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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
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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%Enrolleepays 5%
Enrollee pays 25%
CatastrophicCoverage Limit =
$6,955 in Estimated
Total Drug Costs
Brand-name drugs Enrollee pays 47.5%;
Plan pays 2.5%50% manufacturer discount
Generic drugsEnrollee pays 79%;
Plan pays 21%
INITIAL COVERAGE
PERIOD
COVERAGE GAP
CATASTROPHIC COVERAGE
DEDUCTIBLE
Exhibit 2
2006 2007 2008 2009 2010 2011 2012 2013
409 483 442 308 307 258 252 218
1,020
1,2351,329
1,381 1,269
777 714 700157
5374 75 113
1,429
1,875 1,8241,689
1,576
1,109 1,041 1,031
Non-benchmark plansDe minimis plans*Benchmark plansSeries4
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
Exhibit 4
Name of PDP
2013 Enrollment (of 18.0 million)
Weighted Average Monthly Premium1 % Change
Number % of Total 2006 2012 2013 2012-
20132006-2013
AARP MedicareRx Preferred 3,851,372 21.4% $26.31 $39.85 $40.45 +2% +54%
SilverScript Basic 3,022,209 16.8% $30.94 $30.75 $33.05 +7% +7%
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
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acy
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Dig
est
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eric
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ript
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are
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RxPl
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ilver
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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
Exhibit 7
33 10 26 19 7 1 20 18 15 22 21 14 28 2 16 29 9 3 12 13 23 24 34 8 32 27 6 25 4 17 31 11 30 5$0
$20
$40
$60
$80
$100
$18.
50
$15.
00
$15.
00
$15.
00
$15.
00
$18.
50
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$18.
50
$15.
00
$15.
00
$15.
00
$15.
00
$18.
50
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$15.
00
$40.
50
$41.
10
$45.
00
$46.
00
$47.
60
$49.
10
$49.
10
$50.
20
$50.
30
$50.
30
$51.
20
$51.
30
$51.
40
$52.
50
$52.
50
$52.
90
$53.
10
$54.
40
$56.
70
$56.
70
$56.
80
$57.
00
$57.
70
$61.
00
$61.
00
$61.
40
$63.
80
$64.
10
$66.
50
$71.
10 $80.
50
$81.
00
$82.
00
$105
.80
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
Delaware, Maryland, DC
Hawaii
TexasGeorgia Illinois
PDP Region #
New York California
Florida
Exhibit 8
Type of benefit package
1 2 3 4
$31.98 $36.70 $33.47
$66.24$12.00 $9.62
$33.78
$31.98
$48.70 $43.09
$100.02Enhanced benefit packageBasic benefit package
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
Of Total LIS Enrollees, Share Paying Premiums:
2006 2007 2008 2009 2010 2011 2012 2013
6% 7% 21% 26% 22% 13% 17% 19%
Number Paying Premiums: 488,400 530,100 1,718,800 2,042,200 1,731,000 1,040,100 1,433,900 1,597,500
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
Exhibit 19
3% <1%
16% 23%
42%45%
30%23%
8% 6%<1% <1%<1% 2%
5 stars4.5 stars4 stars3.5 stars3 stars2.5 stars2 stars
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
Exhibit 21
Name of Plan2013 2006
Change 2006-2013Rank Enrollment
(in millions)% of Total Part
D in 2013 Rank
AARP MedicareRx Preferred PDP 1 3.87 11.0% 1 +21%
SilverScript Basic PDP* 2 3.04 8.6% 5 +284%
Express Scripts Medicare PDP (Employer)** 3 2.33 6.6% 11 +461%
Humana Walmart-Preferred PDP 4 1.76 5.0% N/A N/A
Humana Enhanced PDP 5 1.32 3.7% 3 +37%
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.