Transcript Access Denied? The Medicare Part D Benzodiazepine

Access Denied?
The Medicare Part D
Benzodiazepine Challenge and
Maine’s Coverage Solution.
Stacie Sparkman
Medicare Prescription Drug Specialist
Eastern Agency on Aging
Medicare Prescription Drug,
Improvement and Modernization
Act of 2003
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Signed into law December 8, 2003.
Implemented outpatient prescription drug
coverage for seniors and the disabled
population.
Is a voluntary program. If a person has
state Medicaid and wants to continue to
receive prescription assistance, they must
be enrolled into a Part D plan.
Medication Coverage
• Prescription
Drug Plan (PDP) formularies must
include drugs within each therapeutic category and
class of covered Part D drugs, though not
necessarily all the drugs in each category or class.
• The legislation excludes from coverage the
following drugs or classes of drugs, or their medical
uses:
Excluded Medications
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Agents when used for anorexia, weight loss, or weight
gain
Agents when used to promote fertility
Agents used for cosmetic purposes or hair growth
Agents when used for the symptomatic relief of cough
and colds
Prescription vitamins and mineral products, except
prenatal vitamins and fluoride preparations
Non-prescription drugs
Outpatient drugs for which the manufacturer seeks to
require associated tests or monitoring services be
purchased exclusively from the manufacturer or its
designee as a condition of sale
Barbiturates
Benzodiazepines
All of the classes of excluded medications
have the potential to impact medical care in
the elderly or disabled population.
Continuity of care issues could
include the use of:
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Benzodiazepines, widely used for management of
acute anxiety, panic attacks, seizure disorders, and
muscle spasms in those with cerebral palsy or other
disorders like Ativan, Xanax and Valium.
Over-the-counter medications, including agents for
pain, constipation, and other common conditions.
Medications used to treat weight loss, such as in those
persons who lose weight due to cancer or AIDS.
Barbiturates like Phenobarbital, which is widely used in
the elderly for treatment of seizures.
Hospitalization
and
Stabilization
Medication
is
Denied
Discharge to a
system where:
Maine’s Coverage Solution
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The Centers for Medicare and Medicaid Services
authorized states to provide coverage of –and
receive federal matching funds for-medications
the Medicare Modernization Act excludes.
Before Medicare Part D started on 1/1/06, the
State of Maine made the decision to continue
coverage of excluded medications already on the
state’s preferred drug list. This coverage
included members who received prescription
assistance under state Medicaid and the Low
Cost Drug Program.
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1 Policy Guidance Regarding Medicaid Coverage of Prescription Drugs Excluded from the New Medicare Prescription
Drug Benefit, http://www.cms.hhs.gov/letters/smd060305.pdf
Low Income Subsidy
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The Medicare Modernization Act gave
three groups automatic Low Income
Subsidy.
Individuals with State Medicaid.
Individuals with Supplemental Security
Income.
Individuals with their state’s Medicare
Savings Program.
Medicare Savings Program
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Pays for the Medicare Part B Premium-$93.50
in 2007 and $96.40 in 2008
Enrollment into the MSP will deem a person
eligible for full Low Income Subsidies for Part
D which includes:
Payment of the part D premium for approved
plans
Payment of the deductible
Small co-pays of between $1 and $5.35
No Coverage Gap
Catastrophic Coverage
Medicare Savings Program
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Each state sets the income and asset levels for the MSP.
The state of Maine did away with the asset test on
1/1/06 and raised the income limit to 185% of the
federal poverty limit on 4/1/07.
The Department of Health and Human Services
determines eligibility and countable income. There are
some instances where individuals or couples may be
eligible for the MSP even if their income is higher than
185% of the federal poverty limit.
Maine also provides a wrap benefit through the state’s
Low Cost Drug program. This program continues to
provide coverage for excluded medications listed on the
state’s preferred drug list. This benefit helps those
transitioning, from the Low Cost Drug Program and
Mainecare into Medicare and Medicare Part D, continue
to receive their medications without interruption.
Direct Savings
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Since Medicare Part D started in 2006 Maine has
covered
benzodiazepine and barbiturate
prescriptions.
The estimated total savings for the consumer is
We will never know the total cost of savings
related to hospitalizations and mass confusion,
but we know it is priceless.
Resources
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Legal Services for the Elderly, Inc. Part D
Appeals Unit 1-877-774-7772
Maine Area Agencies on Aging/State Health
Insurance Assistance Program (SHIP)
1-877-353-3771
Maine Department of Health and Human
Services Regional Offices
Maine Office of Elder Services 1-800-262-2232
TTY 1-800-606-0215
Maine Pharmacy Helpdesk 1-866-796-2463
Medicare 1-800-Medicare or 1-800-633-4227
TTY 1-877-486-2048
Social Security Office 1-800-772-1213
TTY 1-800-325-0778