Medicare Part D 2025 Reduces Out-of-Pocket Costs for Oral Prostate Cancer Treatments - David Morris
September 25, 2024
Ruchika Talwar interviews David Morris about changes in 2025 for Medicare Part D resulting from the Inflation Reduction Act (IRA). Dr. Morris discusses how these changes benefit prostate cancer patients and all Medicare recipients who have Medicare Part D coverage. This Medicare change reduces the out-of-pocket expenses for prescription drugs paid by Part D plans.
Key points include the introduction of a $2,000 annual out-of-pocket maximum cap, the option for cost smoothing to spread payments over 12 months, and expanded coverage for both branded and generic medications. This wipes out what has been known as the donut hole for annual out-of-pocket costs. Dr. Morris emphasizes that these changes make it easier for patients to access all oral medications and combination therapies including prostate cancer treatments.
The discussion also touches on the extra low-income subsidy program and the importance of patients exploring different Medicare plans during open enrollment. Both Drs. Talwar and Morris highlight the significance of these policy changes for patients with prostate cancer and other conditions requiring costly medications.
Biographies:
David Morris, MD, FACS, Urology Associates of Nashville, Nashville, TN
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Key points include the introduction of a $2,000 annual out-of-pocket maximum cap, the option for cost smoothing to spread payments over 12 months, and expanded coverage for both branded and generic medications. This wipes out what has been known as the donut hole for annual out-of-pocket costs. Dr. Morris emphasizes that these changes make it easier for patients to access all oral medications and combination therapies including prostate cancer treatments.
The discussion also touches on the extra low-income subsidy program and the importance of patients exploring different Medicare plans during open enrollment. Both Drs. Talwar and Morris highlight the significance of these policy changes for patients with prostate cancer and other conditions requiring costly medications.
Biographies:
David Morris, MD, FACS, Urology Associates of Nashville, Nashville, TN
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee.
I'm really excited to be joined by another fellow Nashville native, Dr. David Morris from Urology Associates. Dr. Morris and I will be discussing some important changes to Medicare Part D as a part of UroToday's new resource series for patients with prostate cancer. We really hope you appreciate the discussion, and I think we're going to highlight some really important points.
Thanks, Dr. Morris, we really appreciate your expertise and your time.
David Morris: My pleasure. So I wanted to run through some of the more recent changes to Medicare Part D that had to do with the Inflation Reduction Act that began to roll out this year, but with more pending changes even coming for next year.
And the reason that this is important is it's really changing some of the out-of-pocket exposure for our prostate cancer patients, and actually any cancer patient with any oral or Part D covered drug.
The reason that it's important is that there's been a shift in terms of how the cost of the medication is covered. And largely this act has shifted it away from patients and more towards the manufacturers of the drug.
And for any patient who's been on medication in the last couple of years, they've seen this roll out in real time. But patients going forward who are new will probably not know the pain that we went through in the last few years to try to get expensive drugs into their hands.
But coming up for next year, we're very excited that there's going to be a $2,000 annual out-of-pocket maximum cap on out-of-pocket expense for a patient.
In years past, patients would have to get up over $3,000 and then had a co-insurance that they would have to pay. So they were always on the hook for each fill for a certain percentage of drugs. And drugs that are very expensive tend to have very high co-insurance payments. And unfortunately, even if they reached catastrophic levels, they still had to pay co-insurance.
So it was very expensive. We had to lean on grant foundations for a lot of that assistance to get drugs to patients. So this has basically effectively shifted some of that burden off the grants that we had to acquire to help pay for it. And now it is mainly on the manufacturers, and the patients thankfully have had some relief with this.
So the real benefit of that is that once the patient has reached that $2,000 out-of-pocket, the rest of their drugs, not just the prostate cancer drugs, but the rest of any prescription, and coming up for next year branded or generic prescriptions, will then be covered with zero out-of-pocket expense.
And there's some additional changes that are very promising. They can opt in with the coming open enrollment. So I've been going over that with any of our patients on therapy now who are Medicare, that, "Hey, when it's time to open enroll, you can elect to do this," which is kind of a smoothing process, where you take the $2,000 out-of-pocket expense and spread it out over 12 payments over the year.
If someone's on a drug or knows they're going to be on drugs that are expensive, or has diabetic drugs that are expensive, that's a great option for them.
And they don't really pay anything to the pharmacy. They basically pay to their health plan, which then covers it on the back end. So it's nice that the patient then doesn't have some giant cost right up front in January if they're on an expensive medication.
So the way that this, as an example, would look, is instead of having a $2,000 out-of-pocket expense for a drug that, say, may cost $8,000, $10,000 a month, like one of the oral AR agents for prostate cancer, if they've elected this cost smoothing, it's $167 a month paid to Medicare. They never have to make that $2,000 payment to the pharmacy when they pick up their first fill.
