Medicare Prescription Drug Plans

1
IMPORTANT INFORMATION FOR HEALTH CARE
PROFESSIONALS

2
Changes in MedicareKeeping up with Todays
Health Care

• Promoting a healthy lifestyle
• Covering preventive services
• Offering prescription drug coverage
• Expanding coordinated care options
• Including care for chronic conditions
• Helping people with Medicare live longer,
  healthier lives

3
Medicare Prescription Drug Coverage

• Begins January 1, 2006
• Available for all people with Medicare
• Part A, Part B, or both
• For minimum standard coverage in 2006,
• enrollees would pay
• Monthly premium of about 32
• First 250 per year for prescriptions
• (deductible)
• Part of the cost of prescriptions after 250
• 5 of the drug costs (or small copayment)
• after paying 3,600 out-of-pocket

4
Savings in 2006

• On average, for a person with Medicare and no
  drug coverage now
• Total drug spending will go down by about 50
• Over 1,100 per year saved
• People with other drug coverage that, on average,
  is at least as good as the minimum standard
  Medicare prescription drug coverage also may save
  money
• These estimates do not include the extra help for
  people with limited incomes and resources

5
Protections for People with Medicare

• Customer service
• Pharmacy access
• Medication therapy management
• Generic drug information
• Privacy
• Uniform benefits and premiums
• Formulary Protections

6
Extra Help With Drug Costs

• Available for many people with limited income and
  resources
• Those below Federal poverty level save over 95
  on average
• People with lowest income and resources
• Pay no premiums or deductibles
• Have small or no copayments
• Those with slightly higher income and resources
• Have a reduced deductible
• Pay a little more out-of-pocket

7
Eligibility for Extra Help

• Income
• Below 150 Federal poverty level
• 1,197 per month for an individual or
• 1,604 per month for a married couple
• Based on family size
• Resources
• Up to 11,500 (individual)
• Up to 23,000 (married couple living together)
• Includes 1,500/person funeral or burial expenses
• Counts savings and stocks
• Does not count home the person lives in
• Higher amounts for Alaska and Hawaii
• -Not available in
  the U.S. territories

2005 amounts
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Automatic Eligibility for Extra Help

• Some people may automatically qualify
• People with Medicare who
• Get full Medicaid benefits
• Get Supplemental Security Income (SSI)
• Get help from Medicaid paying their Medicare
  premiums
• All others must apply

9
Ways to Get Coverage

• Medicare prescription drug coverage is provided
  through
• Medicare Prescription Drug Plans
• Medicare Advantage and other Medicare Health
  Plans
• Coverage is NOT automatic
• People need to understand their options

10
Original MedicareAnd Medigap With Drug Coverage

• People who have a Medigap prescription drug
  policy will receive important information in the
  mail this fall from their Medigap insurance
  company on how the new Medicare prescription drug
  coverage will affect their Medigap prescription
  drug coverage
• Choices to make
• Keep prescription coverage through the Medigap
  policy
• Join a Medicare Prescription Drug Plan after they
• Modify the Medigap policy to remove drug
  coverage, or
• Change to a Medigap policy with no drug coverage
• Drop Medigap policy and join a Medicare Advantage
  Plan or other Medicare Health Plan with
  prescription drug coverage

11
Employer/Union Coverage

• Medicare is working with employers to help people
  with Medicare keep their current prescription
  coverage
• Employer/Union options
• Offer coverage in place of Medicare prescription
  drug coverage and get a tax-free subsidy
• Offer or contract with a Medicare drug plan to
  provide prescription drug coverage
• Provide coverage that supplements the Medicare
  prescription drug coverage
• Pay all or part of Medicare drug plan premiums

12
Employer/Union Coverage

• People with Medicare and employer/union coverage
  will get important information in the mail this
  fall from their plan sponsor
• They should contact their benefits administrator
  before making any changes
• Choices to make
• Keep coverage offered by employer/union
• Join a Medicare Prescription Drug Plan
• Join a Medicare Advantage Plan or other Medicare
  Health Plan with prescription drug coverage
• NOTE If a Medicare beneficiary drops or loses
  their employer/union
• coverage, they may not be able to get
  it back

13
Medicare and Medicaid

• These people automatically qualify for the extra
  help
• They should watch the mail this fall
• Letter about choosing a Medicare Prescription
  Drug Plan
• Medicare You 2006 handbook
• Choices to make
• Compare prescription drug plan options and join
  in a plan
• If not, Medicare will enroll them in one by
  December 31, 2005
• Starting January 1, 2006, Medicare will pay for
  their prescription drugs
• Can switch to another plan at any time

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Other State/Federal Assistance Programs

• These people automatically qualify for the extra
  help if they
• Get help from Medicaid paying their Medicare
  premiums
• Get Medicare and Supplemental Security Income
  (SSI) benefits
• They should watch the mail for Medicare You
  2006 handbook
• Choices to make
• Compare prescription drug plan options
• Find a plan that meets their needs
• If no choice made by May 15, 2006, will be
  enrolled on June 1, 2006
• Also applies to people who applied and qualify
  for extra help

15
Late Enrollment

• Most people will have to pay a penalty if they
  wait to join
• Premium will go up 1 per month for every month
  the person was eligible but did not join
• The person will have to pay this penalty as long
  as they have a Medicare Prescription Drug Plan
• Unless they have other prescription drug coverage
  that is, on average, at least as good as the
  minimum standard Medicare prescription drug
  coverage

