Get prepared for Medicare Part D enrollment changes

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What you need to know before Part D open enrollment

In brief:

  • Medicare changes for 2019 include new cards and opportunities to switch plans
  • Coverage changes will affect when patients enter and leave the “donut hole”
  • New requirements will limit opioid access

Although Medicare Part D open enrollment doesn’t begin until October 15, 2018, take time now to understand how changes for 2019 will affect your pharmacy and patients.

New Medicare cards


Medicare beneficiaries will receive new Medicare cards with a Medicare identification number. Mailing began in April 2018 and will be completed by April 2019. By January 1, 2020, beneficiaries will have to use their new card.

You can track when cards are sent to patients in your state through the Centers for Medicare and Medicaid Services website. Remind your staff and patients to update information in your pharmacy system.

Schedule a plan review in September

By September 15, 2018, plans must have their standard terms and conditions ready. When you request this information, plans must provide it within seven days.

Patients will receive separate mailings

Patients should receive a summary of how their existing Medicare Part D plan will change (the Annual Notice of Change) at least 15 days before open enrollment begins. Plan details, in the Evidence of Coverage, should arrive October 15.

Pharmacies have greater options to participate

The final rule CMS released this spring bars Plan D sponsors from limiting which pharmacies can dispense certain medications, such as specialty drugs, or drugs for certain diseases. To participate, a pharmacy must be capable, meet the licensing laws, and agree to meet the plan’s terms and conditions.1

Prepare patients to pay more

Patients’ initial standard deductible goes up in 2019 by $10, to $415. So a patient must spend more before coverage kicks in.

Donut hole numbers are changing

Patients will spend more before entering the coverage gap known as the donut hole. Changes include: 2,3


Those taking brand-name drugs will pay 25% of the cost while in the hole. But plans may reduce the cost-sharing for preferred drugs or may make cost-sharing for others higher. Check patients’ prescriptions against plan formularies. Patients will pay 37% of the retail price for their generic drugs while in the donut hole.

Plans will limit access to frequently abused drugs4

Expect patients who come in with new opioid prescriptions for acute pain to receive no more than a seven-day supply. That limit for “opioid naïve patients” is one change CMS is requiring to prevent drug abuse. Patients who take opioids may be limited to certain pharmacies and providers. CMS is allowing plans to create this “lock in” feature for patients at risk of abusing drugs.

Another new requirement is an “opioid care coordination edit.” If a prescription, for example, reaches 90 morphine milligram equivalent (MME) per day, the pharmacist must consult the prescriber to receive an override code for coverage.

Plans have some flexibility in how they set the limits. CMS also provides exemptions for certain patients, such as those in hospice care.

Patients will have fewer options to change later

The Special Enrollment Period for dually eligible patients — those who qualify for Medicare and Medicaid — and those who receive the Medicare Part D Extra Help, will be limited to once per quarter in the first nine months of 2019.

Patients enrolled in Medicare Advantage plans will have an opportunity January 1 through March 31 to change plans, including the option to switch to regular Medicare and a Part D prescription drug plan.

Prepare now for how plan changes will affect your pharmacy and your patients, so you can answer patients’ questions during open enrollment and be ready to meet new requirements in 2019.

Note: The information provided here is for reference use only and does not constitute the rendering of legal or other professional advice by McKesson. Readers should consult appropriate professionals for advice and assistance prior to making important decisions regarding their business. McKesson is not advocating any particular program or approach herein. McKesson is not responsible for, nor will it bear any liability for, the content provided herein.

1 “In New Part D Rule, CMS Asserts Authority to Apply DIR at Point of Sale,” National Community Pharmacy Association, April 3, 2018. LINK
2 “Changes Are Coming for 2019 Medicare Part D Plans: A Few Highlights from the 2019 Final CMS Call Letter and Final Rule,” Q1 Group, April 3, 2018. LINK
3 “Medicare Part D Drug Coverage Gap Closing at Faster Clip,” Rachel L. Sheedy, Kiplinger, May 31, 2018. LINK
4 “2019 Medicare Advantage and Part D Rate Announcement and Call Letter,” Centers for Medicare and Medicaid Services, April 2, 2018. LINK