Standard Medicare Prescription Drug Benefit, 2013. CATASTROPHIC COVERAGE. Catastrophic Coverage Limit = $6,955 in Estimated Total Drug Costs. Enrollee pays 5%. Plan pays 15 %; Medicare pays 80%. Brand-name drugs Enrollee pays 47.5%; Plan pays 2.5% 50% manufacturer discount - PowerPoint PPT Presentation
Exhibit 1 NOTE: *Amount corresponds to the estimated catastrophic coverage limit for non-low-income subsidy enrollees ($6,734 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $4,750 (the amount used to determine when an enrollee reaches the catastrophic coverage threshold. SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2013 (standard benefit parameter update from Centers for Medicare & Medicaid Services, 2012). Amounts rounded to nearest dollar. Standard Medicare Prescription Drug Benefit, 2013 Deductible = $325 Initial Coverage Limit = $2,970 in Total Drug Costs Plan pays 75% Plan pays 15%; Medicare pays 80% Enrollee pays 5% Enrollee pays 25% Catastrophic Coverage Limit = $6,955 in Estimated Total Drug Costs Brand-name drugs Enrollee pays 47.5%; Plan pays 2.5% 50% manufacturer discount Generic drugs Enrollee pays 79%; Plan pays 21% INITIAL COVERAGE PERIOD COVERAGE GAP CATASTROPHIC COVERAGE DEDUCTIBLE
Transcript
Exhibit 1
NOTE: *Amount corresponds to the estimated catastrophic coverage limit for non-low-income subsidy enrollees ($6,734 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $4,750 (the amount used to determine when an enrollee reaches the catastrophic coverage threshold.SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2013 (standard benefit parameter update from Centers for Medicare & Medicaid Services, 2012). Amounts rounded to nearest dollar.
Standard Medicare Prescription Drug Benefit, 2013
Deductible = $325
Initial Coverage Limit = $2,970 in Total Drug Costs
NOTE: Excludes PDPs in the territories. *Under a Medicare demonstration, de minimis plans were eligible to retain LIS beneficiaries despite exceeding the benchmark premium by $2 in 2007 and $1 in 2008. SOURCE: Georgetown/NORC/Kaiser Family Foundation analysis of CMS PDP Landscape Source Files, 2006-2013.
Distribution of Medicare Part D Stand-Alone Prescription Drug Plans, by Benchmark Status, 2006-2013
Exhibit 3
2006-2013: 49% increase
2012-2013: 2% increase
2006 2007 2008 2009 2010 2011 2012 2013 $-
$5
$10
$15
$20
$25
$30
$35
$40
$25.93 $27.39 $29.89
$35.09 $37.25 $38.29 $37.78 $38.54
NOTE: Average premiums are weighted by enrollment in each year (March for 2013). Excludes Part D plans in the territories.SOURCE: Georgetown/NORC analysis of data from CMS for the Kaiser Family Foundation.
Weighted Average Monthly Premiums for Medicare Part D Stand-Alone Prescription Drug Plans, 2006-2013
Humana Walmart-Preferred2 1,755,007 9.7% -- $15.10 $18.50 +23% --
Humana Enhanced 1,313,701 7.3% $14.73 $39.58 $43.74 +11% +197%
Cigna Medicare Rx Plan One 684,543 3.8% $35.05 $31.09 $35.72 +15% +2%
First Health Part D Premier 676,334 3.8% $24.98 $32.56 $38.32 +18% +30%
First Health Part D Value Plus3 644,920 3.6% -- $25.43 $29.50 +16% --
NOTE: 1Average premiums are weighted by enrollment in each region for each year. 2Humana Walmart-Preferred PDP was not offered before 2011. 3First Heath Part D Value Plus PDP was not offered before 2012.SOURCE: Georgetown/NORC analysis of CMS 2006-2013 PDP Landscape Source Files for the Kaiser Family Foundation.
