Hot Topics from the Durham Medicare Rx Network Meeting

On June 10, Senior PharmAssist hosted the Durham Medicare Rx Network, a coalition of professionals who work with Medicare beneficiaries, including staff from aging and community-based organizations, healthcare providers, social workers, care managers, pharmacists, insurance counselors, and others who help older adults navigate Medicare and prescription drug coverage options.

The coalition has been meeting several times a year over the last 20 years and serves as a forum for sharing information, identifying emerging issues, and strengthening collaboration across organizations that support older adults in our community.

The network began when our Executive Director, Gina Upchurch, was asked to attend statewide meetings back when Medicare introduced a new benefit, Part D drug coverage. At the time, there were concerns about how the benefit would be made available. Senior PharmAssist joined forces with the Social Security Administration (which enrolls individuals in Medicare), the Department of Social Services (which enrolls individuals in Medicaid), pharmacies, the North Carolina Department of Insurance Senior Health Insurance Information Program (SHIIP), and other community partners to improve communication and support for Medicare beneficiaries across North Carolina.

After attending these meetings, Gina and SHIIP leadership realized this level of integration and coordination would have greater impact if collaboration was also encouraged at the local level. The North Carolina General Assembly agreed, and 10 communities – including Durham, through Senior PharmAssist – received a $10,000 grant to build local Medicare partnerships. Twenty years later, the funding that supported food for meetings, outreach materials, and other needs is long gone, however, the group continues to thrive. The relationships built among local healthcare and social service organizations have played a vital role in improving the support and resources available to the people they serve.

Our June meeting touched on several important topics, including:

• Major changes in eligibility for Medicare and Medicaid for certain non-citizens. However, it is important to note that legal permanent residents (green card holders) not in the targeted groups, should not lose coverage. There is a lot of confusion about these changes, so we need to counter this with facts. Read more about these potentially devastating policy changes here.

• Many people have experienced Wellcare Value Script disruptions. Nationwide, approximately 130,000 Medicare beneficiaries lost coverage in April or May due to unpaid premiums and are only now becoming aware of the issue.

For the past two years, the plan carried a $0 monthly premium. When a monthly premium of $3.60 was reintroduced, many beneficiaries did not realize they needed to establish a new payment arrangement. Many individuals who were used to having their Medicare premiums paid out of their Social Security check, assumed those arrangements would continue automatically, as they often do when remaining in the same plan.

This payment disruption should have been heavily communicated by the Centers for Medicare and Medicaid Services (CMS) during Medicare’s annual open enrollment period. Instead, beneficiaries and organizations that assist Medicare recipients (including SHIIP programs like Senior PharmAssist, insurance agents and brokers) – received little advance notice. The lack of communication has created significant confusion and administrative challenges which could tragically leave some individuals without access to the medications they depend on.

Compounding the issue, many beneficiaries report that the little communication they received from Wellcare appeared suspicious or resembled scam attempts and was therefore ignored. Because prescription cards continued to work during the first quarter of the year, many members had no indication that their coverage was at risk.

Unfortunately, there are currently limited opportunities for individuals who have been disenrolled, and no special enrollment period has been announced. Organizations across the country, including SHIIP programs and other Medicare advocates, are raising concerns with federal officials and urging a resolution for affected beneficiaries. Senior PharmAssist will continue to monitor this situation closely and share updates as they become available.

Bridge and Balance programs to help Medicare beneficiaries access GLP-1 weight loss medications. Meeting participants also discussed the upcoming Bridge and Balance programs, which are designed to help Medicare beneficiaries access GLP-1 medications for weight loss. These programs are intended for individuals who are not already eligible to receive these medications for other FDA-approved uses, such as diabetes.

Historically, Medicare has not covered medications prescribed solely for weight loss. Beginning July 2026, a new 18-month demonstration program called Bridge is expected to provide eligible participants access to GLP-1 medications for a monthly cost of $50, once their healthcare provider has requested and received approval to enroll them in the program. The benefit and cost-sharing structure will be separate from Medicare Part D coverage.

In 2028, the program is expected to transition into Balance, which would incorporate coverage for these medications into the Medicare Part D benefit. However, details about the Balance program have not yet been finalized, and implementation information is still forthcoming. Read more about the Bridge and Balance programs here.

We know that our world is constantly changing, and it takes all of us in the Bull City working together to ensure our neighbors are safe and healthy! We appreciate the on-going enthusiasm from agency participation in the Durham Medicare Rx Network.