Medicare Advantage Prescription Drug plans (MA-PDs) continued to gain more enrollees than stand-alone Prescription Drug Plans (PDPs) in 2024, according to a KFF analysis.

As of 2024, about 53.1 million Medicare beneficiaries were enrolled in a plan with Part D prescription drug coverage, with 57% in MA-PDs and 43% in stand-alone PDPs. Two-thirds of enrollees receiving the low-income subsidies (LIS) — 9 million out of 13.7 million — chose MA-PDs in 2024. Among the 14 national PDPs, 11 of them lost non-LIS enrollees, with only Wellcare Value Script seeing significant membership growth (from 2.6 million to 3.7 million) due to its low monthly premium.

The House Ways and Means Committee on June 27 cleared legislation authorizing Medicare Part D plans to cover obesity drugs for new enrollees who had commercial coverage for the treatments in the year prior to aging into the program, a move that may prove to be largely symbolic because of its limited impact.

The bill is a significantly slimmed down version of the Treat and Reduce Obesity Act (TROA) and was offered at the markup by committee leadership as a substitute for the original bill. TROA advanced in a bipartisan 36-4 vote.

Currently, obesity drugs are not defined as “covered” Part D drugs. The bill would allow, but not require, plans to cover the treatments for obesity in some individuals.

Amazon Pharmacy revealed earlier this month that its RxPass subscription savings program is now available to “more than 50 million Medicare beneficiaries,” allowing those who are Prime members to get 60 common generic medications delivered for a $5 monthly fee. Industry experts tell AIS Health that they can see the appeal in such an offering — including both convenience and potential cost savings — but they aren’t expecting the newly expanded service to significantly impact the Medicare Part D space.

“To be very honest, when I read the news, I didn’t really give it too much of a second glance,” says Marc Guieb, Pharm.D., a consultant at Milliman. “In terms of big-picture market stuff, I don’t think this really is going to change much or have any sort of tangible effects.”

Most industry experts likely would agree that certain provisions in the Inflation Reduction Act (IRA), such as a $2,000 out-of-pocket spending cap for Medicare Part D beneficiaries and copay smoothing — known as the Medicare Prescription Payment Plan (M3P) — are no-doubt wins for patients. But other aspects of the law, particularly Medicare drug price negotiations and inflation-based rebates, have prompted disagreements over their ultimate outcomes, with some experts claiming that they will hurt drug development and will prompt more restrictive utilization management among payers. Ultimately, said pharma industry experts during a recent webinar, stakeholders should keep patient support top of mind as they navigate these changes.

While home infusion has been an option for patients for decades, the space continues to evolve. Within this landscape, providers must successfully execute the contracting process with PBMs and government and commercial insurers, navigating various pitfalls along the way.

Attorney Jesse Dresser, a partner in law firm Frier Levitt’s life sciences department who heads the firm’s pharmacy practice group and frequently helps pharmacies and pharmacy providers on issues with payers and PBMs, moderated a panel discussion titled “Strategies for Successful Payer and PBM Contracts in Home Infusion” at the National Home Infusion Association’s (NHIA) annual conference, held March 23 through 27 in Austin, Texas.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full.

Compounded by known challenges in estimating Medicare Part D costs stemming from the Inflation Reduction Act (IRA), the process of finalizing Medicare Advantage insurers’ bids for the 2025 plan year was an “extra wild ride” due to a variety of unknowns, according to Matt Kranovich, principal and consulting actuary with Milliman. And while national insurers in recent months have publicly disclosed their intent to skinny down their MA offerings through things like benefit adjustments and strategic exits, similar reactions to revenue headwinds may play out across the country and lead to more market consolidation than CMS would care to see, warns Tim Murray, principal with Wakely, an HMA company.

Medicare Part D plans are likely to revise their biosimilar formulary management policies as a result of recent regulatory changes, not least the Inflation Reduction Act (IRA). Part D payers will also be on the hook for a greater share of the cost of biosimilars going forward.

A study in Health Affairs released in May makes the case that the longstanding gap in the coverage of biosimilar products between employer-sponsored insurance plans and Medicare Part D plans is likely to shrink in 2025, when several key components of the IRA take effect.

This article originally appeared as part of the May 16 issue of Radar on Medicare Advantage.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

As Medicare Part D sponsors consider critical steps to setting up the new Medicare Prescription Payment Plan (M3P), CMS is weighing feedback from stakeholders on various aspects of the program, from beneficiary communications to pharmacy interactions. And some warned that potential beneficiary confusion may lead to increased complaints that impact plans’ Star Ratings.

The M3P, which takes effect on Jan. 1, 2025, requires both stand-alone Prescription Drug Plan and Medicare Advantage Prescription Drug carriers to give beneficiaries the option to spread their pharmacy costs over the plan year via a capped monthly payment. CMS in February issued its second draft guidance on the M3P and asked for comments no later than March 16. CMS plans to release the final guidance this summer. The agency sought comment on model materials issued through an Information Collection Request (ICR), including a standardized notice that plans would be required to use for targeted outreach to enrollees who are likely to benefit from the M3P. The initial 60-day comment period on the model materials ended April 29; CMS said it expects to issue a second, 30-day comment period in Spring 2024.