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NationalCouncil forCommunityBehavioralHealthcare

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The ABCs of Part DHelping Consumers Access Medicare

Prescription Drug Coverage

ByJudith F. Cox , MA, National Council Consultant

andKristin Battista-Frazee, MSW, Educational Services Manager

National Council for Community Behavioral Healthcare

October 6, 2005

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Purpose of this Teleconference

This presentation will help participants:Understand how the Medicare Modernization Act (MMA) impacts consumers with mental health disabilities.Formulate specific tasks they can provide to help these consumers access a drug prescription plan that best meets their needs.Know the resources which are available to providers and consumers for implementing the MMA.

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The Medicare Prescription Drug Coverage, Improvement, and Modernization Act (MMA)

The Medicare Modernization Act was passed in 2003.

It is also known as the Part D (for Drug) Benefit or Prescription Drug Program.

It will be effective January 1, 2006.

Under this Act all Medicare beneficiaries will have assistance in paying for prescription drugs.

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Overview: What is Medicare?

Medicare is a federal health insurance program for people:

Age 65 years and older

Under age 65 with certain disabilities

Of any age with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)

Source: The Centers for Medicare and Medicaid Service, http://www.cms.hhs.gov/medicare/

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Medicare has Four Parts:

1. Part A: the hospital insurance program

2. Part B: the medical insurance program

3. Part C: the Medicare Advantage Plan managed care program

4. Part D: the Prescription Drug Program, created by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

Source: The Centers for Medicare and Medicaid Service (CMS), Outreach Toolkit Medicare Prescription Drug Coverage, June 2005, http://www.cms.hhs.gov/partnerships/tools/materials/medicaretraining/MPDCoutreachkit.asp

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Who is Impacted by the Part D Prescription Drug Program?

42 million people in the USA receive Medicare One quarter of seniors and people with disabilities now receiving Medicare have no drug coverageMillions more face limitations and rising costs with the current coverage they receive in drug plans

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Who is Impacted by the Part D Prescription Drug Program

The Part D Benefit will be most used by persons who receive both Medicare and Medicaid as well as other low-income Medicare beneficiaries.

There are 6.3 million individuals who receive both Medicaid and Medicare of which 38% are consumers of mental health services.

There are another 8.1 million low income Medicare beneficiaries.

Source: Kaiser Family Foundation, “Medicare Low-Income Assistance Under the Medicare Drug Benefit” June 2005. www.kff.org/medicare/7327.cfm CMS Fact Sheet (January 21, 2005): Final Rules Implementing the New Medicare Law: A New Prescription Drug Benefit for All Medicare Beneficiaries, Improvements to Medicare Health Plans, and Establishing Options for Retirees, www.cms.hhs.gov/media/?media=facts.

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What is the Role of Providers in Implementing

the Medicare Part D Prescription Drug Program?

Provide leadership in helping consumers access benefits.

For consumers who are currently receiving prescription drug coverage through Medicaid, assist them transition into the new Part D Benefit by January 1, 2006. After this date, Medicaid will no longer cover their prescription drugs.

For consumers who are without drug coverage, assist them in obtaining needed medical & mental health prescription drug coverage.

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Prescription Drug Plans forMedicare Beneficiaries

Beginning January 1, 2006 all Medicare beneficiaries will have the option to enroll in a Medicare drug prescription plan provided through:

Prescription Drug Plans (PDP) which are available to persons in the Original Medicare Fee-for-Service Plan or a Medicare Private Fee-for-Service Plan (PPFS).A Medicare Health Advantage Plan with prescription drug coverage (MA-PD).Plans offered by employers and unions to retirees.

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Beneficiaries Who Have Medicare and Medicaid (Dual Eligible)

These individuals will loose their Medicaid drug prescription coverage on January 1, 2006.

They will be auto-enrolled in a Prescription Drug Plan (PDP) by the Centers for Medicare and Medicaid Services (CMS) before December 31, 2005.

They may experience challenges with this initial enrollment.

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Medicare Beneficiaries Who Do Not Have Medicaid

These individuals will not be auto-enrolled in a PDP.

As applicable they should enroll in a PDP between November 15, 2005 & May 15, 2006.

