Phelan M. Ebenhack/AP
Something strange happened between the time Linda Griffith signed up for a new prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.
She chose a Humana drug plan for its low prices, with the help of her longtime insurance agent and Medicare Plan Finder, an online pricing tool to compare a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.
“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the town of Weaverville, north of California.
“To me, when you buy a plan, you have an implied contract,” she said. “I say I’ll pay the premium on time for this plan. And they’ll make sure I get the medicine for a certain amount.”
But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do so multiple times. occasions. The cost of Griffith’s prescription fluctuated each month, and through March she had already paid $433 more than expected.
A recent analysis from AARP, which is pushing Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 – shortly after the deadline for drug prices. December 7 enrollment — and the end of January 2022, just a month after the new Medicare drug plans begin. The researchers found that the list prices of the 75 brand name drugs most frequently prescribed to Medicare beneficiaries increased by 8%.
Medicare officials recognize that manufacturers’ prices and the disbursements charged by an insurer can fluctuate. “Your plan may increase the co-pay or coinsurance you pay for a particular drug when the manufacturer raises its price or when a plan begins offering a generic form of a drug,” warns the Medicare website.
But no matter the price level, 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. .
Drugmakers typically change the list price of drugs in January and sometimes again in July, “but they may raise prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. This is true for any health insurance policy, not just Medicare drug plans.
Like the list price of a car, the list price of a medicine is the starting point for negotiating discounts – in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price increases, the amount the plan member pays may also increase, she said.
Discounts that insurers or their pharmacy benefit managers receive “usually don’t translate into lower prices over the counter at the pharmacy,” she said. “Instead, these savings are used to reduce premiums or slow 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 older people have insurance coverage for drugs, advocates said, many still cannot afford them.
“We constantly hear from people who are just in absolute shock when they see not just the total cost of the drug, but their cost sharing,” Riccardi said.
The potential for surprises increases. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, said Chiquita Brooks-LaSure, the Centers’ top official. for Medicare & Medicaid Services, in a recent interview. with KHN. Pharmacare is designed to give insurers the “flexibility” to make such changes. “And that’s one of the reasons we’re asking Congress to give us the power to negotiate drug prices,” she said.
CMS is also looking for ways to make drugs more affordable without waiting for Congress to act. “We’re still trying to figure out where it makes sense to be able to allow people to change their plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure in the interview. .
On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also benefit from drug coverage with reduced premiums and out-of-pocket costs.
Grants make the difference. Low-income recipients who have separate drug plans and receive subsidies are nearly twice as likely to take their drugs as those without financial assistance, according to a study Dusetzina co- written for Health Affairs in April.
When the CMS approves plans for sale to beneficiaries, the only part of the drug price it approves is the cost-share amount — or tier — applied to each drug. Some plans have up to six drug levels.
In addition to the level of medication, what patients pay may also depend on the pharmacy, their deductible, co-pay or coinsurance – and whether they choose to drop their insurance and pay in cash.
After Linda Griffith left the pharmacy without her meds, she spent a week phoning her drug plan, pharmacy, Social Security and Medicare, but still had no could understand why the cost was so high. “I finally had to give in and pay because I need medicine – I can’t function without it,” she said.
But she didn’t give up. She appealed to her insurance company for a level reduction, which was denied. The plan denied two other requests for price adjustments, despite the help of Pam Smith, program manager for five California counties served by the health insurance counseling and advocacy program. They now use CMS directly.
“It’s important for us to work with our members who have questions about disbursements that are higher than the member expects,” said Lisa Dimond, spokeswoman for Humana. She could not comment on Griffith’s situation due to confidentiality rules.
However, Griffith said he received a call from a Humana executive who said the company had received a request from the media. After discussing the problem, says Griffith, the woman told him, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information came from.
She won’t have to look far: CMS requires insurers to update their rates every two weeks.
“I want my money back and I want to be charged for the amount I agreed to pay for the drug,” Griffith said. “I think this needs to be fixed because other people are going to be cheated.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).