Medicare Part D Overview

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Medicare Part D Overview

• Brad Tice, PharmD, FAPhA
• Chief Clinical Officer
• PharmMD Solutions, LLC

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Objectives

• To be able to
• Describe the four components of Medicare
• Describe the standard Medicare Part D drug
  benefit
• Be able to use the www.medicare.gov planfinder

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Medicare Overview

• Part A Hospital insurance
• Part B Medical insurance
• Part C Medicare Advantage (managed care)
• Part D Prescription drug coverage through
• Stand-alone prescription drug plans (PDPs)
• Medicare Advantage prescription drug plans
  (MA-PDs)
• Eligibility
• People 65 years of age and older
• Disabled but under age 65
• People with End-Stage Renal Disease (permanent
  kidney failure requiring dialysis or a
  transplant)

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Medicare Part B
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Medicare Part B

• Covers limited number of drugs and biologicals
• Drugs furnished incident to physicians service
• E.g. chemo drugs, iv solutions, blood products,
  tetanus rabies vaccine
• DME drugs
• Via infusion pump or nebulizer
• E.g. pain medications, albuterol
• Drugs covered by statute

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Part B vs. Part D

• Durable Medical Equipment Supply Drugs - B for
  retail and home care, D for LTC
• Immunosuppressants - B for Medicare covered
  transplants, otherwise D
• Oral Anti-Cancer Drugs - B for cancer treatment
  if criteria met, otherwise D
• Oral Anti-emetic Drugs - B within 48 hours of
  chemotherapy, otherwise D
• EPO - B for treatment of anemia for beneficiaries
  undergoing dialysis, otherwise D
• Vaccines - B for Influenza, Pneumococcal, those
  at intermediate to high risk for Hepatitis B,
  otherwise D
• Parenteral Nutrition - B if permanent dysfunction
  of digestive tract, otherwise D

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Medicare Part B vs. Part D Vaccine Coverage

• Previously covered under Part B, then coverage
  stays with Part B (intermediate and high risk
  beneficiaries)
• Influenza, Pneumococcal, Hepatitis B
• Previously not covered through Part B, then
  covered through Part D (but may be subject to
  prior authorization requirements)
• 2008 all formularies must contain all
  commercially available vaccines
• Example Zostavax (zoster vaccine live)

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• Medicare Part D

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Medicare Part D

• Created by the Medicare Prescription Drug,
  Improvement, and Modernization Act of 2003 (MMA)
• 2008 Standard Benefit
• Deductible 275
• Coinsurance 25
• Initial Coverage Limit 2,510
• Coverage Gap 2,510 - 4,050
• Catastrophic Coverage 4,050 out of pocket
• Coinsurance or copays
• Generic/preferred multisource 5 of 2.25
• Other of 5 or 5.60
• (Source CMS)

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Standard Benefit in 2008
Catastrophic Coverage
2510
5726.25
275
Total Spending
75 Plan Pays
Coverage Gap
80 Medicare Reinsurance
Deductible
95
25 Copay
15 Plan Pays
275
558.75
3216.25 Donut Hole
5 Coinsurance
Medicare Pays Reinsurance
Beneficiary Cost
Play Cost
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Standard Benefit Changes 2008 to 2009

• Standard Benefit Parameters
• Deductible
• Initial Coverage Limit
• Out-of-Pocket Threshold
• Minimum Co-Pays (Catastrophic Portion of Benefit)
• Generic/Preferred Drug
• All Other Drugs

• 2009
• 295
• 2,700
• 4,350
• 2.40
• 6.00

2008 275 2,510 4,050 2.25
5.60
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What does this mean for you?