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Important Dates

• September 15 November 15, 2005
• Medigap insurance companies will mail information
  to Medigap policy holders who have a policy that
  covers prescription drugs
• October 13, 2005
• Begin comparing prescription drug plans
• www.medicare.gov
• 1-800-MEDICARE (1-800-633-4227)
• TTY users should call 1-877-486-2048

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Important Dates

• October 2005
• Medicare You 2006 handbook mailed
• Medicare notifies people with Medicare and
  Medicaid of the plan they will be automatically
  enrolled in on January 1, 2006, if they do not
  enroll on their own
• Employer plans send coverage information to
  enrollees
• November 15, 2005
• Initial Enrollment Period begins

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Important Dates

• January 1, 2006
• Medicare Prescription Drug Plan coverage begins
  for those enrolled
• May 15, 2006
• Last day of Initial Enrollment Period
• June 1, 2006
• Facilitated enrollment of people entitled to
  extra help who did not enroll by May 15, 2006

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Information For Your Patients

• See Medicare You 2006 handbook
• To be mailed October 2005
• Read about prescription drug plans in the area
• For help in choosing a plan
• Visit www.medicare.gov on the web
• To get personalized information
• Visit www.shiptalk.org or call the local State
  Health Insurance Assistance Program (SHIP)
• For assistance with enrollment
• Call 1-800-MEDICARE (1-800-633-4227)
• TTY users call 1-877-486-2048
• Attend local community events

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How to Apply For Extra Help

• Social Security Administration (SSA) is mailing
  applications to those who may be eligible
• Throughout the summer of 2005
• Those who think they may qualify should
• Complete this application
• Mail it to the address on the back of the
  application
• Use the enclosed postage-paid envelope
• Use original forms only (do not photocopy)
• People who are not sure should still apply
• www.socialsecurity.gov can help people decide

21
Medicare Prescription Drug Coverage

• Covers drugs available only by prescription
• Prescription drugs, biologicals, insulin
• Medical supplies associated with injection
• of insulin
• A prescription drug plan (PDP) or Medicare
• Advantage prescription drug (MA-PD) plan
• may not cover all drugs
• Brand name and generic drugs will be in
• each formulary

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Medicare Prescription Drug Coverage Plans Must
Cover

• Cancer medications
• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments for epilepsy and other
  conditions
• Immunosuppressants

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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

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Formulary

• Prescription drug plans (PDP) and Medicare
  Advantage prescription drug (MA-PD) plans may
  have a formulary
• CMS will ensure formularies do not
• discourage enrollment among certain groups of
  people
• Formulary review requirements are posted at
  www.cms.hhs.gov/pdps on the web
• CMS will approve formularies in advance for plans
  to complete their bid

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Exception Process

• Ensures access to medically necessary Medicare
  covered prescription drugs
• Provides process for enrollee to
• Obtain a covered Medicare prescription drug at a
  more favorable cost-sharing level
• Obtain a covered Medicare prescription drug not
  on the formulary

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Exception Requests

• Enrollees may request an exception if
• The enrollee is using a drug that has been
  removed from the formulary
• A non-formulary drug is prescribed and is
  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 drug
  covered under the less expensive cost-sharing
  tier is medically inappropriate

27
Exception Procedures

• Adjudication timeframes A plan must notify an
  enrollee of its determination no later than 24 or
  72 hours as appropriate
• Failure to meet adjudication timeframes Forward
  enrollees request to Independent Review Entity
  (IRE)
• Generally, plans are prohibited from requiring
  additional exceptions requests for refills and
  from creating a special formulary tier or other
  cost-sharing requirement applicable only to
  Medicare-covered prescription drugs approved
  under the exceptions process

28
5-Level Appeals Process

• Redetermination by plan sponsor
• Reconsideration by Independent Review Entity
• Review by Administrative Law Judge
• Review by Medicare Appeals Council
• Review by Federal District Court

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Long-Term Care Facilities

• Residents
• Obtain drug benefits from pharmacy chosen by the
  facility
• Can change plans at any time if they have both
  Medicare and full Medicaid benefits
• Will have convenient access
• Those who qualify for extra help have no
  deductibles and no copayments

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More Information for Health Care Professionals

• Toolkit for healthcare professionals
  www.cms.hhs.gov/medlearn/provtoolkit.pdf
• Medicare Prescription Drug Coverage Information
  for Providers Page
• www.cms.hhs.gov/medlearn/drugcoverage.asp
• Official U.S. government website for people with
  Medicare
• www.medicare.gov

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More Information for Health Care Professionals

• Social Security Administration (SSA) posters
• Directs limited income Medicare beneficiaries
  where to call to determine eligibility for help
  with prescription drug costs
• http//www.cms.hhs.gov/medlearn/drugcoverage.asp
• Hard copies of the posters, for display in your
  office, may be ordered from the Medlearn Product
  Ordering Page
• http//cms.meridianksi.com/kc/main/kc_frame.asp?kc
  _identkc0001loc5

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Encourage Your Medicare Patients

• Learn about the Medicare prescription drug
  program by visiting www.medicare.gov on the web
  or by calling 1-800-MEDICARE
• (1-800-633-4227). TTY users should call
• 1-877-486-2048.
• Complete and mail back material that they may get
  from the Social Security Administration