Christine Jordan Sexton
Hundreds of thousands of Floridians are expected to save money under drug pricing changes pushed into law by President Joe Biden. But while seniors welcome the help, some say they still expect to struggle to pay for needed prescriptions.
Initially passed in 2022, the Inflation Reduction Act made a number of changes to the Medicare prescription drug program. Those include capping co-pays for insulin at $35 a month, limiting out-of-pocket co-payments to $2,000 and allowing the federal government to negotiate with drug companies to lower spending on prescription drugs.
The changes are being rolled out over a spate of years, though the insulin caps have already taken effect. According to the federal government, more than 90,000 Floridians on Medicare were expected to save an average of $476.
A new AARP report shows that an estimated 200,000 Floridians on Medicare prescription drug plans will see savings under the new $2,000 out-of-pocket cap that takes effect Jan. 1, 2025. AARP analyzed the number of enrollees who will benefit from the cap by state, age, gender and race between 2025 and 2029. According to the analysis, Medicare drug plan enrollees who hit the maximum out-of-pocket cap will save on average about $1,500 in 2025.
Nationwide, between 3 million and 4 million Medicare Part D plan enrollees are expected to benefit from the new law. More than three-quarters of Medicare drug plan enrollees who will benefit in 2025 are between the ages of 65 and 84.
“Knowing they won’t pay a dime over $2,000 next year — maximum — for prescription drugs they get at the pharmacy gives Florida seniors on Medicare drug plans some peace of mind as they struggle to keep up with rising costs for other everyday essentials like housing, groceries and utilities,” said Jeff Johnson, AARP Florida State Director.
Robert Romanski, 65, is one of the Florida residents who will benefit from $2,000 out-of-pocket cap.
Romanski was rushed to the emergency room in a near coma-like state in November 2017, which is when his diabetes was diagnosed. Diabetes is a disease in which your blood sugar levels are too high because of an insulin problem. Insulin is the hormone that helps glucose get into cells to give them energy. Without proper levels of insulin, glucose stays in the bloodstream and can damage the eyes, kidneys and nerves, among other things.
Since then, Romanski has taken a cadre of medicines — from insulin to metformin to Jardiance — to control the disease. His annual Medicare co-payments for those drugs “is pushing $3,500.”
“I just made $1,500. I just got a bonus for the immediate future,” the Riverview Florida resident said. “That’s just a godsend.”
Romanski said he was initially thrilled to become Medicare eligible because it meant he could drop his private health insurance plan. But he quickly discovered the Medicare Part D coverage gap. People fall into the coverage gap when their total drug costs — meaning what’s paid by the insurer and the enrollee — reach a certain limit. In 2024, that limit is $5,030.
Thereafter, people in the coverage gap — often referred to as the Medicare Part D donut hole — are responsible for 25% of the costs of the drugs.
Romanski fell into the coverage gap after one year on Medicare. That meant his Jardiance went from a $25 monthly co-payment to a $600 monthly payment.
“I just always found it so ironic that the thing that is killing me is a thing called the ‘donut hole,’ which would kill me if I ate a donut hole,” he said.
He went off the drug for one year but resumed the medication this year. His co-payment now is $197 a month — as he likes to put it, “$19 a pill,” or “still way too expensive.” He cannot account for the steep differences in the co-payments he’s been charged for the same drug.
According to Centers for Medicare & Medicaid Services (CMS), more than 1.8 million Medicare beneficiaries took Jardiance in 2023.
In addition to lowering out-of-pocket spending, the Inflation Reduction Act allows CMS to negotiate directly with drug companies to improve access to some of the costliest single-source, brand-name drugs. The government this year negotiated new spending for 10 drugs and the reduced prices take effect January 2026.
According to CMS, had the new prices for those 10 drugs been in effect in 2023, spending would have been reduced by $6 billion, or 22%.
Jardiance is one of 10 drugs covered under Medicare Part D that CMS recently negotiated.
Ft Lauderdale resident Sandra Hankin, 73, agrees with Romanski about the high costs of drugs.
Hankin, like Romanski, is a diabetic. She was diagnosed in 2006.
A self-proclaimed “lifelong fat girl” Hankin had been successfully managing her sugar and A1C levels until recently. She started to take Mounjaro this year hoping to avoid becoming insulin dependent. She switched to Ozempic after three months but has subsequently gone back to Mounjaro. The 73-year-old Ft. Lauderdale resident is paying $262 a month in co-payments.
Prior to hitting the donut hole, she was paying a $5 co-payment. In July, her co-payment was $262 and in August it was $272.
“There’s still four months in the year to go, which is another grand,” she said.
Hankin isn’t sure she’s going to continue to take the drugs, in part because of the costs of the drugs, whether it’s coming from her pocket or from her Medicare plan.
“They are just making up numbers. Let’s throw the numbers on the floor and pick one up and that’s what we’re going to charge,” she said.
AARP’s Johnson called the changes in the Inflation Reduction Act a start, adding that he’s hopeful that the list of negotiated drugs is expanded in the future to include “more of the drugs that are stressing the pocketbooks of Florida Medicare beneficiaries and beneficiaries overall.”
The Inflation Reduction Act initially would have capped insulin costs for everyone, not just those who are on Medicare Part D, a move that AARP also supported, he said.
“This is a good start that can be expanded on,” Johnson said.
One comment
Harry
September 3, 2024 at 9:22 am
This would be great!
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