Transcript Prescription Drug Improvement and Modernization Act

Prescription Drug Improvement
and Modernization Act
Dorothy Della Sherwood, M.D.
Presbyterian Hospital of Dallas
2/22/2006
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• This year, Medicare introduced the
prescription drug benefit-the most
significant change in Medicare coverage
since the program’s inception…which will
help patients and doctors work together to
alleviate symptoms and reduce the rate of
complications from serious illness.
» Mark B. McClellan, M.D., PhD., NEJM 12/05
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• America’s older citizens have been
barraged with educational and marketing
initiatives for various drug plans….an
October poll indicated that 61% did not
understand the program and 54% did not
intend to sign up.
» Richard L. Kravitz, M.D. NEJM 12/05 UC Davis
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CMS Goal for the Drug Benefit
1. Ensure all beneficiaries have access to
high-quality, affordable drug coverage
2. Provide continuous access to drugs
needed by the chronically ill
3. Create a competitive, transparent
marketplace
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• Competitive/Transparent
– Medicare Prescription Drug Plans ( MPDP)
negotiate with drug companies to purchase
drugs at a discounted price which they pass
on to the beneficiary.
– CMS is counting on this competition to hold
down prescription prices
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• When choosing a PDP, one should
compare
– Deductible
– Monthly Premium
– Co-pay for Rx
– Formulary
– Gap Coverage
– Mail-in or local pharmacy
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• The minimum prescription-drug benefit required
by Medicare
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No more than $250.00 deductible
A monthly premium ( average of $37.00/mo)
Pay 25% of the next $2000.00 in costs ($500.00)
Pay 100% of the next $2,850.00 – the gap
Total out of pocket costs could reach $3,600.00/yr
Catastrophic coverage begins and beneficiary pays
only 5%
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• Competition has resulted in better
coverage than those that have been
mandated.
• WWW.CMS.GOV
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• Help for People with Limited Incomes
– People with lowest income and resources
• Pay no premiums or deductibles
• Have small or no co-payments
– Eligibility
• <$1,197 per month for an individual with <$11,500
in assets (excluding house)
• <$1,604 per month for a couple with <$23,000 in
assets (excluding house)
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• How to apply for extra help.
– SSA mailed applications to those who may be
eligible
– www.ssa.gov
• All dual eligible ( Medicare and Medicaid)
are automatically enrolled
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• What about Medigap?
– Information was sent to people with Medigap
giving them the following choices:
• Keep Medigap
• Join Medicare Prescription Drug Plan and delete
drug coverage from Medigap
• Drop Medigap and join Medicare Advantage
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• What about Employer/Union Coverage?
– Choices include
• Keep coverage offered by employer/union
• Join MPDP
• Join Medicare Advantage Plan
– Advise to contact Employers/Union
• There is a tax free subsidy provided by Medicare
to the Employers who offer coverage
• Employers may contract with a MPDP to provide
coverage
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• Specific Drug Coverage mandated by
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– Cancer medications
– HIV/AIDS treatments
– Antidepresssants
– Antipsychotics
– Anticonvulsants
– Immunosuppressants
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• Excluded Drugs
– Weight Loss Drugs
– Fertility Drugs
– Cosmetic hair growth products
– Cough suppressants
– Benzodiazepines
– Barbituates
– Vitamins
– Non-prescription drugs
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• Formularies
– Most MPDP have formularies
– All formularies must include at least 2 drugs
from every category of drug
– The formulary must be approved by CMS
– Tier 1 drugs have the lowest cost sharing
– There must be an exception procedure for
tiered formularies – to obtain a drug at a more
favorable cost or obtain a drug not on
formulary
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PDP Formulary Available at
www.epocrates.com
http://formularyfinder.medicare.gov/formul
aryfinder/selectstate.asp
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• Perils
– Exception Request:
• Patient is unable to take a statin due to myopathy
and therefore requires Zetia
• PDP considers Zetia a ‘Step Drug’ after
maximizing statin
• The enrollee can request an exception to the
plan’s step-therapy requirement
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• Process:
– PDP pharmacy initiates with fax entitled
“Request for Prescription Information or
Change”
– Physician initiates request to the PDP with a
“Request for Prescription Exception”
– Exceptions should be reviewed in 24 hours if
the need is immediate
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• Plan Contacts for appeal:
– www.cms.hhs.gov/PrescriptionDrugCovGenIn
• There are 5 levels of appeal and it may indeed
end up in the Federal Courts!
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Redetermination by plan
Reconsideration by a Medicare drug coverage QIC
Administrative Law judge
Medicare Appeals Council
Federal District Court
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• Why should the Medicare beneficiary
enroll now?
– Late enrollment results in a 1% increase in
premium per month for every month the
person was eligible but did not join.
– This penalty will be paid forever!
– This penalty does not apply to individuals with
prescription drug coverage that equals the
Medicare coverage
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• Individual Choice
• Last date for enrollment is May 15th, 2006
• All Medicaid beneficiaries were
automatically enrolled by Jan 1st if they
had not chosen a plan.
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• So what will this cost? BILLIONS over
the next 8 years.
– Payments to MPDP : 448 to 479
– Low Income Subsides: 192 to 239
• 35% of the Medicare Population
– Spending on health care is expected to
increase from 1.8 trillion dollars in 2003
to 3.6 trillion dollars in 2014
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• Web sites for your patients
– www.medicare.gov
– www.cms.hhs.gov
– www.ssa.gov
• Phone
– 1-800-MEDICARE (800-633-4227)
– SS – 1-800-772-1213