If they enroll after May 15, 2006 they will be penalized with higher premium payments. (1% of the average premium per uncovered month)

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Extra Help Low Income Program

Extra Help is available through the Social Security Administration to defer some costs of the Part D Prescription Drug Program

Who is eligible for Extra Help?All dual eligible consumers and all other consumers with incomes at or below 150 percent of the poverty level are eligible for the Extra Help program.

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Extra Help Low Income Program

Who will be automatically enrolled for Extra Help?

People automatically eligible for this assistance are “deemed” and do not have to apply for assistance. They include persons with:

Medicaid and MedicareMedicare who receive Supplemental Security IncomePartial dual eligibility such as qualified medical beneficiaries, specified low-income Medicare beneficiaries and qualifying individualsMedicare who are in a Medicare Savings Program

What Medicare consumers should apply ?All Medicare beneficiaries other than those who are “deemed” will have to apply to receive assistance.

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A Term to Know

TROOP (True Out–of-Pocket Costs) Out-of-pocket costs include all prescription drug costs paid by you or another person or organization, including the government.

The out of pocket costs include payment of the deductible, co-insurance, co-payments and medication costs that are not covered by another insurance.

Costs do not include expenses paid by the individual for medications that are not on a plan’s covered list of drugs or for medications excluded from the Medicare prescription drug benefit.

For consumers without extra help programs the highest out of pocket cost is $3,600 per year plus premium cost.

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What Does a PDP Cost a Beneficiary and How Much Does the Subsidy Program Defer?

Dual status and

poverty level

Qualify

For subsidy

Client

premium

Client

Annual deductible

Client co-pay costs per prescription

Persons with Medicare & Medicaid with income below 100% of the federal poverty level ($9,570/ single; $12,830/ married couple)

YesWill be auto-enrolled

$0 $0 Co-pays are initially

$1/generic, $3/brand-name

Persons with Medicare with income below $12,920 single; $17,321 married & assets $7,500/ single, $12,000/ married

Yesbut must apply to qualify

$0 $0 Co-pays are initially $2/generic, $5/brand-name

No co-pays if in nursing home

No co-pay once drug expenses (TROOP) reach $3,600/year

Persons with Medicare with income below $12,920 / single; 17,321/ married & assets up to $11,500 /single, $23,000/ married

Yes but must apply to qualify

$0 $0 Co-pays are initially 15% of total drug costs

once drug expenses (TROOP) reach $3600/year co-pay is $2/generic, $5/brand-name

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What Does a PDP Cost a Beneficiary and How Much Does the Subsidy Program Defer?

Dual status &

poverty level

Qualify

For subsidy

Client

premium

Client

Annual deductible

Client co-pay costs per prescription

Persons with income below $14,355/ single; $19,245/married couple) and assets below $11,500 single or $23,000/ married couple

Yes

Must apply to qualify

Sliding scale up

to $33.20/

month

$50 15% of total drug costs

once drug expenses (TROOP) reach $3600/year co-pay is

$2/generic, $5/brand-name

Persons with income above 150% of the federal poverty level (the standard cost without subsidy assistance).

**Some States may provide additional coverage. Check with your state’s Medicaid Office.

No $32.20/ month

$250 25% of drug costs up to $2,250 /year

100% drug expenses between $2,251 and $5,100 (equivalent to $3,600);

Then 5% of drug costs above $5,100

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Case Study: Tammy

Tammy is a 40 yr. old women with major mental illness, challenges with anorexia and 5 serious suicide attempts. She has a monthly income above 150% of the poverty level. She is now receiving services through a Assertive Community Treatment Program. She is on Medicare but not Medicaid. She has a monthly prescription medication drug cost of $600.

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Case Study: Joe

Joe is a 62 year old male with chronic heart problems, diabetes and paranoid schizophrenia. He has never worked & has no current income. He currently receives Medicaid and Medicare and was just enrolled in a Case Management Program. He takes four prescription medications.

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Tammy vs. Joe: Costs of Part D coverageadapted from National Council Meet Me Call presented by Dale Jarvis June 27, 2005

Consumer Premium Annual

deductible

Co-Pay Total

Annual Costs

Tammy’s costs

Standard

Program

$33.20/ month or

$386.40/ year

$250 Tammy’s annual medication costs are $600 x 12mo =$7,200

She pays 25% of the first $2,250 in medication costs or $500.

