Jan 1, 2023

Inflation Reduction Act (IRA)

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):