Presentation on theme: "1 An Easy Guide to… Understanding Medicare’s new Prescription Drug Benefit Blue Cross and Blue Shield of Texas presents."— Presentation transcript:
1 An Easy Guide to… Understanding Medicare’s new Prescription Drug Benefit Blue Cross and Blue Shield of Texas presents
2 Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) The most dramatic and innovative change to the Medicare program since its birth in 1965 New Prescription Drug Benefits (Part D) New and improved Preventive Benefits Medicare Advantage
3 Program Highlights Eligibility Choices Benefits Enrollment
4 Eligibility for Medicare Part D- All Medicare Beneficiaries Entitled to Part A and/or enrolled in Part B Reside in plan’s service area Must not be enrolled in another Medicare prescription drug Part D plan at the same time
5 What are my choices? Buy Part D Switch Plans Do not buy Part D because you already have a creditable (comparable) drug benefit from another source Apply for extra help based on income and assets Enrolled in a Medicare Advantage Plan-must receive drug coverage from this plan if offered
6 Buy Part D: Medicare Prescription Drug Coverage Coverage effective January 1, 2008 Available for Medicare beneficiaries (entitled to Part A and/or enrolled in Part B) Provided through CMS approved companies… –Prescription drug plans (PDPs) –Medicare Advantage Plans (MA-PDs) –Some employers and unions to retirees
7 Medicare Prescription Drug Plans Companies that sell Part D…may Begin Marketing in October 2007 Must offer basic drug benefit –Standard benefit May offer supplemental benefits –Enhanced benefit Can be flexible in benefit design
8 What is Extra Help? If your annual income is below $15,315 for an individual ($20,535 for a married couple living together), you may not have to pay monthly premiums or deductibles, and you could pay as little as $2 for your co-payments. To qualify, your resources must be limited to $11,710 for an individual ($23,410 for a married couple living together). These resource limits can be slightly higher (an additional $1,500 per person) if you will use some of your money for burial expenses. Resources include such things as bank accounts, stocks and bonds. We do not count your house and car as resources.
9 What is Extra Help Continued… Even if your annual income is higher, you still may be able to get some help with your monthly premiums, annual deductibles and prescription copayments. For example, your income may be higher and you possibly could get extra help if you or your spouse: –Support other family members who live with you; –Have earnings from work; or –Live in Alaska or Hawaii.
10 What it costs…how it works Plans will vary -Some may offer coverage that looks like the standard benefit -Some will offer additional drug coverage -Premium will vary based on benefits offered
11 Coverage stages Coverage Ranges Medicare Plan pays Person with Medicare pays Annual Deductible $0 to $275$0 100%$275 Initial Coverage$275-$251075%$ %$ Coverage Gap$2510- $ %$0100%$ Total$ $4050 Catastrophic Coverage $5, and up 95%No Maximum5% or $2.25 generic/ $5.60 brand name No Maximum Standard Medicare Prescription Drug Coverage & Costs
12 TrOOP- What is it?... True out of pocket costs The amount of money to reach catastrophic coverage when Medicare pays 95% of approved drug costs Consists of –Deductible - $275 in 2008 –25% coinsurance - $ in 2008 –100% between $2,510 and $ $ in 2008 TOTAL= $4050 Medicare prescription drug plan premium is not part of out-of-pocket limit
13 Sources Not Applied to Out-of-Pocket Limit Most third party payment arrangements Drugs purchased outside the US Over-the-counter drugs Drugs not on the Plan’s formulary Drugs not covered by law
14 Enhanced Prescription Drug Coverage Plan can structure benefit differently Out-of-pocket limit applies no matter how it is structured Plan may provide coverage where there is no coverage under the standard plan May offer additional drug coverage
15 Medicare Prescription Drug Coverage Available only by prescription Prescription drugs, biologicals, insulin Medical supplies associated with injection of insulin A PDP or MA-PD may not cover all drugs Brand and generic drugs will be in each formulary
16 Excluded Drugs Drugs for –Anorexia, weight loss, or weight gain –Fertility –Cosmetic purposes or hair growth –Symptomatic relief of cough and colds Prescription vitamins and mineral products –Except prenatal vitamins and fluoride preparations Non-prescription drugs Barbiturates Benzodiazepines
17 Exceptions The exception process ensures access to medically necessary Medicare covered prescription drugs Enrollees can request an exception if –The enrollee is using a drug that has been removed –A non-formulary drug is prescribed and medically necessary –The cost sharing status of a drug an enrollee is using changes –A drug covered under a more expensive cost sharing tier is prescribed because the less expensive drug is medically inappropriate
18 Formulary Review for Uninterrupted Access CMS will review certain drug classes to ensure that people treated with these classes have uninterrupted access to the majority of drugs in that class via formulary inclusion, utilization management tools or exception processes –Antidepressants –Antiretrovirals –Antipsychotics –Antineoplastics –Anticonvulsants –Immunosuppressants
19 When do I sign up? There are three enrollment periods 1) Annual Coordinated Election Period (AEP) November 15 to December 31 2) Special Enrollment Period (SEP) 3) Initial Enrollment Period (IEP)
20 Special Enrollment Period Permanent move out of the plan’s service area Individual entering or leaving a long-term care facility Involuntary loss, reduction, or non-notification of creditable coverage Other exceptional circumstances
21 Why would I decide not to buy Part D?
22 Possible Examples of Coverage at Least as Good as Medicare’s Coverage under a PDP (Prescription Drug Plan) or MA-PD (Medicare Advantage-Prescription Drug) Some Group Health Plans Retiree coverage State Pharmacy Assistance Program Veteran Affairs coverage Military coverage including TRICARE
23 Why would I decide to buy Part D?
24 Reasons to consider Part D You can save money on prescription drugs People with limited incomes can save even more Protection against future drug costs
25 Postponing Enrollment Higher premiums for people who wait to enroll, unless you had “creditable” coverage Assessed 1% of base premium for every month in which you were eligible to enroll but did not
26 Resources Medicare web-based tool –Visit –1-800-MEDICARE ( ), 24 hours a day, 7 days –TTY , 24 hours a day, 7 days Social Security web-based tool – Visit , Monday-Friday, 7 a.m.-7 p.m. TTY , Monday-Friday, 7 a.m.-7 p.m.