Help clients cut through the noise around prescription drug plans

By Betsy Chandler and Jay McKnight

Changes in prescription drug costs and access have received a great deal of attention in the news lately. These developments may make it more difficult for Medicare-eligible clients to navigate their plan selection.

Over the last year, pharmaceutical companies and the federal government introduced direct-to-patient prescription drug discount programs that offer certain medications at reduced prices. At the same time, the federal government has introduced most-favored-nation pricing agreements and reductions in out-of-pocket expenses for 15 high-cost drugs under the 2027 Medicare Drug Price Negotiations Program. These changes could make medications more affordable and accessible to beneficiaries. However, deciphering how these developments impact an individual’s prescription plan options can be overwhelming.

It’s important to help clients cut through all the noise and provide the right guidance. That’s especially true now, when we’re hearing questions from clients who seem more confused than ever before.

Why PDP guidance matters more than ever

Brokers already have good reasons to prioritize prescription drug plan discussions each year. About 90% of older adults regularly take at least one prescription medication, while 43% take at least five, making prescription drug coverage the most frequently used health benefit by many seniors. As a result, Medicare beneficiaries tend to be especially conscious of drug costs, coverage issues and their drug plan experience.

Prescription drug plans are complex. Numerous factors - including formularies, pharmacy networks and varying cost-sharing structures - can make plan comparisons difficult. Brokers can simplify the process for their clients and guide them toward the right plan decisions that meet their individual needs.

Starting with a personalized needs analysis

Effective guidance starts with an in-depth conversation. Identifying what matters most to each client - whether minimizing total out-of-pocket costs, maintaining access to specific medications or using a certain pharmacy - lays the foundation for better plan selection.

Some strategies and resources can help drive that discussion.

The first step is to complete a comprehensive needs analysis, which can be made easier by using available client needs assessment worksheets. This process provides a clear picture of the client’s priorities and medication needs, including their preferences and access to specific pharmacies. It also includes a review of their current prescriptions and any anticipated changes for the coming year, which is especially important for those in rural or underserved areas or for those with mobility and transportation limitations.

Looking beyond premiums

Many plan decisions are mistakenly based solely on the cost of the premium, but you can help your client avoid that pitfall by educating them on how to assess the plan’s full value of the plan. That means evaluating formulary coverage, pharmacy network design, home-delivery options, copay and coinsurance costs, and star ratings.

Clients also must understand how the benefit works in practice, including eligibility rules, enrollment timelines and federal policy changes that impact access or costs, such as out-of-pocket caps or negotiated drug pricing.

Although digital tools such as Medicare.gov and carrier websites can help compare plans, they cannot replace the role of the broker. Clients rely on you to listen carefully, ask the right questions and help them avoid costly mistakes.

Making sense of drug pricing headlines

Given the recent prescription drug-related news, brokers should be prepared to address their clients’ questions and misconceptions regarding these developments.

Direct-to-patient discount programs may seem appealing, but they are not a substitute for comprehensive prescription drug coverage. These programs typically apply to a limited number of medications and do not protect against high-cost exposure if a serious or unexpected medication need arises. They also lack built-in safety features, such as medication reviews that help prevent harmful drug interactions. It’s important to note that drugs purchased through DTP programs do not count toward a plan’s maximum out-of-pocket limit. Without that protection, clients could ultimately face higher costs. In addition, because DTP programs are not considered creditable coverage, relying on them instead of enrolling in a PDP may result in late enrollment penalties.

Similarly, while MFN pricing initiatives have generated attention, many details remain uncertain, and they may not apply to Medicare Part D plans. In contrast, the Medicare Drug Price Negotiation Program, which reduced OOP costs for certain drugs, including GLP-1s, will apply across PDPs and must be included in plan formularies, ensuring consistent coverage and costs for those medications.

Building trust through expert guidance

The prescription drug benefit is often one of the most frequently used and most important parts of a client’s healthcare experience. As headlines continue to shape perceptions and raise questions, brokers have an opportunity to provide much-needed clarity to a confusing and complex process.

By understanding your clients’ needs and the evolving prescription drug landscape, brokers can better assist their clients in selecting a PDP that is right for their health and financial situation and, in turn, build stronger, more lasting relationships that will be good for business.

Betsy Chandler is a licensed insurance agent and president of MIC Insurance Services. Contact her at [email protected].

Jay McKnight, PharmD, is associate vice president of Humana’s Medicare Prescription Drug Plans. Contact him at [email protected].

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