($2,250- $250 x25% = $500)

Then she pays 100% of the medication costs between $2251 & $5100 ($2850 doughnut hole)

Then she pays 5% of the medication expenses above $5100

or $105

($7200 - $5100= $2100 x5%= $105)

Tammy’s costs=

$3,455

PDP costs =

$3,745

Joe‘s costsFull Benefit

Program

$0 $0 Joe has 4 prescriptions for brand named drugs

He pays $3 dollars per prescription every time they are renewed

If his medications were renewed monthly his total monthly co-pay for all medications would be $12.00

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Extra Help Resources for Consumers

Notices from the SSA were sent in May – August 2005 to approximately 18.6 million people, informing them of the extra help including an application form for the subsidy.The SSA or state Medicaid offices will provide individuals with information on income and asset requirements for qualifying. They will also assist consumers in completing a low-income subsidy application. Consumers can call 1-800-772-1213 for assistance or their local office.SSA and state Medicaid agencies began making eligibility determinations on applications for low-income subsidy in July 2005. Individuals may apply on line (www.ssa.gov), by phone or consumers can download an application, and use a tool that helps determine if they qualify for the subsidy benefit.

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Help Consumers Apply for Extra Help

Immediately help consumers determine if they qualify for low-income subsidy assistance.

Check with consumers to make sure they have submitted the appropriate subsidy application and used the resources made available to them.

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Resources to Assist Consumers Obtain Extra Help

Ask consumers if they have received the results of their extra help application.

CMS started mailing notices in May 2005 to beneficiaries deemed eligible for low-income subsidy to notify them that they do not have to apply for the subsidy. Service providers should check with consumers to determine if they have received this notice. If they have not, the provider and the consumer should contact their SSA or local Medicaid office to ensure an application is received.

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Resources to Assist Consumers Obtain Extra Help

Once a consumer has a extra help determination and knows his/her assigned plan review the consumer’s costs.

Make sure consumers know that Medicare will only cover the lowest PDP premium. If a plan is chosen with a higher premium, consumers will still be responsible for the difference, despite their income subsidy status.

In reviewing costs with consumers, providers should also discuss the impact of extra help on the consumer’s housing, foods stamp benefits, and Medicaid Spend Down, as applicable. The reduction in medical spending will affect eligibility of other benefit programs.

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How Will Consumers Pay for Co-Pays?

Even the smallest co-pay can represent a hardship for some people.

Co-pays range from $1 to out of pocket costs in the thousands.

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Alternatives to Helping Consumerswith Co-Pays

Pharmacies are permitted to waive or reduce cost sharing:

For consumers who qualify for the extra help pharmacies can do this on a routine basis.For consumers who do not qualify for extra help pharmacies can only do this on a non-routine basis.Pharmacies are restricted from advertising that they can waive costs so providers should prompt consumers to ask for this extra assistance.Other alternatives are charitable organizations, state pharmacy assistance plans or pharmaceutical company assistance programs.

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Key Implementation Entities and Service Regions

Pharmacy networks

Local Medicaid

Office

State Pharmaceutical Assistance

ProgramSPAP State Health

Insurance Assistance Program

SHIP

SSAOffices

Centers for Medicare & Medicaid Services

PPD &MA –PD Regions

Medicare Drug Plans

The Consumer

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Timeframes for Enrolling Consumers in a Part D Prescription Drug Plan

May 2005 CMS sends letters to people with Medicare to notify them that qualify for extra help and do not have to apply.

May - August 2005

SSA sends letters to 20 million people with Medicare informing them of the Extra help for premiums and co-pays. Mailing includes an application.

June 20 - 30, 2005

CMS mails letter to consumers who have Medicare and Medicaid regarding transition to Medicare Prescription Drug Plan.

July 1, 2005 SSA offices and state Medicaid agencies begin making eligibility determinations on applications for the extra help. Consumers may apply on-line or by phone. On-line application for extra help is available www.socialsecurity.gov or by calling 1-800-633-4227. On-line tools will be available to determine if they qualify before they apply.

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Fall 2005 Medicaid agencies send notices to people with Medicare and Medicaid that they will lose their Medicaid drug coverage on January 1, 2006 and that they will be automatically enrolled in a Medicare Prescription Drug Plan.

Sept. 2005 Medigap insurance companies send notices to policyholders with drug coverage informing them of their options. Employers/unions who provide prescription drug coverage to their retirees will directly notify them about their new prescription drug coverage choices.

