pharmacy pricing?
Both our PDP-Finder and MA-Finder show the note: "Higher cost-sharing at standard network pharmacies" if a drug plan uses preferred network pharmacy pricing – and again, this means the cost-sharing you pay is different depending on whether you purchase your medications from a preferred network pharmacy or a standard network pharmacy.  You can see an "Rx$" icon after this note and then a link that will show you more details about the preferred vs. standard cost-sharing for the chosen Medicare Part D plan.

How many Medicare prescription drug plans use preferred pharmacy pricing?
About 99% of all 2019 stand-alone Medicare prescription drug plans (PDPs) will use different cost-sharing for preferred vs. standard (non-preferred) network pharmacies (as compared to 85% of all 2017).  In fact, 904 stand-alone 2019 Medicare prescription drug plans will offer additional cost-sharing savings if you shop at one of their preferred network pharmacies. 

Which 2018 Medicare Part D plans will start using preferred pharmacy pricing in 2019?
Five (5) 2018 stand-alone Medicare Part D plans will introduce preferred vs. standard network pharmacy pricing strategies in 2019. They include: *The AR Blue Cross plans under contract ID S5795 are currently sanctioned and not accepting new members. Read more here.

How do preferred and standard pharmacy co-payments compare?

As an example of different cost-sharing between network pharmacies, the chart below shows the variation between preferred and standard network pharmacies for the 2019 California SilverScript Choice (PDP) plan:

California SilverScript Choice (S5601-064)
  30-Day Supply Cost-Sharing 90-Day Supply Cost-Sharing
Preferred Pharmacy Standard
Pharmacy
Mail-Order Preferred Pharmacy Standard
Pharmacy
Mail-Order
Initial Coverage Phase Cost-Sharing (before Donut Hole)
Tier 1 - Preferred Generic: $3.00 $7.00 $3.00 $9.00 $21.00 $0.00
Tier 2 - Generic: $13.00 $20.00 $13.00 $39.00 $60.00 $32.50
Tier 3 - Preferred Brand: $42.00 $47.00 $42.00 $126.00 $141.00 $105.00
Tier 4 - Non-Preferred Brand: 45% 50% 45% 45% 50% 45%
Tier 5 - Specialty Tier: 33% 33% 33% n/a n/a n/a

Note: The preferred and standard network pharmacy cost-sharing can vary by state.  You can use our Rx$ icon on our PDP-Finder or MA-Finder to see the cost-sharing details for all tiers and pharmacies for any Medicare Part D or Medicare Advantage plan with prescription drug coverage.

As a second example, the chart below shows the variation between preferred and standard network pharmacies for the 2019 WellCare Classic plan:

Texas WellCare Classic (PDP) (S4802-013)
  30-Day Supply Cost-Sharing 90-Day Supply Cost-Sharing
Preferred Pharmacy Standard
Pharmacy
Mail-Order Preferred Pharmacy Standard
Pharmacy
Mail-Order
Initial Coverage Phase Cost-Sharing
Tier 1 - Preferred Generic: $0.00 $5.00 $0.00 $0.00 $15.00 $0.00
Tier 2 - Generic: $1.00 $6.00 $1.00 $3.00 $18.00 $2.50
Tier 3 - Preferred Brand: $29.00 $45.00 $29.00 $87.00 $135.00 $72.50
Tier 4 - Non-Preferred Brand: 40% 47% 40% 40% 47% 40%
Tier 5 - Specialty Tier: 25% 25% 25% n/a n/a n/a

Note: The preferred and standard network pharmacy cost-sharing can vary by state. You can use our Rx$ icon on our PDP-Finder or MA-Finder to see the cost-sharing details for all tiers and pharmacies for any Medicare Part D or Medicare Advantage plan with prescription drug coverage.

How about an actual example of how cost sharing can vary between preferred and standard pharmacies?
As an example of how the different cost-sharing could affect you, the chart below shows how the total prescription costs for three medications (Atorvastatin, Clopidogrel, and Esomeprazole Magnesium) can vary between network pharmacies (such as CVS, Walmart, or Walgreens), depending on your Medicare Part D plan.

Spoiler Alert:  You may pay more for your medications at a standard network pharmacy (but not always!) — and you may pay a whole lot more for medications at a non-network pharmacy.

2019 Medicare Part D Plan Name Annual Cost at CVS* Annual Cost at Walmart* Annual Cost at Walgreens* Annual Cost Mail Order*
Express Scripts Medicare - Saver
$785 (P)
$787 (P) $911 (S) $775
Mutual of Omaha Rx Value
$790 (P)
$791 (P) $855 (S) $773
Cigna-HealthSpring Rx Secure-Essential
$992 (S)
$1,288 (P)
$1,285 (P) $1,233
SilverScript Plus
$1,045 (P) $1,279 (S) $1,045 (P) $951
WellCare Value Script
$1,230 (P)
$1,687 (S)
$1,352 (S) $917
AARP MedicareRx Walgreens
$1,235 (S) $6,629 (non-network pharmacy)
$946 (P) $851
*Annual Cost Estimates from Medicare.gov Plan Finder 10/20/2018.

(P) Preferred network pharmacy pricing for the designated Medicare Part D plan
(S) Standard network pharmacy pricing for the designated Medicare Part D plan
(non-network pharmacy) This pharmacy is not in the designated plan's pharmacy network.

Bottom Line: If you want to lower your prescription drug costs, make sure you are using one of your plan’s preferred network pharmacies (or mail order option). HOWEVER, as noted in the chart above, it can happen that the retail prices at a standard network pharmacy may be lower and your plan's co-insurance is not significantly different between preferred and standard network pharmacies.

How do we know which pharmacies have preferred or standard cost-sharing for our drug plan?
Your Medicare Part D plan documentation (Summary of Benefits and Evidence of Coverage ) should tell you whether your Medicare Part D plan has preferred cost-sharing.  You might have also received a printed Pharmacy Directory that will tell you more about preferred / standard pharmacies in your area.  (Look for text in your Evidence of Coverage document such as "The Pharmacy Directory will also tell you which of the pharmacies in our network have preferred cost-sharing, which may be lower than the standard cost-sharing offered by other network pharmacies.") 

Medicare Part D plans also usually have an easily accessible online tool that allows you to search for network pharmacies in your area and then indicates which pharmacies are preferred or standard.

We also have a Blog section with tips to using some of the more popular Medicare plan pharmacy and provider searches:  https://q1medicare.com/q1group/MedicareAdvantagePartD/Blog.php?cat=Pharmacies-and-Providers&category_id=24.

If you cannot find your plan's online pharmacy search, you can call the Medicare plan's Member Services toll-free number (found on enrollment information, printed plan information, and your Member ID card) and ask a Member Services representative to help you find a preferred pharmacy in your area or to send you a Pharmacy Directory.


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