American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Effects of Medicare Part D on Dual Eligibles in LTC Settings Thomas R. Clark, RPh, MHS ASCP Director of Policy & Advocacy

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® What is Long-Term Care? Freestanding NF Freestanding NF Hospital-based NF Hospital-based NF ICF/MR ICF/MR IMD (usually state-operated) IMD (usually state-operated)

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Impact so far? Negligible impact on beneficiaries Negligible impact on beneficiaries Impact on other LTC stakeholders is significant and may have future impact on beneficiaries Impact on other LTC stakeholders is significant and may have future impact on beneficiaries

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® LTC Stakeholders Residents Residents Physicians Physicians LTC facilities/staff LTC facilities/staff LTC pharmacies LTC pharmacies –Institutional free-standing –Hospital, retail

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Medicare Part D: Square Peg in a Round Hole Built on commercial insurance model Built on commercial insurance model Applied to institutionalized populations (4.5% of benes) Applied to institutionalized populations (4.5% of benes) Differences: clinical, regulatory, operational Differences: clinical, regulatory, operational Heavy administrative burden Heavy administrative burden

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® The number of Part D plans, and the wide variability from plan to plan, create challenges in the long-term care setting. Quality of care and efficiency are achieved through consistency and uniformity.

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Progress Since Jan. 1 CMS has been very responsive CMS has been very responsive Individual problem/plan approach versus broad plan “requirements” Individual problem/plan approach versus broad plan “requirements” Numerous issues addressed through memos to plans, guidance documents Numerous issues addressed through memos to plans, guidance documents

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Part D Plan Response Variable Variable Part D plans have come a long way in short time Part D plans have come a long way in short time Coalitions, workgroups resulting in progress Coalitions, workgroups resulting in progress Standardized messaging Standardized messaging

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® PDP Tools Formulary restrictions Formulary restrictions Tiered formularies Tiered formularies Prior authorization Prior authorization Step therapy Step therapy Quantity limits Quantity limits

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® PDP Diversity Kaiser study, Medicare.gov Kaiser study, Medicare.gov 14 national and near national PDP sponsors; 35 plans 14 national and near national PDP sponsors; 35 plans Sample of 152 generic/brand medications Sample of 152 generic/brand medications Plans cover 81% of drugs (64 to 97% range) Plans cover 81% of drugs (64 to 97% range)

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® PDP Diversity-Kaiser Study 4 of 35 plans use UM tools on less than 10% of medications 4 of 35 plans use UM tools on less than 10% of medications 13 of 35 plans use UM tools on 40% or more of medications 13 of 35 plans use UM tools on 40% or more of medications Half of plans use UM tools on 5 of the top ten brand name drugs Half of plans use UM tools on 5 of the top ten brand name drugs

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® PDP Diversity Avalere study, database Avalere study, database Overview of ten national PDPs Overview of ten national PDPs # drugs 626–2,773 # drugs 626–2,773 Percent PA from 2.1% to 40% Percent PA from 2.1% to 40%

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Current Challenges Excluded medications Excluded medications Co-pays for dual eligibles in group homes and AL Co-pays for dual eligibles in group homes and AL Part B/Part D payment coordination Part B/Part D payment coordination

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Current Challenges Infusion therapy, home & LTC Infusion therapy, home & LTC LTC facility “on the hook” for denied medication claims LTC facility “on the hook” for denied medication claims Physician burden from uncompensated administrative work to obtain medications Physician burden from uncompensated administrative work to obtain medications

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Current Challenges CMS marketing guidelines CMS marketing guidelines CMS survey and certification memo on LTC facilities and Medicare Part D CMS survey and certification memo on LTC facilities and Medicare Part D CMS Q&A on contracting between Part D plans and LTC pharmacies CMS Q&A on contracting between Part D plans and LTC pharmacies

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Current CMS policies restrict LTC residents from getting help choosing and enrolling in a Part D plan, and restrict Part D plans and LTC pharmacies from including patient protections in contractual agreements.

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Resources on Medicare Part D and Long-Term Care:

American Society of Consultant Pharmacists America’s Senior Care Pharmacists ® Thank you!