Oct. 2005 Comparison information about the Medicare Prescription drug plans is available at www.medicare.gov, 1-800-Medicare or through State health Insurance Assistance programs (SHIPS) and other local organizations.

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Oct. 2005 Medicare and You 2006 Handbook is mailed to people with Medicare. People with Medicare and Medicaid will get information about how they will be automatically enrolled in a plan if they do not choose one on their own. People with Medicare Advantage plans are notified about drug coverage options.

Nov. 2005 Enrollment for Medicare prescription drug plans begins November 15, 2005. People who are not automatically enrolled must call the company offering the plan to enroll or enroll through 1-800-MEDICARE.

By Dec. 31, 2005

Review caseload to ensure persons with Medicare and Medicaid were auto-enrolled in a Medicare Prescription Drug Plan as Medicaid coverage stops on January 1, 2006.

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January 1, 2006

Medicare Prescription Drug Coverage begins for those enrolled in a plan by December 31,2005. Medicaid stops drug coverage for people with Medicare and Medicaid.

May 15, 2006

People with Medicare that have not enrolled in a Medicare Prescription Drug Plan or applied for extra help must do so by this date or pay a penalty for late enrollment. (NOTE: CMS has set this penalty for the first few years of the program at one percent of the average drug premium per uncovered month. In subsequent years, the amount of the penalty will increase with the growth in the base Part D premium). Providers should advise consumers that Medicare will only cover the lowest Medicare PDP premium. If a plan is chosen with a higher premium, consumers must pay the difference, despite their extra help status.

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General Provider Tasks to Help Implement the Medicare Part D Drug Program

1. Review your case loads ASAP to identify Medicare beneficiaries.

2. Divide Medicare beneficiaries on your caseload into 4 groups based upon their income, dual eligibility and current Medicare drug plans, and then follow relevant enrollment procedures. The four groups are:

Group 1: Beneficiaries in the Original Medicare Fee-for-Service Part A and/or Part B plan and Medicaid. Also know persons in a dual eligible status.Group 2: Beneficiaries in the Original Medicare Fee-for-Service Part A and/or Part B plan who receive Supplemental Security Income (SSI) or are in a Medicare Savings ProgramGroup 3: Medicare beneficiaries enrolled in the Original Medicare Fee-or-Service Part A and/or Part B plans who do not receive MedicaidGroup 4: Medicare beneficiaries enrolled in a Medicare Advantage plan but who do not receive Medicaid

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Groups of Medicare Beneficiaries

3. Partner with consumers on accessing Part D4. Review each consumer’s medications needs,

the pharmacy they are using and prescribing physician (consider a standard worksheet)

5. Assist consumers in applying for extra help6. Assist consumers to enroll in a appropriate

prescription drug plan7. Find out more information-review NMHA’s

Medicare workbook for consumers, www.nmha.org

8. Report major problems consumers have in accessing Part D Drug Program to National Council for Community Behavioral Healthcare

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A TOOL to Help the Consumer and the Provider Find the Best Plan

Medicare Prescription Drug Plan FinderThis is a web based resource that will be available to consumers and providers beginning October 13, 2005 at www.medicare.gov to compare the plans point by point, such as their premiums, co-payments, drugs they cover (formulary) and pharmacy network information. Program contact and pricing information is displayed at the network pharmacy level.If you don’t have access to the Internet, you can get the same kind of information by calling Medicare at 1-800-MEDICARE.A customer representative will send you printed versions of details of all the plans that are available to you. This service, too,will be available after October 13, 2005.

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The Enrollment and Extra Help Application Procedures for each of

the Four Groups of

People with Medicare

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Medicare Beneficiaries Who are Dual Eligible Status & Enrolled in the Original Fee-for-Service Plans

Part A and /or Part B Plans

Group 1

Will they be auto-enrolled in the Part D PDP?Yes

They will be auto-enrolled by CMS in the Fall 2005

CMS will randomly assign consumers to drug plans in their region that have the lowest cost plans

Will they automatically receive subsidy assistance?

Yes

They do not have to apply for assistance

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Medicare Beneficiaries Who are Dual Eligible and Enrolled in the Original Fee-for-Service Plans

Group 1

Provider Tasks and Critical Information1. In October 2005, partner with consumers to discuss the

specific drug plan to which they were auto-enrolled. Review the characteristics of the plan including:

• Medications covered and not covered

• Co-payment charges,

• Grievance procedures, • Pharmacies in the plan’s network

2. If this plan does not cover the consumer’s prescription medications, review other plans in the Region and select the plan which matches the person’s prescription medication needs. Remember there are at least 2 plans in each region.

