1. Prescription Drug Improvement and Modernization Act Dorothy Della Sherwood, M.D. Presbyterian Hospital of Dallas 2/22/2006

2. MMA 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

3. MMA 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

4. MMA 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

5. MMA 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

6. MMA When choosing a PDP, one should compare –Deductible –Monthly Premium –Co-pay for Rx –Formulary –Gap Coverage –Mail-in or local pharmacy

7. MMA The minimum prescription-drug benefit required by Medicare –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%

8. MMA Competition has resulted in better coverage than those that have been mandated. WWW.CMS.GOV

9. MMA 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)

10. MMA How to apply for extra help. –SSA mailed applications to those who may be eligible –www.ssa.govwww.ssa.gov All dual eligible ( Medicare and Medicaid) are automatically enrolled

11. MMA 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

12. MMA 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

13. MMA Specific Drug Coverage mandated by MMA –Cancer medications –HIV/AIDS treatments –Antidepresssants –Antipsychotics –Anticonvulsants –Immunosuppressants

14. MMA Excluded Drugs –Weight Loss Drugs –Fertility Drugs –Cosmetic hair growth products –Cough suppressants –Benzodiazepines –Barbituates –Vitamins –Non-prescription drugs

15. MMA 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

16. MMA PDP Formulary Available at www.epocrates.com http://formularyfinder.medicare.gov/formul aryfinder/selectstate.asp

17. MMA 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

18. MMA 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

19. MMA Plan Contacts for appeal: –www.cms.hhs.gov/PrescriptionDrugCovGenInwww.cms.hhs.gov/PrescriptionDrugCovGenIn There are 5 levels of appeal and it may indeed end up in the Federal Courts! –Redetermination by plan –Reconsideration by a Medicare drug coverage QIC –Administrative Law judge –Medicare Appeals Council –Federal District Court

20. MMA 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

21. MMA Individual Choice Last date for enrollment is May 15 th, 2006 All Medicaid beneficiaries were automatically enrolled by Jan 1 st if they had not chosen a plan.

22. MMA 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

23. MMA Web sites for your patients –www.medicare.govwww.medicare.gov –www.cms.hhs.govwww.cms.hhs.gov –www.ssa.govwww.ssa.gov Phone –1-800-MEDICARE (800-633-4227) –SS – 1-800-772-1213