The Inflation Reduction Act (IRA) will take effect on January 1, 2023.The Act includes the following updates which will impact Medicare Advantage plan members prescription benefits:
- Insulin cost cap of $35 for a month’s supply of covered insulin
- This will cap member Part D cost share for insulin at $35. This is per one-month supply through their plan’s coverage year. This does not include items like syringes, lancets or other support products
- Members administering insulin via non-disposable insulin pump receive insulin under the Part B benefit. The cost share for Part B insulin will be capped at $35 per one-month supply beginning July 1, 2023
- As our pharmacy benefits manager (PBM) transitions their system to this new program, member cost share may exceed $35 in the month of January 2023. Should this occur the member does not need to take any action. Their claim will automatically be reprocessed within the required 30 days. A check for the amount overpaid will be mailed to the member.
- BCBSRI will continue to offer the Part D Senior Savings benefit on select plans in which the member may already have an insulin cost share less than $35 per one-month supply. If their cost share is already at or below $35, they will not be impacted.
- Members have been notified of these upcoming changes.
- No out-of-pocket (OOP) costs for adult vaccines under Medicare Part D
- Our PBM will adjudicate ACIP-recommended, Medicare D covered vaccines for adults ages 19 and over at the $0 cost share as outlined in CMS’ guidance as of January 1, 2023.
- There are currently three vaccines not meeting the CMS guidance; they will continue to be processed based on formulary status. • BCG VACCINE (Tuberculosis), ROTATEQ (Rotavirus) and DENGVAXIA (Dengue).
- Weekly roll-in reviews will identify new vaccines. Prime will assume new Medicare D eligible vaccines will meet the criteria for $0 copays until ACIP recommendations are posted.
- 2023 Adult ACIP-Recommended Vaccines Included in IRA (This list is current as of 11/21/22):
