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Health Line
12 hours ago
- Health
- Health Line
Medicare's Limited Income Newly Eligible Transition (LI NET) Program
LI NET Medicare gives temporary drug coverage to people from low income households who haven't yet enrolled in a Part D. It covers all drugs that Part D covers, allowing you to visit any pharmacy. Medicare launched the Limited Income Newly Eligible Transition (LI NET) Program in 2010 to provide temporary Part D prescription drug coverage for beneficiaries from low-income households who have yet to join a Medicare drug plan. In 2024, LI NET became a permanent part of the Medicare Part D program due to Section 118 of the Consolidated Appropriations Act of 2021. Humana currently administers the LI NET program nationwide. What is LI NET in Medicare? Unlike Original Medicare (parts A and B), which is a government-run insurance plan, private insurers operate Medicare Part D drug plans. There are many different Part D plans, and depending on the plan you select, your exact benefits and costs will vary. However, if you live on a lower income and are eligible for Medicare but haven't yet enrolled in a Part D plan, you can qualify for the LI NET program under certain criteria. LI NET coverage lasts up to 2 months, giving you time to choose and sign up for a Part D plan that fits your needs. Once you qualify, your enrollment in LI NET begins on the first day of the month when you become eligible and continues for 2 months. Some people may be eligible for retroactive coverage. If this applies to you, you can get reimbursed for any qualifying prescriptions from when you became eligible for LI NET or 36 days before you signed up for Part D coverage, whichever comes later. Am I eligible for LI NET Medicare? Depending on how you qualify for LI NET, your exact coverage may vary slightly as follows: You're dually enrolled in full-benefit Medicare and Medicaid: 36 months of retroactive coverage. You're eligible for Supplemental Security Income (SSI): 36 months of retroactive coverage. You're eligible for Extra Help: 30 days of retroactive pharmacy counter coverage. You're eligible for certain Medicare Savings Programs (MSPs): 30 days of retroactive pharmacy counter coverage. Pharmacy counter coverage means that when you pick up your medication, you will automatically pay reduced pricing according to your plan. What medications can I get through LI NET Medicare? Each full Part D plan typically covers specific medications, determined by the plan's formulary. However, LI NET maintains an open formulary, which means this program covers all medications that Part D plans can cover. Exceptions include those that Part D never covers or those that federal law prohibits. However, you might need to provide proof of a particular diagnosis to secure coverage for certain medications under LI NET. This program does not restrict network pharmacies, which means you can visit any pharmacy you want. Frequently asked questions Does LI NET have premiums, deductibles, or copays? You don't have a monthly premium or a deductible with LI NET. However, you may have a copay when you purchase prescription drugs. However, this will depend on how you're eligible and your eligibility level. You don't have a monthly premium or a deductible with LI NET. However, you may have a copay when you purchase prescription drugs. However, this will depend on how you're eligible and your eligibility level. How do I fill a prescription in a pharmacy with LI NET? In order for your pharmacy to bill LI NET, the pharmacist may be able to find this within the Medicare system. Alternatively, you may need to show the pharmacist your Medicaid card or another document that verifies either your Medicaid eligibility or your eligibility for Extra Help. Once they have a reasonable expectation of your eligibility, the pharmacy will generally bill your medications directly to the LI NET program. In order for your pharmacy to bill LI NET, the pharmacist may be able to find this within the Medicare system. Alternatively, you may need to show the pharmacist your Medicaid card or another document that verifies either your Medicaid eligibility or your eligibility for Extra Help. Once they have a reasonable expectation of your eligibility, the pharmacy will generally bill your medications directly to the LI NET program. How do I contact Medicare with questions about LI NET? For information about Medicare's LI NET Program, call the LI NET help desk at 1-800-783-1307 between 8 a.m. and 11 p.m. Eastern Time (ET). TTY users should call 711. For information about Medicare's LI NET Program, call the LI NET help desk at 1-800-783-1307 between 8 a.m. and 11 p.m. Eastern Time (ET). TTY users should call 711. Takeaway Medicare Part D provides prescription drug coverage through private insurance companies, with costs varying depending on the plan you choose. The LI NET Program, started in 2010 and made a permanent option in 2024, can offer you temporary Part D coverage if you're living on a low income and haven't yet joined a full Part D plan. With LI NET, you can get immediate drug coverage for up to two months, allowing you time to select and enroll in your preferred Part D plan. Humana manages the LI NET program, which features an open formulary and allows you to use any pharmacy without restrictions. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Health Line
