Minimizing Dual-Eligible Beneficiaries Out-of-Pocket Prescription Drug Costs: A Paradigm Shift

Document Type

Conference Presentation

Conference Title/Conference Publication

American Public Health Association Annual Meeting


American Public Health Association (APHA)


New Orleans, LA

Conference Dates

November 15-19, 2014

Date of Presentation



Background: Medicare beneficiaries receive prescription drug coverage through Part D and those with limited income/resources receive additional governmental assistance through Medicaid (Medi-Cal in California). For these dual-eligible beneficiaries, Part D is the primary payer and Medicaid can be billed secondarily when medications are not on the beneficiary’s Part D plan formulary. As opposed to having co-pays when billed through their Part D plan, dual-eligible beneficiaries are not responsible for drug co-pays when billed through Medi-Cal. We examined potential out-of-pocket costs savings through: 1) Part D plan optimization and 2) strategic utilization of existing formularies (Part D plan and Medi-Cal).

Methods: We assisted 151 dual-eligible beneficiaries with their Part D plan in Northern/Central California in fall 2013. In addition to determining the lowest cost Part D plan, we examined if beneficiaries’ out-of-pocket costs could be further reduced by selecting an alternative plan under which their medication(s) was non-formulary but covered by Medi-Cal.

Results: Dual-eligible beneficiaries could annually save an average (SD) of $1174 ($3286) through Part D plan optimization. In 44 (27.8%) instances, beneficiaries could save additional money (Mean + SD: $107+281) through Part D and Medi-Cal formulary optimization. Each time, the lowest cost plan was a benchmark plan.

Conclusions: Dual-eligible beneficiaries have incomes <100% of the Federal Poverty Line. Research has shown that as out-of-pocket costs increase so too does medication non-adherence. Aside from Part D plan optimization, we identified a novel approach that can be utilized to help further lower out-of-pocket prescription drug costs in the vulnerable dual-eligible beneficiary population.