November 2018 Pharmacy Update

2019 Medicare Part D Updates

As the 2019 Medicare open enrollment process has begun for patients, it is important for you as prescribers and healthcare providers to understand the changes coming in 2019 and how they will affect your practice and your patients.

Changes in 2019:

  • Annual deductible for most Medicare Part D plans will increase from $405 to $415
  • Coverage gap (“donut hole”) will begin when total Rx costs reach $3820 (it was $3750 in 2018)
  • The good news: Patients may exit the donut hole faster due to a decrease in total patient amount paid during the gap

What should I be aware of?

  1. Open enrollment is from October 15 – December 7
  2. Patients are automatically re-enrolled in their current plans if they do not make changes
  3. After December 7th, patients cannot change plans unless they switch to a 5-Star Rated plan
  4. Plan changes are effective January 1, 2019
    • Encourage office staff to remind patients to bring Medicare letters or all new insurance cards to prevent billing issues for both your practice and the pharmacy
    • Anticipate Prior Authorization (P.A.) requests for newer brand drugs or drugs that may have “fallen out of favor” but were previously covered
      • ex: Express Scripts will require a P.A. for Pradaxa® and Savaysa® (Eliquis® and Xarelto® are preferred starting 2019)
  5. Continue to prescribe lower cost but equally effective generic alternatives to decrease possible out-of-pocket patient costs
    • See SVHP Brand vs. Generic “Red List” as a reference for prescribing the most cost-effective medications
    • Some insurance plans have already uploaded their 2019 formulary online. Look out for insurance communications regarding updated formularies as this may affect your patient’s current medications.
    • Be aware of upcoming generics coming out
      • ex: Lyrica® generic is expected around December 2018
  6. If you would like more information or resources such as the SVHP Red List, list of anticipated generic availability list, or patient-friendly handouts explaining Medicare, please feel free to contact the SVHP Clinical Pharmacist via phone or email. Information can also be found online at