PACE Plus and the Medicare Drug Benefit

1
PACE Plus and the Medicare Drug
Benefit Thomas M. Snedden,
(
tsnedden_at_state.pa.us ) Director Pennsylvan
ia PACE Program
( www.aging.state.pa.u
s ) Elder Law Update November 29,
2006 Harrisburg, PA
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Income Limits and Eligibility Requirements

• Eligibility Requirements
• Must be 65 Years of Age or Older
• Must be a Resident of PA for at Least 90 Days

2006 PACE Income Limits Single Applicant
14,500 Married Couple
17,700
2006 PACENET Income Limits Single
Applicant 14,500 - 23,500
Married Couple 17,700 - 31,500

• No Asset test!

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Plus
PACE/PACENET Becomes PACE

• ACT 111-2006 signed July 7, 2006
• PACE Plus selects partner Part D plans
• PACE Plus assigns 155,000 selected enrollees to
  partner plans
• Enrollment with plans effected September 1, 2006

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Previous PACE/PACENET Benefits and Copays
Benefit Structure Prior to September 1, 2006

• Open Formulary
• Open Pharmacy Network

• First Dollar Coverage

• Low Co-pays

PACE
PACENET 6.00 Copay for Generic Rx
40.00 Monthly Cumulative Deductible 9.00
Copay for Brand Name Rx 8.00
Copay for Generic Rx 15.00 Copay for
Brand Name Rx
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PACE/PACENET Benefits and Copays
Benefit Structure Changes for Cardholders

Enrolled in Medicare Part D plan

After September 1, 2006

• First Dollar Coverage

• Minimal Formulary Restrictions

• Restricted to Plan Pharmacy Network

PACEPlus
PACENETPlus PACE Pays
Part D Premium Cardholder pays Part D
Premium PACENET Deductible Eliminated 9.00 Copay for
Brand Name Rx 8.00 Copay for Generic
Rx 15.00 Copay for Brand Name Rx
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PACE/PACENET Benefits and Copays
Benefit Structure Changes for Cardholders

Not Enrolled in Medicare Part D plan

After September 1, 2006

• First Dollar Coverage

• Open Pharmacy Network

• Open Formulary

• Low Co-pays

PACE
PACENET 6.00 Copay for
Generic Rx 32.59 Monthly Cumulative
Premium 9.00 Copay for Brand Name Rx
8.00 Copay for Generic Rx 15.00
Copay for Brand Name Rx
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Pennsylvania 65 Population 1.9
Million PACE/PACENET Eligibility Pool
800,000 PACE Enrollment 185,000 PACENET
Enrollment 125,000 2005 PACE Average Spend
1,900 per enrollee 2005 PACENET Average Spend
1,600 per enrollee
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• Evolutionary Challenges for PACE
• Maintaining integrity of comprehensive drug
  benefit for 310,000 older Pennsylvanians
• Seamlessly merging PACE benefit administration
  with that of selected Part D plans
• Coping in a federal regulatory environment that
  is unfamiliar with state pharmacy assistance
  program operations
• Saving 170 million, annually, in cost shifting
  to Medicare

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Plus
PACE
Partner Part D Plans Premiums

• AmeriHealth Advantage
• 24.18
• First Health Premier
• 27.21
• Highmark Blue Rx
• 26.55
• Humana
• Standard 10.14
• Enhanced 16.94

• Ovations
• AARP 25.03
• MedAdvance 29.20
• Pacificare
• 25.20
• MemberHealth
• 32.10

2 0 0 6
10
Plus
PACE
Partner Part D Plans Premiums

• AmeriHealth Advantage
• 28.45
• First Health Premier
• 28.45
• Highmark Blue Rx
• 23.20
• Humana
• Standard 14.80
• Enhanced 22.90

• Ovations / AARP
• Rx Saver 20.80
• Medicare Rx 27.40
• Elder Health 23.60
• MemberHealth 26.70
• UPMC 23.50
• Geisinger 22.80

2 0 0 7
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How PACEPlus Auto Assigned

• Reviewed Enrollee Drug Usage for Past Year
• Reviewed the Enrollee Pharmacy Choice
• Reviewed Formulary and Network for Each Partner
  Plan
• Make the most Cost Effective Comprehensive
  Prescription Plan Choice for the Cardholder

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Why Were Some Cardholders Not Assigned to Part D
Plans?

• Medicare Advantage Members (MAP) (110,000)
• Retirees with Prescription Coverage (
  4,500)
• Non-Utilizers
  ( 23,000)
• Not Eligible for Medicare (
  3,000)
• Declined Part D enrollment ( 5,000)

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• Key PACE Plus Initiatives
• Initiated enrollment of 70,000 enrollees in the
  Low Income Subsidy (LIS)
• Auto-enrollment of 170,000 enrollees in Part D
• PACE is authorized representative for its
  enrollees
• Special Enrollment Period (SEP) for PACE
  enrollees, each year
• Plans waive prior authorization and step therapy
  protocols for all auto-enrollees

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Standard Medicare Prescription Drug Benefit 2007
Out-of-Pocket Spending
Catastrophic Coverage
Medicare Pays 95
5
5,451.25 in Total Drug Costs
3,151.25 Gap CH Pays 100
No Coverage doughnut hole
2,400 in Total Drug Costs
Medicare Pays 75
25
Partial Coverage Up to Limit
265 Deductible
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PACE Plus Medicare Prescription Drug Benefit 2007
PACE Pays
PACE Enrollee Out-of-Pocket Spending
Medicare Pays 95
Catastrophic Coverage
5,451.25 in Total Drug Costs
PACEPlus Pays
PACE Covers the Doughnut Hole
2,400 in Total Drug Costs
Partial Coverage Up to Limit
Medicare Pays 75
265 Deductible