This ARC TALKS Webinar covered information on Medicare basics, choosing a Part D plan, and coverage gaps. ARC was joined by Sylvia Gary from the Centers for Medicare and Medicaid Services (CMS).
The webinar concluded with a Q and A session.
Original Presentation Date:
October 29, 2024
0:00 — Intro
4:13 — Getting Started with Medicare
5:36 — What is Medicare?
7:00 — What are the Parts of Medicare?
11:36 — Medicare Enrollment Periods
19:05 — Medicare Parts A&B
27:15 — Medigap Policies
27:45 — Medicare Part D
32:17 — Choosing a Part D Plan
42:23 — Q&A
42:31 — Are Vyndaqel and Vyndamax (tafamidis) both listed on Medicare plans?
46:17 — Can I limit my costs before the $2000 out of pocket cap begins in 2025?
47:37 — What are my options for cost assistance?
48:49 — Do patient assistance programs impact my ability to qualify for financial assistance?
49:20 — How does a pharmacy’s deductible impact my payments?
49:59 — How do I know if a drug requires prior authorization, step therapy, or has other limitations?
50:50 — Who is absorbing the difference in costs with the impact of the Inflation Reduction Act?
51:17 — Can my Medigap plan cover at home treatment?
52:52 — If a drug is given as an infusion, is that covered under Part A or Part B?
53:11 — Troubleshooting yearly cost over the out of pocket maximum
58:02 — Do I need separate plans for December 2024 and all of 2025?
With such an important and complex topic as Medicare, attendees had many questions. Unfortunately we didn’t have time to answer all of the questions during the webinar itself. Sylvia Gary was kind enough to answer these questions after the conclusion of the webinar. Her answers are listed below:
Q: Is there an appeal process if your medication is not on the formulary? Are there options to ask for exceptions?
A: Yes, you can file for an exception through your plan. Follow the steps they outline, and you will need provider support from your doctor.
Q: Does Medicare cover the infusion drugs Onpattro, Amvuttra, and Wainua? How is the coverage different since some are given at home and some are given at the hospital/infusion center?
A: Onpattro and Amvuttra are covered by Part B, but I didn’t find that Wainua is covered. I would check with your provider.
Typically drugs that need to be administered by a health care professional are covered by Part B. If you can administer them yourself (like you can with Wainua) they would be covered under Part D.
Q: When I was on commercial insurance, Onpattro and the home infusion support was billed to my medical insurance, not my prescription drug plan. Now that I’m on Medicare I’m being told that it will be billed to Part D, not Part B. Why?
A: It is my understanding that it will be covered by Medicare Part B. I recommend checking with your plan.
The Onpattro website directs providers to the following guidance:
For patients on Medicare who are receiving ONPATTRO and are covered under Medicare Part B benefit, the Medicare Administrative Contractors (MACs) may require additional chart documentation to determine the medical necessity of the treatment, although prior authorization is not required.
Q: Is Amvuttra covered by Part B if administered by home health?
A: Medicare Part B does cover Amvuttra since it has to be administered by a health care provider. I would check with your plan to see if they offer this as a home health benefit. If you have Original Medicare, check with your provider in order for it to be coded correctly.
Q: Can you share any information on drug coverage through the V.A.?
A: Veterans Affairs (VA) benefits offer creditable drug coverage. This means that if you are enrolled in VA drug coverage, you can delay Medicare Part D enrollment without incurring a late enrollment penalty (LEP). Be sure to compare the costs and benefits of Part D and your VA drug coverage to decide which best suits your needs. Typically, VA drug coverage has no premiums and no or limited copayments for prescriptions—but you must use VA pharmacies and facilities.
Q: Is there a helpline for specific insurance questions?
A: For Medicare questions, you can call 1-800-MEDICARE. If you have specific plan question, you need to reach out to them directly.
Q: Where can we find more information on Medicare Advantage Plans? What is the difference between Medicare Advantage and Medigap?
A: Medicare Advantage is another way to get Medicare coverage; it includes Part A and B and possibly Part D. You will need to follow the plan’s rules and providers; managed care. Medigap is an insurance policy that fills in the gaps of Original Medicare; 20% out of pockets costs.
Medicare.gov has information on all parts of Medicare as well as a Plan Finder to see what Medicare Advantage plans are available in your area.
Q: Can you get “kicked-out” of a plan? My 2024 plan is not offered in 2025.
A: Your plan may transition you to another plan for the following year. Also, the Medicare Open Enrollment is occurring October 15-December 7.
