Philanthros Market Access Consulting

Good morning! I want to follow up on our last blog, and the cost per beneficiary is helpful to understand as you forecast the liability that you may cause the Plan Sponsor to have in 2025. As mentioned, as low as 5% or less of patients will impact the payer's financial liability the most. Let's take a closer look. Philanthros has taken a deeper dive into the 2021 spending as a comparison. How much did Medicare Part D spend on prescription drugs in 2021? 215.7 billion. How many medications/NDCs accounted for this? 10,185. Ten drugs accounted for 22% of the total, and the top twenty accounted for 31%. What do you think about the total cost per beneficiary in 2021? As you project the probability for the patients you care for, factor in the historical spend per beneficiary with your medication. The average spend per beneficiary in 2021 was $6,060.16. How about the patients you care for? Consider this: 18% of all Rxs exceeded $2000.00 per beneficiary in 2021. This utilization data is the total cost the Sponsor pays per patient. This data from a historical context will help you determine the out-of-pocket expenses (pct of cost is co-insurance). If you analyze the cost per beneficiary, you can calculate their likely out-of-pocket costs and consider their comorbidities. As you negotiate your bid for 2025, the patient access you are negotiating for is in a manageable range. Remember that 66% of patients were less than $1000.00 of costs each to the Plan Sponsor. Historical trends matter. Have a great Monday! #medicarepartd #inflationreductionact #payers #pharmaceutical #marketaccess #bidseason #pbms #plansponsors

Good morning! Bid Season is upon us! As recently as 2024, Medicare's reinsurance payments to plans subsidized 80% of total drug spending incurred by Part D enrollees above the catastrophic coverage threshold. In 2025, this share will drop to 20% for brand-name drugs and 40% for generic drugs. A Part D Plan Sponsor can have more financial liability in 2025. The manufacturer will be asked to pay more in rebate (bid). Will ALL manufacturers have to pay more? A tiny percentage of patients will fall into this liability window of catastrophic coverage. As low as 5% or less of all patients will impact the payer's financial liability most. Study your therapeutic area. If this is your first year in Medicare Part D, come prepared to show the Plan Sponsor the patient type, the nature of their condition, and the likelihood of them entering the catastrophic phase. If your patient does not present the risk of entering the catastrophic phase, this will support your bid and negotiation. In recent years, 5-7 million patients spent more than $2000 in copay. There are 50 million patients with Rx benefits in Medicare Part D. Show that you are going to avoid falling into catastrophic areas. If you have worked with the Plan Sponsor in previous years: Review Historical Rebates. Analyze historical rebate trends for similar drugs in your therapeutic class. Consider how rebate percentages have changed over time and adjust accordingly. Show your patient's utilization trends. Negotiate with Medicare Plan Sponsors to understand their specific needs and preferences. Be prepared to customize your rebate offer based on individual payer requirements.

Good morning! It is bid season! Part D sponsors will have full details soon. Comments on the redesign for 2025 will be accepted by CMS through 6:00 PM EST, Friday, March 1. Final program instructions will be published by April 1, 2024. I am sure you have studied the working parts of 2025 Medicare Part D by now and are aware of your manufacturer discounts. Have you considered what your bid will be versus your 2024 rate? This week, we will discuss "bid season," the overall process, and things you should consider. Sponsor, Manufacturer, and Patient. By studying each versus your 2024 model, you can be better prepared for your bid and how it improves patient access in 2025. Plan Sponsors will be sharing their overall projected liability with you. They may have already done so. You might hear, "The manufacturer liability is decreasing, and the health plan sponsor liability is increasing." The good news is, you have time. Start building a financial model of what percentage the Plan Sponsor pays for your medication in 2025 and how much the patient pays. Factor in your discounts versus the Coverage Gap in 2024 with initial coverage discounts and catastrophic phase discounts. Are they more? Less? We'll make sure to share things to consider this week as you're able to map this out. #inflationreductionact #medicarepartd #rebates #medicarecoverage #manufacturerdiscountprogram