Wraparound 101: Basics and updates

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Wraparound 101 Basics and updates

• Marisa Scala-Foley
• Associate Director, ABC
• November 18 November 23

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Transitional Assistance (TA) Credit

• Medicare pays card enrollment fee
• Drug card comes with 600 credit per year that
  can be used toward drug costs
• Can use 600 to help pay for the cost of most
  drugs, except barbiturates, benzodiazepines,
  cosmetic drugs, cough cold remedies, fertility
  drugs, over-the-counter (OTC) drugs, vitamins
  (except those for prenatal care), weight-related
  drugs, and other drugs already covered by Part B
  
• Depending on income, consumers pay only 5 or 10
  co-insurance (i.e., 5 or 10 of the discounted
  cost of the drug they are buying).

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TA Eligibility

• Must be below 135 Federal Poverty Level (FPL)
• Income limits 12,569 for individuals (16,862
  for married couples)
• Higher limits in Alaska (15,701 for individuals,
  21,074 for couples) and Hawaii (14,445 for
  individuals, 19,386 for couples)
• No asset test
• Cannot get TA if already have prescription
  coverage from employer (including Federal
  Employee Health Benefits Program -- FEHBP),
  Medicaid or TRICARE for Life
• Can get TA if in Medicare Advantage plan, Medigap
  plan, or have VA benefits

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What Counts As Income

• Includes employment-related compensation, Social
  Security benefits, VA benefits, pensions and
  annuities, IRA distributions, alimony and more
• Does NOT include workers compensation, welfare
  and other public assistance benefits, SSI
  benefits, home sale proceeds, child support, and
  more
• For full lists, visit http//questions.medicare.go
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  _li

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What Happens After the 600 is Used Up?

• After 600 credit is spent, then pay full
  discounted price unless have other coverage
• HOWEVER, eight pharmaceutical companies offering
  additional wraparound programs/coverage
• Abbott, AstraZeneca, Eli Lilly, Genzyme, Johnson
  Johnson, Merck, Novartis, Pfizer
• Offered by these companies, but administered by
  the card sponsors
• This additional coverage goes into effect once
  someones 600 credit is used up
• No separate application needed card sponsors
  automatically sign up beneficiaries who are
  enrolled in their card

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More about wraparounds and how they work

• Programs are linked to specific cards and cover
  specific lists of drugs (formularies)
• Number of drug discount cards with which programs
  are affiliated ranges from 6-48
• Beneficiary can get drugs included in the
  programs affiliated with their card either for a
  flat monthly fee, or for the pharmacys
  dispensing fee.
• This is a critical factor in decision-making
  about the cards for beneficiaries with low
  incomes.

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Abbott

• Abbott Expanded-Medicare Assistance Program
• Affiliated with 36 cards
• Covers 5 drugs
• Beneficiaries pay flat fee of 12 ( dispensing
  fee) for a 30-day supply of 4 of the 5 drugs
  covered under this program
• Pay a flat fee of 5 ( dispensing fee) for a
  30-day supply of the 5th drug (Synthroid)

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AstraZeneca

• AstraZeneca Expanded-Medicare Assistance Program
• Affiliated with 11 cards
• Covers 19 drugs
• U-Share Beneficiaries pay flat fee of 15 (
  dispensing fee) for a 30-day of supply of drugs
  covered under this program
• Through this program, help also available for
  those between 135 200 FPL enrolled in the
  U-Share card
• Other cards Beneficiaries pay only the pharmacy
  dispensing fee for a 30-day supply of drugs
  covered under this program

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Eli Lilly

• Eli Lilly Expanded-Medicare Assistance Program
• Affiliated with 46 cards
• Covers 14 drugs
• Beneficiaries pay flat fee of 12 ( dispensing
  fee) for a 30-day supply of drugs covered under
  this program
• Through this program, help also available for
  those between 135 200 FPL enrolled in the
  U-Share card

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Genzyme

• Genzyme Expanded-Medicare Assistance Program
• Affiliated with 6 cards
• Covers 1 drug (Renagel)
• Beneficiaries pay flat fee of 5 ( pharmacy
  dispensing fee) for a 30-day supply of Renagel
• Those who do not qualify for the 600 credit pay
  25 for a 30-day supply

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Johnson Johnson

• Johnson Johnson Expanded-Medicare Assistance
  Program
• Affiliated with Janssen and Ortho-McNeil
• Affiliated with 23 cards
• Covers 44 drugs
• Beneficiaries pay flat fee of 12-15 (
  dispensing fee) for a 30-day supply of drugs
  covered by this program
• Fee varies by drug
• Through this program, help also available for
  those between 135 200 FPL enrolled in the
  U-Share card

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Merck

• Merck Expanded-Medicare Assistance Program
• Affiliated with 45 cards
• Covers 39 drugs
• Beneficiaries pay only the dispensing fee for a
  30-day supply of drugs covered under this program

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Novartis

• Novartis Expanded-Medicare Assistance Program
• Affiliated with 48 cards
• Covers 27 drugs
• Beneficiaries pay only the pharmacy dispensing
  fee for a 30-day supply of drugs covered under
  this program

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Pfizer

• Pfizer Expanded-Medicare Assistance Program
• Affiliated with 18 cards
• Covers 57 drugs
• Beneficiaries pay flat fee of 15 for a 30-day
  supply of drugs covered under this program
• Through this program, help also available for
  those between 135 200 FPL enrolled in the
  U-Share card

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More about U-Share card

• Four pharmaceutical company wraparound programs
  offer additional coverage to those between 135
  200 of FPL (Individuals between 12,569 and
  18,620 Married couples 16,862 24,980)
  enrolled in the U-Share card
• These beneficiaries pay a flat fee ( dispensing
  fee) for medications offered by the AstraZeneca
  (15), Johnson Johnson/Janssen/Ortho-NcNeil(12-
  15 depending on drug), Lilly (12), and Pfizer
  (15)
• Also receive a discount of up to 47 on many
  other prescriptions

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Facilitated Enrollment Wraparounds

• 25 cards participating in facilitated enrollment
  initiative this fall
• Those enrolled in Medicare Savings Programs
  received a randomly assigned active card, but
  must call to activate 600 credit
• All cards except one (ScripSolutions Choice) are
  affiliated with at least one wraparound program
• Most affiliated with several wraparounds

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Helpful Links

• List of card sponsors http//www.cms.hhs.gov/medi
  carereform/drugcard/sponsorinfo/
• Wraparound lists/descriptions http//www.cms.hhs.
  gov/medicarereform/drugcard/mfragreements.asp
• Cards affiliated with facilitated enrollment
  http//www.cms.hhs.gov/partnerships/news/autoenrol
  l/sponsors.pdf

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Questions?

• Contact
• Marisa Scala-Foley
• marisa.scala-foley_at_ncoa.org
• 202-479-6976