Transcript Medicare Part D - Pro Pharma Pharmaceutical Consultants, Inc

Medicare Part D
Elena Chan PharmD candidate, UCSF
Tiffany Jew PharmD, MBA candidate, USC
Overview
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Background on Medicare
The MMA
Medicare Part D
 Enrollment/Eligibility
 Coverage
 Benefit Design
 Formulary
 Coordination of Care
Medication Therapy Management
Background on Medicare
Medicare is health insurance for Americans:
 65 years or older
 Younger than 65 with disabilities or endstage renal disease
 2 types of Medicare Coverage:
 Original Medicare Plan
 Medicare Advantage
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Original Medicare Plan
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Medicare Part D
Prescription Drug Plan
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Automatically enrolled in original plan unless you enroll in
Medicare Advantage
Fee for service plan -- just present your Medicare card
Monthly premiums for Part A+B depends on income and if you paid
Medicare taxes:
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Part A premium usually $0
Part B premium no more than $161/month
Medicare Advantage
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Medicare Part D
Prescription Drug Plan
Provide the same Part A
and Part B coverage but
may have extra benefits
like dental, eye, or
prescription drug plans
Premiums differ by plan
Have to stay “in network”
as determined by HMO or
PPO
Medicare Modernization Act (MMA)
Signed into law Dec 2003
 “Medicare Part D” was added
 Voluntary out-patient prescription drug
plan to begin Jan 2006
 Can be added to Medicare (original and
Advantage)
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Part A Coverage
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Inpatient/hospital charges
“Medically necessary” - anything needed to
diagnose or treat a condition
Critical care
SNF’s, but not LTC
Home health
Hospice
Blood
Part B Coverage
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Ambulatory/Outpatient Care
Medically necessary
Ambulance, blood, am care surg, lab tests, MD
services, DME, ER, dialysis, mental health
Medicare-covered preventatives: lab tests,
screenings, vaccinations to help diagnose or
prevent disease
Some drugs covered: immunosuppressants,
clotting factors for hemophilia, some vaccines,
erythropoetin…
Part C Coverage
Also known as Medicare Advantage
 Combines the coverage of part A and B, but
like an HMO or PPO
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Part D Coverage
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Adding Rx Drug Benefit to Original Medicare
Adding Rx Drug Benefit to Medicare Advantage
(MA):
 May already be included in MA
Administered by private plans that are reimbursed
by CMS
Formularies are 1st reviewed by CMS
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Covers drugs in the most commonly used therapeutic
classes
Most generics covered
Doesn’t cover drugs already paid by Part A and B
Part D Eligibility and Enrollment
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Anyone who qualifies for Medicare can get part D
Optional to enroll, but if you do not enroll when
you are first eligible you pay a penalty if you sign
up later
2 ways to get Part D:
 Join Medicare Prescription Drug Plan
 Join Medicare Advantage that includes a drug
plan
Part D Benefit Design
2007 Costs
Out of Pocket $
For the Year
Premium
$25/month
$300
Deductible
$265
$265
Coinsurance
25% of drug costs up to
$2400
$534
Donut Hole
100% of drug costs until
you’ve paid $3850
$3051
Catastrophic
Coverage
5% of drug costs for the
rest of the year
--
Total out of pocket costs before catastrophic coverage = $4150
An example of Benefit Design
Medicare Part D Requirements
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Since Part D benefits administered by private companies,
CMS requires the following for reimbursement:
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Formulary must cover 146 therapeutic categories commonly
used by this population as determined by CMS
Formulary must cover at least 2 drugs in each of these 146
therapeutic classes
 Except: must cover all or almost all antidepressants,
antipsychotics, anticonvulsants, anticancer,
immunosuppressants, and HIV/AIDS meds
If generic available, it must be on formulary
All rebates must go back to the payer
Prior authorizations, step-therapy, generic sub, preferred
brands OK
CMS must review and approve all formularies in advance
Some Common Formulary Restrictions
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Prior Authorization: doctor must show that the
medication is medically necessary before it is
covered
Quantity limits: limits how many pills you can
get at a time
Step therapy: one or more lower cost drugs must
be tried before step-up therapy drug is covered
Non-Formulary Drugs: BZD’s, barbiturates,
weight loss/gain drugs, erectile dysfunction meds,
cough/cold meds, OTC’s, fertility drugs…
Formulary Tier Copays
Coordination of Care
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What if a person has coverage other than
Medicare?
Medicaid: state benefit
 Dual eligibility- Medicare beneficiary currently
receiving Medicaid benefits
 Medicaid drug coverage for Medicare eligibles
terminated December 31, 2005
 Auto-enrolled into qualifying plans October
2005
Coordination of Care
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Third Party Insurance
 Any other insurance will kick in before
Medicare is charged
Other insurers:
-FEHBP (Federal Employee Health
Benefits Program), VA, TRICARE
(active duty service, retirees, family),
Medigap
MediGap
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In original medicare plan, fills in gaps in coverage
for part A and B
Can’t have drug coverage from both MediGap and
Medicare Part D coverage- one must be removed
MediGap coverage is not as good as Medicare Part
D for drug coverage
Under Medicare Advantage, MediGap won’t
work- doesn’t pay deductibles, copays/coinsurance
Medication Therapy Management
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MMA requires that Part D plans have an MTM
program
 Clinician (pharmacist) reviews patients’
medication therapy
 Focus on patients with chronic diseases or on a
multitude of Part D medications
CMS allows for MTM reimbursement
Benefits include optimization of therapy,
improved outcomes, and close monitoring of side
effects
Conclusion
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Enroll in Medicare Part D if:
 You have Medicare but do not have prescription
drug benefits
 You qualify for limited income assistance
 You spend a lot on prescription drugs
Enroll by Dec 8th for coverage beginning Jan 1st;
there are late enrollment penalties
Research the different options available to you
Part D as well as most drug benefits are subject to
change year to year
Additional Resources
www.medicare.gov
 www.healthdecisions.org/guide
 www.partdoptimizer.com
 www.medicare.gov/medicarereform/localplans-2007.asp
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