Premiums in Medicare Part D Stand-Alone Prescription Drug Plans with Highest 2013 Enrollment, 2006-2013
Exhibit 5
2013 National Monthly Average Premium for Basic PDPs = $31.98
Less than $30(9 regions)
$30 to <$32(7 regions)
$32 to <$34(9 regions)
$34 or higher(9 regions)
$28.82
$32.13
$31.81
$33.65OR, WA
$27.66
$23.13
$33.24IA, MN, MT, NE,
ND, SD, WY
$25.53
$30.61
$28.53 $20.67
$32.18
$31.44
$32.22
$34.59
$34.21IN, KY
$32.11
$30.65
$31.85
$30.64
$34.56
$34.12
NJ
$31.96HI
$32.34 $35.09
$29.56 CT, MA, RI, VT
$33.23ME, NH
$28.47
$32.48AL, TN
$38.84DE, DC, MD
$35.09PA, WV
$38.83 ID, UT
$41.50
$24.67 FL
NOTE: PDP is stand-alone prescription drug plan. Average premiums are weighted by enrollment.SOURCE: Georgetown/NORC analysis of CMS 2013 PDP Landscape Source File for the Kaiser Family Foundation.
Weighted Average Premium for Medicare Part D Basic Stand-Alone PDPs, by Region, 2013
Exhibit 6
AA
RP M
edic
areR
x Sa
ver.
..
Hum
ana
Wal
mar
t-Pr
efe.
..
Aet
na C
VS/p
harm
acy
PDP
Smar
tD R
x Sa
ver
Read
ers
Dig
est
Valu
e Rx
Uni
ted
Am
eric
an-S
elec
t
Wel
lCar
e Cl
assi
c
Silv
erSc
ript
Bas
ic
Firs
t H
ealt
h Pa
rt D
Pre
...
Expr
ess
Scri
pts
Med
icar
...
Cign
a M
edic
are
Rx P
lan.
..
Envi
sion
RxPl
us S
ilver
Hea
lthS
prin
g PD
P
NOTE: PDP is stand-alone prescription drug plan. SOURCE: Georgetown/NORC analysis of CMS 2013 PDP Landscape Source File for the Kaiser Family Foundation.
Range of Monthly Premiums for National and Near-National Medicare Part D Basic Stand-Alone PDPs, 2013
NOTE: PDP is stand-alone prescription drug plan.SOURCE: Georgetown/NORC analysis of CMS 2013 PDP Landscape Source File and Plan Crosswalk for the Kaiser Family Foundation.
Minimum and Maximum Monthly Premiums for Medicare Part D Basic Stand-Alone PDPs, by Region, 2013
PDP Regions, Sorted from Lowest to Highest Maximum Monthly Premium
NOTE: PDP is stand-alone prescription drug plan.SOURCE: Georgetown/NORC analysis of data from CMS for the Kaiser Family Foundation.
Weighted Average Monthly Premiums for Stand-Alone PDPs, by Type of Benefit Package, 2013
Exhibit 9
PDPs MA-PD plans
In 2013, the coverage gap is partially filled by a 50% price discount plus 2.5% plan coverage for brand-name drugs and 21% coverage of generic drug costs, as required by the ACA
Level of gap coverage in 2006:
Level of additional gap coverage in 2013:
Little/no additional gap coverageMostly genericsBrands & generics
2006 2013 2006 20133% 3% 4% <1%3% 2%
23% 35%
94% 94%
73% 65%
Little/no gap coverageMostly gener-icsBrands & generics
NOTE: Estimates include Part D enrollees receiving low-income subsidies, but who receive coverage for costs in the gap regardless of whether their plan offers it. SOURCE: Georgetown/NORC analysis of CMS Part D landscape and enrollment files, 2006-2013, for the Kaiser Family Foundation.
