HCP role in the process
Out-of-pocket example
HCP roles in each process for patients with Medicare insurance
Buy-and-bill (Medicare Part B)1
ASP, average sales price; BI, benefits investigation; HCP, health care professional; MAPD, Medicare Advantage prescription drug plan; PA, prior authorization; PDP, prescription drug plan; SP, specialty pharmacy; WAC, wholesale acquisition cost.
*Patients with Medicare Advantage (Medicare Part C, Medicaid, or other public insurance coverage) may require precertification or prior authorization as conditions for coverage.
†Timing approximate and may vary.
‡The HCP will need to store and track drug inventory.
§Sequestration applies. 2% reduction to the Medicare allowable.
‖Since the drugs will be labeled with the patient's name, a separate inventory to manage patient-specific treatments may have to be created and maintained.
Specialty pharmacy (Medicare Parts C and D)2
ASP, average sales price; BI, benefits investigation; HCP, health care professional; MAPD, Medicare Advantage prescription drug plan; PA, prior authorization; PDP, prescription drug plan; SP, specialty pharmacy; WAC, wholesale acquisition cost.
*Patients with Medicare Advantage (Medicare Part C, Medicaid, or other public insurance coverage) may require precertification or prior authorization as conditions for coverage.
†Timing approximate and may vary.
‡The HCP will need to store and track drug inventory.
§Sequestration applies. 2% reduction to the Medicare allowable.
‖Since the drugs will be labeled with the patient's name, a separate inventory to manage patient-specific treatments may have to be created and maintained.
Patient out-of-pocket (OOP) costs
Medicare Part B – 20224,5
-
$233 deductible per year, 20% coinsurance cost
-
Supplemental insurance may cover some or all of the 20% coinsurance
MA plans5
-
34% of Medicare patients have MA; co-pay and coinsurance vary based on the type of plan
-
OOP maximum limits ranged from $0 to $6700 in 2018
Medicare Part D – 20226
-
Up to $480 deductible
-
Co-payment or coinsurance
-
Coverage gap
-
25% of costs if total drug costs are between $4430 and $7050 ("donut hole")
-
5% of cost after
-
Extra Help (Low-Income Subsidy)6
-
Assistance for Medicare recipients below poverty line
-
Main benefit is low OOP costs
PDP or MAPD plans6
-
Co-pay and coinsurance vary based on the type of plan
-
May require high deductibles, co-pay/coinsurance
Click here to learn more about the programs some manufacturers may offer to support patients.
References: 1. Fein AJ. Accessed June 21, 2020. https://www.drugchannels.net/2016/10/follow-vial-buy-and-bill-system-for.html 2. McCain J. Biotechnol Healthc. 2012;9(2):8-13. 3. CSI Specialty Group. Accessed June 22, 2020. https://academynet.com/sites/default/files/csi2019spreport.pdf 4. Medicare.gov. Accessed June 3, 2021. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance 5. Kaiser Family Foundation. Accessed June 21, 2020. http://files.kff.org/attachment/issue-brief-an-overview-of-medicare 6. Kaiser Family Foundation. Accessed June 2, 2021. https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/
References: 1. Fein AJ. Accessed June 21, 2020. https://www.drugchannels.net/2016/10/follow-vial-buy-and-bill-system-for.html 2. McCain J. Biotechnol Healthc. 2012;9(2):8-13. 3. CSI Specialty Group. Accessed June 22, 2020. https://academynet.com/sites/default/files/csi2019spreport.pdf 4. Medicare.gov. Accessed June 3, 2021. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance 5. Kaiser Family Foundation. Accessed June 21, 2020. http://files.kff.org/attachment/issue-brief-an-overview-of-medicare 6. Kaiser Family Foundation. Accessed June 2, 2021. https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/
EXAMPLE
Out-of-pocket costs for patient with Medicare coverage
EXAMPLE DRUG WHOLESALE ACQUISITION COST (WAC) PER TREATMENT IS $1000
Buy-and-bill
under Medicare Part B
(fee-for-service)
Medical
benefit1
Example
based on
recent costs*
Benefit
coverage
Specialty
pharmacy
under 2022 Medicare Part D benefit design
Pharmacy
benefit2
$0-$233
Deductible
$480
20% ($200)
Coinsurance
(initial coverage + donut
hole)
25%†,‡
n/a
Catastrophic coverage
5% of cost after total
OOP threshold is met
Supplemental
insurance
covering
50% of
coinsurance
(-$100)
Other coverage
n/a
$100-$333
Total patient OOP
$610
Data for benefit design based on 2022 Medicare cost data. This information is provided for educational purposes only and the costs presented are a hypothetical example based on the first prescription of a new benefit year. Coverage, reimbursement, and patient costs may vary significantly by payer, plan, patient, and setting of care.
*Supplemental coverage may cover up to 100% of the remaining OOP costs.
†Coinsurance payment may need to be collected prior to administration.
‡Applicable to non–low-income subsidy patients only.
References: 1. Medicare.gov. Accessed June 3, 2021. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance 2. Q1Medicare. 2022 Medicare Part D outlook. Accessed December 28, 2021. https://q1medicare.com/PartD-The-2022-Medicare-Part-D-Outlook.php.
References: 1. Medicare.gov. Accessed June 3, 2021.
https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
2. Q1Medicare. 2022 Medicare Part D outlook. Accessed December 28, 2021.
https://q1medicare.com/PartD-The-2022-Medicare-Part-D-Outlook.php.
EXAMPLE
Out-of-pocket costs for patient with Medicare coverage
EXAMPLE DRUG WHOLESALE ACQUISITION COST (WAC) PER TREATMENT IS $1000
Buy-and-bill
under Medicare Part B
(fee-for-service)
Medical
benefit1
Example
based on
recent costs*
Benefit
coverage
Specialty
pharmacy
under 2022 Medicare
Part D benefit design
Pharmacy
benefit2
$0-$233
Deductible
$480
20% ($200)
Coinsurance
(initial coverage + donut
hole)
25%†,‡
n/a
Catastrophic coverage
5% of cost after total
OOP threshold is met
Supplemental
insurance
covering
50% of
coinsurance
(-$100)
Other coverage
n/a
$100-$333
Total patient OOP
$610
Data for benefit design based on 2022 Medicare cost data. This information is provided for educational purposes only and the costs presented are a hypothetical example based on the first prescription of a new benefit year. Coverage, reimbursement, and patient costs may vary significantly by payer, plan, patient, and setting of care.
*Supplemental coverage may cover up to 100% of the remaining OOP costs.
†Coinsurance payment may need to be collected prior to administration.
‡Applicable to non–low-income subsidy patients only.
References: 1. Medicare.gov. Accessed June 3, 2021. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance 2. Q1Medicare. 2022 Medicare Part D outlook. Accessed December 28, 2021. https://q1medicare.com/PartD-The-2022-Medicare-Part-D-Outlook.php.
References: 1. Medicare.gov. Accessed June 3, 2021.
https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
2. Q1Medicare. 2022 Medicare Part D outlook. Accessed December 28, 2021.
https://q1medicare.com/PartD-The-2022-Medicare-Part-D-Outlook.php.