And the nice also extension of that is it lets it stretch that out. It's much more budget-friendly for a patient if they know they're going to be on expensive medications. And if you're on combination therapy, the nice thing for oral agents like this is we have expensive AR agents, but we also have a first-line ADT agent which is oral, different than the Part B buy and bill injectable coverage in many of our offices.
And so if someone's on a combination therapy, they would effectively be able to get the ADT oral agent for free if they're already reaching their out-of-pocket max expense with this expensive AR medication that they're already going to be taking in combination.
So I think that's kind of the two main changes for next year. This year there was already a lower cap and no co-insurance. The next year the cap gets even better and it helps cover both branded and generic medications. And the big thing is the cost smoothing, so the payments per month to the plan, so that they then don't necessarily have to make some big lump sum payment to the pharmacy when they're picking up the first expensive medication.
And then a kind of caveat, kind of sidebar to all of that is Medicare has always had an extra low-income subsidy for patients who may reach certain income criteria. They actually get extra benefits for that and could get expensive branded medications for much lower out-of-pocket co-pays.
They do have to qualify for those plans. And in some sense, if there are a limited number of prescriptions, that may actually be a better thing for them than doing the cost smoothing, because they may not have that many prescriptions that they're having to fill and they may already get a cheaper price with the extra help program.
Many of the patients already know about that if they're going to be eligible. But a lot of these patients are hit for the first time with a very expensive drug and it's a totally new ballgame for them in terms of expenses.
And so this, I just wanted to have a brief update on how we've seen it roll out in our clinic, and I think many clinics across the U.S. that have been using oral agents. It's much easier now to get patients onto the therapy and that's probably going to get even better.
And patients would be able to get combination therapy and not have to use a Part D to cover the oral agent and a Part B to potentially cover a buy and bill. They may be able to get both out-of-pocket basically for no expense if it's smoothed out over the course of the year.
So that's kind of my update, at least from boots on the ground and what we've seen in practices that dispense themselves or deal with outside specialty pharmacies.
So I just wanted to give thanks to the UroToday team for letting me kind of come on and walk through the changes that we are excited about for the coming year. And then see what kind of questions you have for me as kind of a clinician that's dealt with this here to begin with this year, which has been a positive, but next year we're hoping to see even more positive change.
Ruchika Talwar: Yeah, absolutely. Thank you for that really informative review. I think it is enlightening for physicians who perhaps may not be as familiar with prior changes.
But also I think this video has some important information for our patients as well. So I'll just back up and level set for patients, caregivers, or other folks who may be tuning in, this doesn't just apply to our advanced prostate cancer patients, right? It would apply in some cases to localized prostate cancer patients also?
David Morris: Yes. So I mean, I think anyone who's using any oral drug that's dispensed from a specialty pharmacy could benefit from Part D improvements. And let's face it, a lot of expensive anticoagulant medications, there's a lot of benefit even that's not a cancer directive, but from a urology perspective, expensive overactive bladder medications, expensive cancer medications, all of those fall under this umbrella.
And even if you're not on combination therapy for metastatic disease, if you're just getting oral or potential hormone therapy, or localized radiation treatments, there's a chance that you would potentially be able to get that out-of-pocket for zero out-of-pocket versus paying for injections as a 20% co-insurance, as you would often do with a buy and bill in a physician office.
Ruchika Talwar: Exactly.
David Morris: So it's worth the patient being motivated to find out.
Ruchika Talwar: Yeah. And that's the point I wanted to highlight there, was that patients who may be getting hormone therapy injections, due to the financial toxicity associated with the oral agents we've seen in the past, this is a real win for them. So thanks for digging into that a bit.
And you went over this really thoroughly, but in your mind, what are some other points that physicians should be aware of just in terms of plan changes outside of this specific clinical scenario?
David Morris: So I think another thing to consider, there are plan finders that patients can use where they can kind of shop around with. "These are the diseases that I have, these are the current medications I'm using." It may give them some guidance towards, "This is the sort of coverage plan you would best benefit going forward."
There are whole, I guess, industries set up around trying to help patients make the right choice for their Medicare coverage and their Part D coverage. There are Medicare Advantage plans that have that folded in, and they often have different restrictions based off which commercial payer is administering that plan.
But in general, if you're straight Medicare and you have a Part D prescription coverage plan, this is a win for you. It's just trying to find which other options to choose within your plan. And we're coming up on open enrollment and now's the time to start the process, because it takes some time to digest what's going to be going on.
And I guess the good news for our patients, I have a lot of patients who've been on cancer therapy for a long time, and every year I tell them, "Check, because the plans may change and something may be better for you."