Share of Enrollment in Medicare Part D Plans, By Level of Gap Coverage, 2006 and 2013
Exhibit 10
In 2013, the coverage gap is partially filled by a 50% price discount plus 2.5% plan coverage for brand-name drugs and 21% coverage of generic drug costs, as required by the ACA
Level of additional gap coverage in 2013
Little/no additional gap coverage
Mostly generics Brands & generics
$35.19
$79.51
$101.32
NOTE: PDP is stand-alone prescription drug plan.SOURCE: Georgetown/NORC analysis of data from CMS for the Kaiser Family Foundation.
Weighted Average Monthly Premiums for Medicare Part D Stand-Alone PDPs, by Level of Gap Coverage, 2013
Exhibit 11
Share of Medicare Part D Stand-Alone Prescription Drug Plans, By Deductible Amount, 2006-2013
34% 32% 33% 34% 36% 40% 43% 45%
8% 8% 8% 11%24% 18% 10% 10%
58% 60% 59% 55%40% 42% 47% 45%
No deductible
Partial de-ductible
Standard deductible
NOTE: Estimates may not sum to total due to rounding and are unweighted. SOURCE: Georgetown/NORC analysis of CMS PDP landscape source files, 2006-2013, for the Kaiser Family Foundation.
Standard deductible amount:
2006 2007 2008 2009 2010 2011 2012 2013
$250 $265 $275 $295 $310 $310 $320 $325
Exhibit 12
FORMULARY TIER
PART D PLAN TYPE
PART D COST SHARING EMPLOYER PLANS
2006 2007 2008 2009 2010 2011 2012 2013 2013
GenericPDP $5 $5 $5 $7 $7 $7 $5 $2
$10MA-PD $5 $5 $5 $5 $6 $6 $6 $5
Preferred brand
PDP $28 $28 $30 $37 $42 $42 $41 $40$29
MA-PD $26.70 $29 $30 $30 $39 $40 $42 $45
Non-preferred brand
PDP $55 $60 $71.50 $74.75 $76.50 $78 $92 $85$52
MA-PD $55 $60 $60 $60 $79 $80 $84 $90
SpecialtyPDP 25% 30% 30% 33% 30% 30% 29% 26%
32%MA-PD 25% 25% 25% 33% 33% 33% 33% 33%
NOTES Part D cost-sharing amounts are medians; employer plan cost-sharing amounts are means. Part D plan estimates weighted by enrollment in each year; analysis excludes generic/brand plans, plans with coinsurance for regular tiers, and plans with flat copayments for specialty tiers.SOURCE: Georgetown/NORC analysis of data from CMS for MedPAC and the Kaiser Family Foundation; data on employer plans from Kaiser/HRET Employer Health Benefits Survey, 2013.
Cost Sharing for Medicare Part D Plans, 2006-2013, and Employer-Sponsored Plans, 2013
Exhibit 13
MA-PD plans
Coinsurance
rates:
2009 2010 2011 2012 2013 2009 2010 2011 2012 2013
37% 34% 38%49% 50%
39%
19% 14%7% 12%
6% 19% 14%
11% 2%
4%
3%4%
6%5%
57%47% 48%
41%48%
56%
75% 81% 87% 82%
0.0175 0.02 0.0115 1% <1%
33%26%-32%25%<25%
NOTE: Estimates weighted by enrollment in each year. Analysis of MA-PD plans excludes Special Needs Plans.SOURCE: Georgetown/NORC analysis of data from CMS for the Kaiser Family Foundation.
Share of Enrollment in Medicare Part D Plans with Specialty Tiers, by Specialty Tier Coinsurance Rate, 2009-2013
PDPs
Exhibit 14
Nexium
Crestor
Advair Diskus
Namenda
Lantus
Spiriva
Cymbalta
Zetia
Celebrex
Lyrica
66%
73%
72%
100%
86%
80%
43%
60%
35%
47%
12%
1%
16%
1%
20%
57%
40%
42%
53%
21%
26%
11%
13%
22%
Preferred brand tier Non-preferred tier Not listed
NOTE: PDP is stand-alone prescription drug plan. Analysis is weighted by enrollment. Preferred brand includes plans using standard benefit without tiers. Non-preferred brand includes plans using specialty tiers. SOURCE: NORC/Social & Scientific Systems analysis of data from CMS.
