Your Pharmacy’s Guide to Key Medicare Part D Changes in 2019 – Part 1

Jan 24, 2019 | Independent Pharmacy Insights, Pharmacy Growth

2018 saw some drastic changes across the board in terms of U.S. policy and regulations. Unsurprisingly, healthcare remains one of the biggest hot-button issues, which has led to adjustments that impact all players – from healthcare professionals to patients to stakeholders.

In terms of Medicare Part D, there are several changes that independent pharmacies should be aware of. In this two-part series, we’ll discuss a few of the key concepts that will impact your pharmacy’s operations and interactions with partners and patients.

Some of the most notable changes include, but aren’t limited to:

    • New policies aimed at limiting opioid access and potential abuse
    • Changes that impact when patients enter and exit the coverage gap, or “donut hole”
    • “Any willing pharmacy” term clarification that allows increased participation from non-traditional pharmacies
    • Formulary flexibility that allows plans to substitute or remove brand-name drugs
    • New Medicare cards that patients must use by 2020

Let’s discuss these changes closer, as well as the impact they’re projected to have on pharmacies.

New Policies for Limiting Opioid Access

According to the CDC, an average of 130 Americans die each day from opioid overdose — a number that’s six times higher than it was in 1999. In an effort to minimize opioid addiction and curtail the nation’s epidemic, CMS has implemented some changes in prescribing policies for Medicare Part D beneficiaries.

Seven-Day Supply Limit

For opioid naïve patients, or patients who haven’t recently filled an opioid prescription, initial dispensing is expected to be limited to a supply of seven days or less. If the prescriber believes that the patient needs more, the provider can request a proactive coverage determination on the patient’s behalf. Through this determination, the provider can attest to the patient’s medical need for a supply lasting longer than seven days.

“Care Coordination” Edit Alerts

These alerts are triggered when a patient’s attempts to fill one or more prescriptions that reach or exceed 90 MME (morphine milligram equivalent) per day. The prescriber is alerted, and the pharmacy must contact the prescriber to ensure the legitimacy and medical need of the prescription.

After this is confirmed, the pharmacist is required to document the discussion so that the claim can pay, as well as enter a code to override the alert. This consultation between prescriber and pharmacist only needs to take place once per plan year, unless the plan has further restrictions.

Takeaway for pharmacies: You’ll have more communication with prescribers to ensure that opioids are used legitimately and only as medically necessary. Part D plans will provide your pharmacy with the necessary information.

Changes to the Donut Hole

In 2018, the initial coverage limit (ICL) to enter the donut hole was $3,750. In 2019, this amount increased by $70 to $3,820. Once patients are in the donut hole, patients are required to pay 25% of brand-name drugs — 70% of which is covered by the manufacturer, and 5% is paid by the Part D plan.

For generic drugs, the patient must pay 37% of the cost. For this reason, patients taking brand-name drugs are expected to pass through the donut hole faster than patients on generics.

The out-of-pocket threshold (TrOOP), or exit point of the donut hole, has also increased. This figure is now $5,100, up $100 from $5,000 in 2018. Once this amount has been reached, the patient’s catastrophic coverage kicks in and the plan covers the remaining costs.


Though it doesn’t directly relate to the donut hole, it’s also worth noting that the initial deductible for minimum allowable plans also increased $10 to $415. Up until this point, patients pay 100% of drug costs.

Takeaway for pharmacies: Patients may need assistance in explaining/interpreting price differences for their prescriptions.

Closing Thoughts

Pharmacists are front-and-center in the battle against America’s opioid epidemic, which can be seen through new requirements to confirm the legitimacy and medical necessity of these prescriptions. In terms of patient coverage, pharmacists should be equipped to discuss how changes to the donut hole and cost-sharing may impact their financial situation.

Stay tuned for Part 2 of our Medicare Part D discussion, where we’ll outline a few more of the 2019 changes that your pharmacy must be on top of for the coming year.

How has your pharmacy tackled the 2019 changes to Medicare Part D? Do you have a strategy or tip you want to share?

We’d love to know and may even share those experiences in future blog posts, white papers, and e-books. If you’d like to add your experience, please contact Jessica Gardner.

And, of course, be sure to subscribe to our blog for more tips, insights and bulletins that can help grow your pharmacy and save you money – all from your partners at AlliantRx.