But even for patients who are brand new to this, in February of next year will still reap the benefits if they are found to have prostate cancer then and have the option of potentially getting an oral medicine for cheaper, because they're already getting expensive medications for some other disease's sake.
Ruchika Talwar: Absolutely. And to our audience, I'll just remind you all that we did feature an article by Dr. Pockros that walked us through how to go about using that Medicare Part D plan finder. So I'd encourage you, if you're interested in looking at that now that open enrollment season is upon us. We'll make sure to link that video in the notes for this discussion.
Dr. Morris, thank you again for your time. These are really important policy changes that we wanted to highlight and emphasize for our patients, caregivers, and clinicians who treat patients with prostate cancer. So we're grateful for your expertise.
David Morris: It's been my pleasure. Thank you for having me.
Ruchika Talwar: And to our audience, thanks again for tuning in. We'll see you next time.
Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee.
I'm really excited to be joined by another fellow Nashville native, Dr. David Morris from Urology Associates. Dr. Morris and I will be discussing some important changes to Medicare Part D as a part of UroToday's new resource series for patients with prostate cancer. We really hope you appreciate the discussion, and I think we're going to highlight some really important points.
Thanks, Dr. Morris, we really appreciate your expertise and your time.
David Morris: My pleasure. So I wanted to run through some of the more recent changes to Medicare Part D that had to do with the Inflation Reduction Act that began to roll out this year, but with more pending changes even coming for next year.
And the reason that this is important is it's really changing some of the out-of-pocket exposure for our prostate cancer patients, and actually any cancer patient with any oral or Part D covered drug.
The reason that it's important is that there's been a shift in terms of how the cost of the medication is covered. And largely this act has shifted it away from patients and more towards the manufacturers of the drug.
And for any patient who's been on medication in the last couple of years, they've seen this roll out in real time. But patients going forward who are new will probably not know the pain that we went through in the last few years to try to get expensive drugs into their hands.
But coming up for next year, we're very excited that there's going to be a $2,000 annual out-of-pocket maximum cap on out-of-pocket expense for a patient.
In years past, patients would have to get up over $3,000 and then had a co-insurance that they would have to pay. So they were always on the hook for each fill for a certain percentage of drugs. And drugs that are very expensive tend to have very high co-insurance payments. And unfortunately, even if they reached catastrophic levels, they still had to pay co-insurance.
So it was very expensive. We had to lean on grant foundations for a lot of that assistance to get drugs to patients. So this has basically effectively shifted some of that burden off the grants that we had to acquire to help pay for it. And now it is mainly on the manufacturers, and the patients thankfully have had some relief with this.
So the real benefit of that is that once the patient has reached that $2,000 out-of-pocket, the rest of their drugs, not just the prostate cancer drugs, but the rest of any prescription, and coming up for next year branded or generic prescriptions, will then be covered with zero out-of-pocket expense.
And there's some additional changes that are very promising. They can opt in with the coming open enrollment. So I've been going over that with any of our patients on therapy now who are Medicare, that, "Hey, when it's time to open enroll, you can elect to do this," which is kind of a smoothing process, where you take the $2,000 out-of-pocket expense and spread it out over 12 payments over the year.
If someone's on a drug or knows they're going to be on drugs that are expensive, or has diabetic drugs that are expensive, that's a great option for them.
And they don't really pay anything to the pharmacy. They basically pay to their health plan, which then covers it on the back end. So it's nice that the patient then doesn't have some giant cost right up front in January if they're on an expensive medication.
So the way that this, as an example, would look, is instead of having a $2,000 out-of-pocket expense for a drug that, say, may cost $8,000, $10,000 a month, like one of the oral AR agents for prostate cancer, if they've elected this cost smoothing, it's $167 a month paid to Medicare. They never have to make that $2,000 payment to the pharmacy when they pick up their first fill.
And the nice also extension of that is it lets it stretch that out. It's much more budget-friendly for a patient if they know they're going to be on expensive medications. And if you're on combination therapy, the nice thing for oral agents like this is we have expensive AR agents, but we also have a first-line ADT agent which is oral, different than the Part B buy and bill injectable coverage in many of our offices.
And so if someone's on a combination therapy, they would effectively be able to get the ADT oral agent for free if they're already reaching their out-of-pocket max expense with this expensive AR medication that they're already going to be taking in combination.
So I think that's kind of the two main changes for next year. This year there was already a lower cap and no co-insurance. The next year the cap gets even better and it helps cover both branded and generic medications. And the big thing is the cost smoothing, so the payments per month to the plan, so that they then don't necessarily have to make some big lump sum payment to the pharmacy when they're picking up the first expensive medication.
