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Inflation Reduction Act and specialty drugs drive sharp pharmacy cost increases for St. Charles Parish Medicare Advantage plan
Summary
Humanana told the St. Charles Parish School Board that IRA-driven benefit changes and a membership increase led to far more members reaching catastrophic coverage in 2025 and a steep rise in pharmacy PMPM; specialty Tier‑4 drugs account for a disproportionate share of drug spend.
Humanana’s pharmacy presentation to the St. Charles Parish School Board highlighted a sharp rise in pharmacy costs for the parish’s fully insured Medicare Advantage plan and traced much of the increase to federal policy changes under the Inflation Reduction Act together with an enrollment jump in 2025.
Mia Basaraj, Humanana clinical pharmacy lead, told the board that pharmacy net paid per member per month rose to about $755 — a roughly 56% year‑over‑year increase — and that specialty and high‑cost medications were the main drivers. She said tier‑4 prescriptions made up about 1% of scripts but accounted for roughly 43% of pharmacy spend.
Basaraj and Jodie Hagewood explained that two factors combined to produce the increase: the parish added approximately 153 members when retirees moved onto the Humanana Medicare Advantage plan Jan. 1, 2025, and IRA changes lowered members’ out‑of‑pocket exposure and eliminated the Part D coverage gap. That combination made high‑cost specialty therapies more accessible to members and shifted more of the financial burden onto the plan.
Basaraj summarized the member‑phase data this way: 51 members reached catastrophic coverage in 2024 (about 6.5% of membership in that snapshot) versus 274 members (about 29%) in 2025, and the average member out‑of‑pocket among those reaching catastrophic fell from roughly $1,059 in 2024 to about $440 in 2025. “There were four times more members who reached the catastrophic phase in 2025 than 2024,” she said.
Humanana also described specialty pharmacy channels (CenterWell mail order, regional specialty providers) and said the plan saw a large increase in specialty scripts PMPM (reported as a 189% increase in specialty scripts PMPM and a 291% increase in net paid PMPM for specialty drugs). The presentation noted CMS programs and timelines that may affect future costs, including the CMS negotiated‑price program for certain Part D medications and a bridge program for GLP‑1 therapies that offers a $50 copay for eligible members through a CMS pilot.
Board members pressed for actionable options to manage renewal costs while preserving access. Humanana and USI said they will prepare plan‑design scenarios (e.g., cost‑sharing alternatives, deductible or copay options, contribution strategy changes) and pricing impacts to present alongside market proposals when renewal materials arrive.
The board did not adopt any plan changes at the meeting; staff and vendor follow‑ups were requested before the renewal vote.