Share of Medicare Part D Stand-Alone PDP Enrollees with Coverage of Top Ten Brand-Name Drugs, by Formulary Tier, 2013
Exhibit 15
Any UM Restriction Prior Authorization Step Therapy Quantity Limits
18%
8%
1%
12%
21%
9%
2%
14%
26%
12%
3%
16%
28%
14%
3%
16%
32%
17%
2%
19%
36%
20%
2%
21%
35%
21%
1%
18%
2007 2008 2009 2010 2011 2012 2013
NOTE: PDP is stand-alone prescription drug plan. Calculations are share of listed chemical entities, weighted by enrollment in each year.SOURCE: NORC/Social & Scientific Systems analysis of data from CMS.
Share of Covered Drugs with Utilization Management (UM) Restrictions Across All Medicare Part D Stand-Alone PDPs, 2007-2013
Exhibit 16
Top Brand-Name Drug
% Enrollees with Drug Not
Covered % Enrollees
with Any UM% Enrollees with Prior
Authorization
% Enrollees with Step Therapy
% Enrollees with Quantity
Limits
Nexium 21% 61% 0% 0% 57%
Crestor 26% 83% 0% 9% 82%
Advair Diskus 11% 79% 0% 4% 79%
Namenda 0% 76% 0% 0% 76%
Lantus 13% 30% 0% 0% 30%
Spiriva 0% 78% 0% 0% 78%
Cymbalta 0% 86% 20% 8% 83%
Zetia 0% 73% 7% 2% 72%
Celebrex 22% 74% 40% 26% 73%
Lyrica 0% 82% 25% 13% 74%
NOTE: PDP is stand-alone prescription drug plan. UM is utilization management. Presence of UM restrictions is measured as a share of plans with the drug listed on formulary.SOURCE: NORC/Social & Scientific Systems analysis of data from CMS.
Share of Medicare Part D Stand-Alone PDP Enrollees Facing UM Restrictions for Top Ten Brand-Name Drugs, 2013
Exhibit 17
24%9%
20%11% 16%
4% 6%
25%40%
42%
11%14%
12% 25%26%
28% 22%
24%
38%37%
35%
36% 29%
13% 27%10%
34%26%
36%30% 31%
11%2%
5% 7% 7% 14% 9% 8%
More than $25$25-$10$10-$5$5-$2Less than $2
NOTE: PDP is stand-alone prescription drug plan.SOURCE: Georgetown/NORC analysis of CMS 2006-2013 PDP Landscape and Enrollment files for the Kaiser Family Foundation.
Distribution of Monthly Part D Premiums for Low-Income Subsidy PDP Enrollees Paying Premiums, 2006-2013
Average premiums: $9.20 $12.69 $6.87 $11.10 $9.95 $14.71 $12.45 $11.82
Exhibit 18
2006 2007 2008 2009 2010 2011 2012 2013
488,400 530,100
1,718,800
2,042,200
1,731,000
1,040,100
1,423,9001,597,500
112,900259,800 257,800
821,300
575,400 517,500 555,900 614,400
Paying Any PremiumsPaying $10 or More
NOTE: PDP is stand-alone prescription drug plan.SOURCE: Georgetown/NORC analysis of CMS 2006-2013 PDP Landscape and Enrollment files for the Kaiser Family Foundation.
Number of Low-Income Subsidy PDP Enrollees Paying Monthly Premiums, 2006-2013
NOTE: PDP is stand-alone prescription drug plan. Unrated plans are excluded from percentages.SOURCE: Georgetown/NORC/Kaiser Family Foundation analysis of CMS Ratings, 2013.