2 days ago
- Health
- Health Line
What to Know About Preferred Pharmacies with Medicare
Medicare Part D plans typically have preferred in-network pharmacies, which usually offer a discount to certain plan members. Medicare Part D covers prescription drugs. If you have Original Medicare (parts A and B), you can purchase a stand-alone Part D plan from a Medicare-approved private insurance company. Most Medicare Advantage (Part C) plans include prescription drug coverage. Both Part D and Medicare Advantage plans will often have a list of in-network preferred pharmacies where you can receive prescriptions at a lower cost. What is a Medicare preferred pharmacy? A preferred pharmacy is a network pharmacy that offers prescription drugs to Part D beneficiaries at negotiated lower prices. These pharmacies contract at lower rates because it gives an exchange of increased volume of users. A recent analysis showed that the adoption of preferred network pharmacies by Medicare Part D plans reduced spending by 2% for beneficiaries. Over 90% of Part D plans use preferred pharmacy networks. Using a preferred pharmacy can help save on your out-of-pocket costs, such as coinsurance and copayments. Vs. nonpreferred A nonpreferred pharmacy is a pharmacy that accepts Part D coverage for prescription drugs, but at a higher cost than preferred pharmacies. Preferred pharmacy vs. in-network pharmacy Medicare Part D plans generally have contracts with pharmacies that are in their network. Using in-network pharmacies means you can typically get your prescriptions at a discounted price. Some Part D plans will only cover your prescriptions if you use an in-network pharmacy. Since Part D plans are offered by private insurance companies, they can choose what drugs they cover, what pharmacies are in-network, and costs, as long as they meet Medicare's standards. To find out if a particular pharmacy is in your plan's network, you can contact your plan, the pharmacy, or Medicare (800-633-4227). Preferred pharmacy vs. mail-order pharmacy Some Part D plans may offer the ability to use a mail-order pharmacy so you can have your prescriptions sent directly to your house. With a mail-order pharmacy, you may be able to receive 3 months of your prescriptions at a time. Your Part D plan may also allow you to automatically refill your prescriptions when using this service. Mail-order pharmacies may be a cost-effective and convenient way for you to get your prescriptions. You can contact your plan for more information and to see if mail-order pharmacies are available. Preferred pharmacy vs. out-of-network pharmacy An out-of-network pharmacy is one that's not contracted with a Part D plan. If a pharmacy is not in your plan's network, you'll typically pay a higher out-of-pocket cost for your prescriptions. Some plans may not cover your prescriptions from an out-of-network pharmacy. Keep in mind that if you do get your prescriptions from an out-of-network pharmacy, you may have to pay the full cost for them. Some plans may offer a reimbursement for part of your out-of-pocket cost. You can contact your plan for more information. Summary Medicare Part D plans will typically have in-network pharmacies. These are pharmacies that are contracted with the plan to offer prescriptions at lower costs to beneficiaries. Some Part D plans will not cover your prescriptions if you don't use an in-network pharmacy. Sometimes, Part D plans will also have preferred in-network pharmacies. These are pharmacies that have agreed to give larger discounts to Medicare beneficiaries in exchange for higher volumes of use. You can check with your plan or contact Medicare for more information on in-network and preferred pharmacies. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Gulf Insider
2 days ago
- Health
- Gulf Insider
What To Know About Big Pharma, In Charts
Prescription drugs provide relief from pain, fight infection, stabilize moods, reduce inflammation, combat dread diseases, and extend lives. These medications have become a fact of life for many—perhaps most—Americans. On average, half of them took at least one prescription drug in a given month, according to a recent CDC survey. More than 13 percent took five or more. And the rate is growing. In 2020 Americans filled 6.4 billion prescriptions, about 19 per person. By 2023, Americans were consuming more than 210 billion daily doses of medication annually. That's more than 600 pills, shots, drops, IVs, creams, mists, or suppositories for every person in the country. A child born in 2019 in the United States can expect to spend roughly half of his or her life taking prescription medications, according to Jessica Y. Ho, a researcher at Pennsylvania State University. The United States consumes more prescription drugs than any country in the world and spends nearly twice as much for them as all other nations combined. Global pharmaceutical sales were estimated at $1.6 trillion in 2023, according to Statista. That's roughly equal to the gross domestic product of Spain