Q: Can the formulary change? Vyndamax was listed in my plan on October 17th, but it is not listed now. How often do I have to check back?
A: Yes, plans can change their formulary. They must notify affected individuals in writing at least 60 days before changes take effect, unless the change is a maintenance change. Maintenance changes include adding a new generic drug or changing a drug’s tier placement.
You can file an exception/appeal with the plan for it to be covered.
I would check to see if Vyndamax is covered the following plan year. Check with your plan directly.
Q: Can you discuss the concept of total drug cost if you are on multiple costly drugs? Last year I was on Vyndamax, Jardiance, and Xarelto. I paid $8,000 and got catastrophic coverage so all my meds were paid for. Is there a catastrophic level in 2025?
A: Costs in the coverage gap (catastrophic coverage) will be reflected in the $2000 cap.
Starting in 2025, all Medicare plans will include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan. If your out-of-pocket spending on covered drugs reaches $2,000 (including certain payments made on your behalf, like through the Extra Help program), you’ll automatically get “catastrophic coverage.” That means you won’t have to pay out-of-pocket for covered Part D drugs for the rest of the calendar year.
Q: Is there a cap of $3300 in 2024 for Part D?
A: The Part D catastrophic drug coverage for 2024 is $8,000 in out-of-pocket spending.
Your true out of pocket (TrOOP) costs include your own out-of-pocket payments, plus other payments for your covered drugs that certain people or organizations make for you (like Medicare’s Extra Help program or manufacturer payments for brand name drugs as part of the Medicare Coverage Gap Discount Program).
When total gross covered prescription drug costs for a person reach the initial coverage limit, that person transitions into the coverage gap. By contrast, progression through the coverage gap is determined by accumulated TrOOP spending (see above). Once accumulated TrOOP for a person reaches the annual OOP threshold, that person enters the catastrophic coverage phase.
Your exact out-of-pocket contribution to reach $8,000 in TrOOP depends on your plan’s benefit design and the mix of brand name and generic drugs you take. Based on our analysis of total out-of-pocket spending, when you reach the catastrophic coverage phase using only brand-name drugs, you’ll have around $3,300 in total out-of-pocket costs.
Q: Can you go back to Original Medicare with Part D drug coverage after being on Medicare Advantage? Can you go back to Original Medicare with a Part G Medigap after being on Medicare Advantage?
A: Yes, you can make changes on how you want your Medicare coverage. The Medicare Open Enrollment is occurring now, October 15-December 7.
You can go back to Medigap, but double check with the policy. For more information visit: https://www.medicare.gov/health-drug-plans/medigap/basics/how-medigap-works.
Q: Do all providers accept Medicare Advantage plans?
A: No, check with the plan’s directory.
Q: Many hospitals are no longer covered by Advantage plans. Can I sign up for prescription coverage under Advantage and still sign up for Medicare B? Can I sign up for a supplemental plan at the same time?
A: You can enroll into a stand-alone Part D plan for drug coverage, enroll into Part A and B and sign up for Medigap all at the same time. You will need Part A and B in order to buy a Medigap policy.
Q: When will we know what the premiums will be for 2025? And do we just keep checking back on the Medicare site to get the information or does everyone currently on Medicare get notified?
A: https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles
Q: Can you receive help from a patient assistance program if you are on Medicare? How are patient assistance programs and Medicare related?
A: Yes, but some patient assistance programs may not allow. Check with their requirements.
Q: If a drug requires prior authorization, does it show as “not covered” until prior authorization is achieved for the new year?
A: No, it will state “prior authorization” required.
Q: I have an $8000 out of pocket cap this year and a $2000 cap next year. Will the pharmacy or insurer stop my copays automatically when I hit the limit, or must I take some action to take advantage of the cap?
A: The pharmacy and plan will coordinate, and it will reflect when you pick up prescriptions.
Q: Are there any Part D plans that still cover Vyndmax?
A: I encourage you to search on the Medicare Plan Finder for plans in your area. You can search on Medicare.gov.
Q: If the yearly max is now $2000, why join a Part D plan?
A: Starting in 2025, all Medicare plans will include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan. If your out-of-pocket spending on covered drugs reaches $2,000 (including certain payments made on your behalf, like through the Extra Help program), you’ll automatically get “catastrophic coverage.” That means you won’t have to pay out-of-pocket for covered Part D drugs for the rest of the calendar year.
This is a Part D benefit. You do not receive this benefit if you are not enrolled in a Part D plan.
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