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Medicare Part D Elena Chan PharmD candidate, UCSF Tiffany Jew PharmD, MBA candidate, USC.

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Presentation on theme: "Medicare Part D Elena Chan PharmD candidate, UCSF Tiffany Jew PharmD, MBA candidate, USC."— Presentation transcript:

1 Medicare Part D Elena Chan PharmD candidate, UCSF Tiffany Jew PharmD, MBA candidate, USC

2 Overview Background on Medicare Background on Medicare The MMA The MMA Medicare Part D Medicare Part D  Enrollment/Eligibility  Coverage  Benefit Design  Formulary  Coordination of Care Medication Therapy Management Medication Therapy Management

3 Background on Medicare Medicare is health insurance for Americans: Medicare is health insurance for Americans:  65 years or older  Younger than 65 with disabilities or end- stage renal disease 2 types of Medicare Coverage: 2 types of Medicare Coverage:  Original Medicare Plan  Medicare Advantage

4 Original Medicare Plan Medicare Part D Prescription Drug Plan + + Automatically enrolled in original plan unless you enroll in Medicare Advantage Automatically enrolled in original plan unless you enroll in Medicare Advantage Fee for service plan -- just present your Medicare card Fee for service plan -- just present your Medicare card Monthly premiums for Part A+B depends on income and if you paid Medicare taxes: Monthly premiums for Part A+B depends on income and if you paid Medicare taxes:  Part A premium usually $0  Part B premium no more than $161/month

5 Medicare Advantage 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 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 Premiums differ by plan Have to stay “in network” as determined by HMO or PPO Have to stay “in network” as determined by HMO or PPO

6 Medicare Modernization Act (MMA) Signed into law Dec 2003 Signed into law Dec 2003 “Medicare Part D” was added “Medicare Part D” was added  Voluntary out-patient prescription drug plan to begin Jan 2006  Can be added to Medicare (original and Advantage)

7 Part A Coverage Inpatient/hospital charges Inpatient/hospital charges “Medically necessary” - anything needed to diagnose or treat a condition “Medically necessary” - anything needed to diagnose or treat a condition Critical care Critical care SNF’s, but not LTC SNF’s, but not LTC Home health Home health Hospice Hospice Blood Blood

8 Part B Coverage Ambulatory/Outpatient Care Ambulatory/Outpatient Care Medically necessary Medically necessary Ambulance, blood, am care surg, lab tests, MD services, DME, ER, dialysis, mental health 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 Medicare-covered preventatives: lab tests, screenings, vaccinations to help diagnose or prevent disease Some drugs covered: immunosuppressants, clotting factors for hemophilia, some vaccines, erythropoetin… Some drugs covered: immunosuppressants, clotting factors for hemophilia, some vaccines, erythropoetin…

9 Part C Coverage Also known as Medicare Advantage Also known as Medicare Advantage Combines the coverage of part A and B, but like an HMO or PPO Combines the coverage of part A and B, but like an HMO or PPO

10 Part D Coverage Adding Rx Drug Benefit to Original Medicare Adding Rx Drug Benefit to Original Medicare Adding Rx Drug Benefit to Medicare Advantage (MA): Adding Rx Drug Benefit to Medicare Advantage (MA):  May already be included in MA Administered by private plans that are reimbursed by CMS Administered by private plans that are reimbursed by CMS Formularies are 1st reviewed by CMS Formularies are 1st reviewed by CMS  Covers drugs in the most commonly used therapeutic classes  Most generics covered  Doesn’t cover drugs already paid by Part A and B

11 Part D Eligibility and Enrollment Anyone who qualifies for Medicare can get part D 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 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: 2 ways to get Part D:  Join Medicare Prescription Drug Plan  Join Medicare Advantage that includes a drug plan

12 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

13 An example of Benefit Design

14 Medicare Part D Requirements Since Part D benefits administered by private companies, CMS requires the following for reimbursement: Since Part D benefits administered by private companies, CMS requires the following for reimbursement:  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

15 Some Common Formulary Restrictions Prior Authorization: doctor must show that the medication is medically necessary before it is covered 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 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 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… Non-Formulary Drugs: BZD’s, barbiturates, weight loss/gain drugs, erectile dysfunction meds, cough/cold meds, OTC’s, fertility drugs…

16 Formulary Tier Copays

17 Coordination of Care What if a person has coverage other than Medicare? What if a person has coverage other than Medicare? Medicaid: state benefit 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

18 Coordination of Care Third Party Insurance 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

19 MediGap In original medicare plan, fills in gaps in coverage for part A and B 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 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 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 Under Medicare Advantage, MediGap won’t work- doesn’t pay deductibles, copays/coinsurance

20 Medication Therapy Management MMA requires that Part D plans have an MTM program 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 CMS allows for MTM reimbursement Benefits include optimization of therapy, improved outcomes, and close monitoring of side effects Benefits include optimization of therapy, improved outcomes, and close monitoring of side effects

21 Conclusion Enroll in Medicare Part D if: 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 8 th for coverage beginning Jan 1 st; there are late enrollment penalties Enroll by Dec 8 th for coverage beginning Jan 1 st; there are late enrollment penalties Research the different options available to you Research the different options available to you Part D as well as most drug benefits are subject to change year to year Part D as well as most drug benefits are subject to change year to year

22 Additional Resources plans-2007.asp plans-2007.asp


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