and nearly double that of Switzerland. The ten largest pharmaceutical companies in the United States alone have a combined worth of more than $2.1 trillion. Recent growth in the industry has been driven by the creation of new types of medications including biologics and peptides. These medications can be highly effective but also very expensive. Biologics are drugs derived from living sources rather than chemicals. Medicare paid nearly $66,000 per patient for prescriptions of Humira in 2023. That's a biologic medication to treat rheumatoid arthritis, plaque psoriasis, and other diseases. Development of biologics has more than tripled over the last decade. The Food and Drug Administration (FDA) approved 17 biologics in 2023, up from an average of 4 per year between 1999 and 2013. Americans consumed 72 percent of the top 50 biologic drugs sold in the world in 2022, according to the Department of Health and Human Services. Peptides are drugs that mimic the function of certain substances within the human body. A particular type of peptide called GLP-1 helps regulate blood sugar and appetite. Ozempic, Weygovy, and Trulicity are GLP-1 medications. Medicare Part D alone paid more than $22 billion to provide GLP-1 medications in 2023, an increase of nearly 130 percent in two years. Currently, the GLP-1 market is dominated by Novo Nordisk, Eli Lilly, AstraZeneca, and Sanofi, though others are working to develop similar medications. U.S. drug prices were more than double those in other countries as of 2022, and more than 4 times as much for brand-name drugs, according to global consulting firm RAND. Pharmaceutical companies do considerable business with the federal government, deriving $387 billion in payments from Medicare Part D and Medicaid in 2023 alone. Pharmaceutical companies and some 100 allied political action committees spent more than $15 million in campaign contributions during each of the last two presidential elections, and nearly as much during the mid-terms. Those amounts are overshadowed by the pharmaceutical industry's annual lobbying expenditures. The industry spent more than $150 million to influence federal and state legislatures in 2024. Of its more than 700 lobbyists, nearly two thirds were former government employees. The pharmaceutical lobby spent more money over the past quarter century than did electric utilities, oil and gas companies, hospitals and nursing homes—more than the automotive and defense aerospace industries combined. Research Developing new medications is expensive. The average cost of bringing a new drug market can range up to $2 billion, according to data cited by the Congressional Budget Office. Congress aided companies investing in research via the One Big Beautiful Bill Act, which includes a provision for makers of drugs that treat rare diseases. The law widens the definition of a rare disease drug and further delays Medicare price negotiations on drugs that treat them. That allows the makers of those drugs to continue charging Medicare full price for the medications, in order to fund future research. Normally, a drug that has been marketed for at least 9 years and receives $200 million per year in Medicare payments would be eligible for price negotiation.
Medscape
7 days ago
- Health
- Medscape
Volume Fueling Rise in Part D Specialty Derm Drug Spending
Prescription volume for specialty medications, not price hikes, largely seems to be the main factor in the ongoing huge increase in Medicare Part D dermatology drug spending, according to a new study. Harvard Medical School researchers reported that from 2013 to 2022, prices were higher and rose faster for specialty medications, but that 80% of the increase in spending 'was due to increased prescriptions, not prices.' Price increases only accounted for 20% of the total growth in Medicare Part D dermatologic drug spending during the study period, lead author Edward L. Kong, PhD, told Medscape Medical News . Specialty medications — primarily immunomodulators — 'are just very expensive in general,' and are being rapidly adopted by clinicians, which is driving increased spending, said Kong, who is pursuing an MD degree at the Harvard-MIT Health Sciences and Technology program. Kong and Arash Mostaghimi, MD, MPA, MPH, medical director of the dermatology consult service at Brigham and Women's Hospital, and associate professor, Harvard Medical School, both in Boston, published their findings in JAMA Dermatology on July 16. They examined some 95 million prescriptions for Medicare beneficiaries, written by almost 25,000 dermatologists and dermatology-focused advanced practice clinicians. Inflation-adjusted spending increased an average of 16% a year, reaching $2.95 billion in 2022. Over the study time period, specialty drug spending increased just under 30% a year, reaching $2.4 billion in 2022. Spending on nonspecialty medications only grew 0.7% annually during the study period. By 2022, specialty medications accounted for 81% of all dermatology drug spending, having risen from a third of spending in 2013. Even so specialty medications only represented about 3% of all Medicare Part D dermatology prescriptions in 2022. Four of the specialty drugs were introduced before 