And then a kind of caveat, kind of sidebar to all of that is Medicare has always had an extra low-income subsidy for patients who may reach certain income criteria. They actually get extra benefits for that and could get expensive branded medications for much lower out-of-pocket co-pays.
They do have to qualify for those plans. And in some sense, if there are a limited number of prescriptions, that may actually be a better thing for them than doing the cost smoothing, because they may not have that many prescriptions that they're having to fill and they may already get a cheaper price with the extra help program.
Many of the patients already know about that if they're going to be eligible. But a lot of these patients are hit for the first time with a very expensive drug and it's a totally new ballgame for them in terms of expenses.
And so this, I just wanted to have a brief update on how we've seen it roll out in our clinic, and I think many clinics across the U.S. that have been using oral agents. It's much easier now to get patients onto the therapy and that's probably going to get even better.
And patients would be able to get combination therapy and not have to use a Part D to cover the oral agent and a Part B to potentially cover a buy and bill. They may be able to get both out-of-pocket basically for no expense if it's smoothed out over the course of the year.
So that's kind of my update, at least from boots on the ground and what we've seen in practices that dispense themselves or deal with outside specialty pharmacies.
So I just wanted to give thanks to the UroToday team for letting me kind of come on and walk through the changes that we are excited about for the coming year. And then see what kind of questions you have for me as kind of a clinician that's dealt with this here to begin with this year, which has been a positive, but next year we're hoping to see even more positive change.
Ruchika Talwar: Yeah, absolutely. Thank you for that really informative review. I think it is enlightening for physicians who perhaps may not be as familiar with prior changes.
But also I think this video has some important information for our patients as well. So I'll just back up and level set for patients, caregivers, or other folks who may be tuning in, this doesn't just apply to our advanced prostate cancer patients, right? It would apply in some cases to localized prostate cancer patients also?
David Morris: Yes. So I mean, I think anyone who's using any oral drug that's dispensed from a specialty pharmacy could benefit from Part D improvements. And let's face it, a lot of expensive anticoagulant medications, there's a lot of benefit even that's not a cancer directive, but from a urology perspective, expensive overactive bladder medications, expensive cancer medications, all of those fall under this umbrella.
And even if you're not on combination therapy for metastatic disease, if you're just getting oral or potential hormone therapy, or localized radiation treatments, there's a chance that you would potentially be able to get that out-of-pocket for zero out-of-pocket versus paying for injections as a 20% co-insurance, as you would often do with a buy and bill in a physician office.
Ruchika Talwar: Exactly.
David Morris: So it's worth the patient being motivated to find out.
Ruchika Talwar: Yeah. And that's the point I wanted to highlight there, was that patients who may be getting hormone therapy injections, due to the financial toxicity associated with the oral agents we've seen in the past, this is a real win for them. So thanks for digging into that a bit.
And you went over this really thoroughly, but in your mind, what are some other points that physicians should be aware of just in terms of plan changes outside of this specific clinical scenario?
David Morris: So I think another thing to consider, there are plan finders that patients can use where they can kind of shop around with. "These are the diseases that I have, these are the current medications I'm using." It may give them some guidance towards, "This is the sort of coverage plan you would best benefit going forward."
There are whole, I guess, industries set up around trying to help patients make the right choice for their Medicare coverage and their Part D coverage. There are Medicare Advantage plans that have that folded in, and they often have different restrictions based off which commercial payer is administering that plan.
But in general, if you're straight Medicare and you have a Part D prescription coverage plan, this is a win for you. It's just trying to find which other options to choose within your plan. And we're coming up on open enrollment and now's the time to start the process, because it takes some time to digest what's going to be going on.
And I guess the good news for our patients, I have a lot of patients who've been on cancer therapy for a long time, and every year I tell them, "Check, because the plans may change and something may be better for you."
But even for patients who are brand new to this, in February of next year will still reap the benefits if they are found to have prostate cancer then and have the option of potentially getting an oral medicine for cheaper, because they're already getting expensive medications for some other disease's sake.
Ruchika Talwar: Absolutely. And to our audience, I'll just remind you all that we did feature an article by Dr. Pockros that walked us through how to go about using that Medicare Part D plan finder. So I'd encourage you, if you're interested in looking at that now that open enrollment season is upon us. We'll make sure to link that video in the notes for this discussion.
Dr. Morris, thank you again for your time. These are really important policy changes that we wanted to highlight and emphasize for our patients, caregivers, and clinicians who treat patients with prostate cancer. So we're grateful for your expertise.
David Morris: It's been my pleasure. Thank you for having me.
Ruchika Talwar: And to our audience, thanks again for tuning in. We'll see you next time.