• On a monthly basis, you will pay
• Your plan premium
• Your cost of medications within the plan
• These examples covered the Standard Benefit.
  You must determine the specifics of the plan you
  choose.
• You need to budget to also be able to cover the
  coverage gap or donut hole for later in the
  year if you expect to reach it
• www.Medicare-PartD.com

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Fast Facts for Tennessee in 2009
88 of people with Medicare have prescription
drug coverage (including 66 in Part D). 26
of those in Part D are receiving the low-income
subsidy (LIS). 49 Medicare Prescription Drug
Plans (PDPs) are available for 2009. 99.98
of people in a PDP can switch to a PDP with a
lower premium in 2009. 25 PDPs offer enhanced
benefits or services. 26 PDPs have 0
deductibles. 3 PDPs have premiums under 25.
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Fast Facts for Tennessee in 2009

• 17.60 is the lowest monthly premium for a PDP.
• 55.10 is the lowest monthly premium for a PDP
  with any generic coverage in the Gap.
• 12 PDPs have a premium amount of 0 for people
  who qualify for the full extra help.
• 92.30 of people with Medicare will have access
  to a Medicare Advantage plan with Drug Coverage
  (MA-PD) for a 0 premium.
• 24 MA-PDs have a 0 premium.
• 100 of people with Medicare will have access to
  a MA-PD with a 0 drug deductible.

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Important Dates in 2009 October

• Medicare, Social Security, Health Plans, and
  Drug Plans notify you of changes for 2009.
• Your copy of Medicare You 2009 arrives in
  the mail.
• Beginning October 15, you can compare 2009
  plans on www.medicare.gov.
• November 15 through December 31
• Annual Open Enrollment Period for 2009.

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Part D Drugs

• Benefits only apply to covered Part D drugs
• Generally, a Part D drug is a prescription drug
  that is prescribed and dispensed for
  administration by the patient
• Also includes the following
• Biological products
• Insulin
• Medical supplies associated w/insulin injection
  (syringes, needles, alcohol swabs, and gauze)
• Vaccines not covered under Part A or B

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Part D Exclusions

• Anorexia, weight loss, or weight gain
• Fertility promotion
• Hair growth
• Symptomatic relief of cough and colds
• Prescription vitamin and mineral products (except
  prenatal vitamins and fluoride preparations)
• Nonprescription drugs
• Outpatient drugs for which the manufacturer seeks
  to require that associated tests or monitoring
  services be purchased exclusively from the
  manufacturer or its designee as a condition of
  sale

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Medication Therapy Management (MTM) under Part D

• Plans must establish MTM programs for targeted
  beneficiaries who
• Have multiple chronic diseases (diabetes, asthma,
  hypertension, hyperlipidemia, congestive heart
  failure)
• Take multiple covered Part D drugs, and
• Are likely to incur costs above a certain level
• MTM services may be provided by a pharmacist
• Programs must be developed in consultation with
  practicing pharmacists
• Include a range of services
• Part D plans determine compensation rate

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MTM Services

• MTM programs may be designed to promote
• Enhanced enrollee understanding that promotes the
  appropriate use of medications and reduces the
  risk of potentially adverse events associated
  with medications
• Increased enrollee adherence to prescription
  medication regimens
• Detection of adverse events and patterns of
  overuse and underuse of prescription drugs
• Generally include
• Complete Medication Review (CMR)
• Personal Medication Record (PMR)
• Medication Action Plan (MAP)

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Other Important Provisions in MIPPA

• Inclusion of benzodiazepines as covered Part D
  medications
• Several sections targeted at low income Medicare
  beneficiaries
• Coordinated education, outreach and enrollment
• Elimination of LIS late enrollment penalties
• E-prescribing incentive/penalty for physicians

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Specific to Parkinsons

• Use the www.medicare.gov planfinder
• Understand
• Formulary
• Prior Authorization requirements
• Quantity limits
• Step Therapy requirements
• TrOOP

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For More Information

• Websites
• www.medicare.gov
• www.cms.hhs.gov
• www.socialsecurity.gov
• Publications
• Medicare You handbook
• Facts About Medicare Prescription Drug Plans
• 1-800-MEDICARE (1-800-633-4227)
• Social Security Administration
• 1-800-772-1213
• State Health Insurance Assistance Program (SHIP)

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• Email brad.tice_at_pharmmd.com
• Phone [phone] ext 125