2013: adalimumab (Humira), etanercept (Enbrel), ustekinumab (Stelara), and vismodegib (Erivedge). Six came on the market after 2013: apremilast (Otezla), secukinumab (Cosentyx), ixekizumab (Taltz), dupilumab (Dupixent), guselkumab (Tremfya), risankizumab-rzaa (Skyrizi), and sonidegib (Odomzo). The older medications had higher price growth than the six newer therapies during the study period. Humira, at the high end, had a 12% price increase per year, while Skyrizi, at the low end, had a 5% yearly decrease. It's possible that biosimilars for Humira and Stelara — introduced in 2023 and this year — might help restrain cost growth, wrote Kong and Mostaghimi. The introduction of generic oral JAK inhibitors such as tofacitinib may also put a dent in spending, they noted. Medicare will also likely achieve cost savings in 2026 on Enbrel and Stelara, which are included as part of a law — the Inflation Reduction Act— that gave the health program the power to negotiate prices of certain medications. Patients for affordable drugs now estimate that list prices for Enbrel will drop from around $7000 to $2355 and for Stelara from $13,836 to $4695. The study did not examine the value of the high-cost specialty drugs, but the rise in prescriptions — indicated by each of the 10 achieving a 1% market share — shows that the medications are being embraced, wrote Kong and Mostaghimi. The authors' work is similar to other studies that have documented major increases in Medicare Part D dermatologic drug spending being driven in part by increased adoption of specialty medications. A 2022 study in the Journal of the American Academy of Dermatology found that from 2013 to 2019, the price of six dermatology drugs in the top 10 most-prescribed medications decreased, mostly among nonspecialty medications. But in 2013, Enbrel was the most expensive medication in the top 50 most prescribed. Enbrel had been replaced in 2019 by Humira. In 2020, researchers reported in the Journal of Dermatological Treatment that annual spending on immunomodulator medications by Medicare Part D increased 303% from $1.7 billion in 2012 to $6.9 billion in 2018. 'Immunomodulator spending is growing and may be more substantial than previously reported posing significant burden on patients and the health system,' the authors wrote. Kong and Mostaghimi agreed, writing that 'the growing significance of specialty medications will have important implications for healthcare costs and patient affordability.' Kong reported receiving grants from the National Institute on Aging. Mostaghimi reported receiving personal fees from Hims & Hers Health, AbbVie, Sun Pharma, Digital Diagnostics, Eli Lilly, Equillium, ASLAN Pharmaceuticals, Boehringer Ingelheim, Figure 1, Indomo, Olaplex, Legacy Healthcare, Pelage, Q32 Bio, Astria Therapeutics, ACOM Health, Bioniz, Concert, and Digital Diagnostics; equity from ACOM Health, Figure 1, and Hims & Hers Health; licensing or royalties from Concert and Pfizer; and research funding from Aclaris, Concert, Eli Lilly, and Incyte outside the submitted work.
Health Line
17-07-2025
- Health
- Health Line
Does Medicare Cover Rinvoq?
Doctors prescribe Rinvoq (upadacitinib) to treat certain inflammatory conditions, such as rheumatoid arthritis (RA) and ulcerative colitis (UC). It's available as an extended-release oral tablet and an oral solution known as Rinvoq LQ. Rinvvoq belongs to the drug class known as Janus kinase (JAK) inhibitors. Generally, Medicare drug plans can cover Rinvoq. But whether they do or not and how much you must pay out of pocket depends on the specific plan. Which Medicare plan covers Rinvoq? You can get Medicare coverage for prescription drugs via a stand-alone Medicare Part D or a Medicare Advantage prescription drug (MAPD) plan. Private insurers manage these plans and set their coverage and costs. According to the manufacturer's website, experts have performed clinical trials involving Rinvoq for more than 11 years and have prescribed it to more than 100,000 people for RA in the United States since 2019. With both types of drug coverage, your plan must cover at least two drugs from commonly prescribed drug categories. This means that Medicare drug plans may cover them. If they don't, they often cover alternative drugs within the same categories with similar effectiveness. You can check whether your specific plan covers Rinvoq by examining the plan's formulary, which lists all the drugs the plan covers. How much is a 30-day supply of Rinvoq? Without insurance, Rinvoq is a pricey drug. As of 2025, the list cost of a 30-day supply of the drug is $6,752.77. If your Medicare drug plan covers the drug, how much you pay out of pocket depends on the drug's tier within the plan's formulary. Generally, generic drugs tend to be in lower tiers, costing less. However, currently there's no generic version of Rinvoq. That said, under a Medicare drug plan, you may never pay more than $2,000 out of pocket on prescription drugs per year in 2025. Once you reach this amount, your plan may cover the rest of your annual cost in full. This limit changes from year to year. In 2026, it may rise to $2,100. In addition, no Medicare drug plan deductible can be higher than $590 in 2025.