Share of Medicare Part D Stand-Alone PDPs and PDP Enrollees, by Plan Star Ratings, 2013
4 or more stars
Total number of PDPs = 1,031 Total enrollment = 17.9 million
Distribution of PDPs by quality ratings:
Distribution of PDP enrollees, by quality ratings:
Exhibit 20
Name of firm
2013 2006Change in
Total Enrollment, 2006-2013Rank Enrollment
(in millions)% of Total Part
D in 2013 Rank
UnitedHealth Group 1 7.86 22.3% 1 +38%
Humana 2 5.17 14.7% 2 +19%
CVS Caremark 3 4.51 12.8% 11 +920%
Express Scripts 4 2.75 7.8% 10 +563%
Aetna 5 2.58 7.3% 12 +530%
CIGNA 6 1.65 4.7% 17 +675%
Kaiser Permanente 7 1.12 3.2% 6 +44%
Wellpoint 8 1.06 3.0% 3 -19%
WellCare Health Plans 9 1.01 2.9% 4 +3%
Envision 10 0.47 1.3% N/A N/A
TOTAL TOP 10 FIRMS 28.2 mil 79.9%
TOTAL PART D 35.3 mil 100.0%
NOTE: Includes plans in the territories and employer plans. SOURCE: Georgetown/NORC/Kaiser Family Foundation analysis of CMS Enrollment Files, 2006-2013.
Top 10 Firms Offering Medicare Part D Plans Ranked by 2013 Enrollment
SilverScript Group Calendar PDP (Employer) 6 0.94 2.7% N/A N/A
Humana Gold Plus HMO 7 0.81 2.3% 14 +113%
Kaiser Permanente Senior Advantage HMO 8 0.77 2.2% 7 +16%
Cigna Medicare Rx Plan One PDP 9 0.69 2.0% 29 +470%
First Health Part D Premier PDP 10 0.68 1.9% 18 +157%
NOTE: Includes plans in the territories and employer plans. SOURCE: Georgetown/NORC/Kaiser Family Foundation analysis of CMS Enrollment Files, 2006-2013.
Top 10 Medicare Part D Plans Ranked by 2013 Enrollment
Exhibit 22
Top 5 Medicare Part D Stand-Alone PDPs, Ranked by 2013 LIS Enrollment and Non-LIS EnrollmentPrescription Drug Plan Total LIS
EnrollmentShare of All LIS Enrollees
Share LIS in Plan
Number of Regions Where PDP is
Benchmark Plan SilverScript Basic 2,601,000 31.6% 86.0% 30Humana Walmart-Preferred Rx Plan 926,000 11.2% 52.8% 34AARP MedicareRx Preferred 737,000 8.9% 19.1% 0Cigna Medicare Rx Plan One 592,000 7.2% 86.4% 21WellCare Classic 436,000 5.3% 69.0% 19
TOTAL FOR TOP 5 LIS PDPs 5,292,000 64.2%
Prescription Drug PlanTotal Non-
LIS Enrollment
Share of All Non-LIS
Enrollment
Share Non-LIS
in Plan
Number of Regions Where PDP is
Benchmark Plan AARP MedicareRx Preferred 3,114,000 31.9% 80.9% 0Humana Enhanced 1,134,000 11.6% 86.3% 0Humana Walmart-Preferred Rx Plan 829,000 8.5% 47.2% 34First Health Part D-Value Plus 617,000 6.3% 95.7% 0SilverScript Basic 422,000 4.3% 14.0% 30
TOTAL FOR TOP 5 NON-LIS PDPs 6,116,000 62.6%
NOTE: LIS is low-income subsidy. Excludes employer group plans and plans in the territories.SOURCE: Georgetown/NORC analysis of CMS PDP Landscape and Enrollment Files, 2013, for the Kaiser Family Foundation.