Specific information about drug plans in the region can be obtained from the consumer’s pharmacy and online at www.medicare.gov using Plan Finder search tool.

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Medicare Beneficiaries Who are Dual Eligible and Enrolled in the Original Fee-for-Service Plans

Group 1

3. When medically necessary, consumers should be permitted to continue utilizing a non-formulary drug (one not covered by a prescription drug plan) that is providing clinically beneficial outcomes. Each plan should describe how consumers can

continue to have access to a non-formulary drug, when there is a known risk for a negative clinical outcome associated with substituting another drug.

Providers should understand the plan’s policy and ensure that the consumer’s coverage continues. See NMHA’s Exceptions and Appeals FAQ provided in Appendix B.

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Medicare Beneficiaries who are Dual Eligible and Enrolled in the Original Fee-for-Service Plans

Group 1

4. In mid December 2005, again discuss with consumers their selected PDP and the plan’s participating pharmacies.

5. Providers should help consumers make sure that they have a new pharmacy card for the pharmacy in their plan’s network.

6. Providers should contact the local State Health Insurance Program (SHIP) if they have questions regarding Medicare prescription drug benefits. This is a free counseling service funded by CMS.

7. In January 2006 or prior to the first visit to the pharmacy, providers should ensure consumers know where their new pharmacies are located and have transportation. For some consumers the provider or a significant other should accompany the consumer on the first visit.

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Medicare Beneficiaries in the Original Medicare Fee-for-Service Plans who are on SSI or in a Medicare Savings Program

Group 2

Are they auto-enrolled in the Part D PDP?These individuals will not be auto-enrolled by January 1, 2006 but will be auto-enrolled by May 15, 2006

They will need to choose and enroll in a plan by May 15, 2006 but can enroll by 12/31/05

Consumers who do not join a plan by May 15, 2005 will be auto-enrolled in a Part D plan effective June 1, 2006, but this plan may not be consistent with their medication needs.

Will they automatically receive subsidy assistance?

Yes. They do not have to apply for assistance.

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Medicare Beneficiaries in the Original Medicare Fee-for-Service Plans Who are on SSI or in a Medicare Savings Program

Group 2

Provider Tasks and Critical information1. Between November 15, 2005 and May 15, 2006, assist

consumers in enrolling in an appropriate Drug Plan. 2. Facilitate the consumer being enrolled in a plan by May 15,

2006 at the latest. If they are not enrolled by this date, Medicare will enroll them in a plan that will be effective June 1, 2006, but this plan may not be consistent with their medication needs.

3. Similar to Group 1 providers should work in partnership with the consumer to compare their medication needs with the plans available in the region using the available tools and follow steps 3- 7.

4. Additionally if the consumer is auto-enolled on June 1, 2006 the provider should review the plan to ensure it meets the consumers needs.

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Beneficiaries Who are Enrolled in the Original Medicare

Fee-for-Service Plans but do not Receive Medicaid

Group 3How will their prescription drugs be covered as of January 1, 2006?

Individuals in the Original Medicare Plan without drug coverage can enroll in the Medicare Part D PDP.

Medigap consumers should compare their current coverage and make sure it is as good as coverage through a Medicare Part D PDP.

Individuals who have prescription drug coverage through their employer or Union Health need to decide whether they should keep their current plan or enroll in a Medicare part D PDP.

Are they auto-enrolled in a Part D PDP? No, They must enroll.

Are they auto-enrolled for subsidy assistance? No, They must apply for this assistance.

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Beneficiaries Who are Enrolled in the Original Medicare Fee-for-Service Plans but do not Receive Medicaid

Group 3

Provider Tasks and Important InformationFor consumers with existing prescription drug coverage 1. Compare the existing plan with the Part D Prescription

Drug plans and select the plan that best meets the consumer’s needs.

2. A SHIP counselor can be contacted to determine if it is in the consumer’s best interest to change plans www.shiptalk.com or call 1-800-MEDICARE.

3. If a consumer has a Medigap policy or has prescription drug coverage through their employer, they should receive a notice in the Fall of 2005 from Medigap or their employer telling them whether or not their coverage is at least as good as coverage through a Medicare Prescription Drug Plan (PDP).

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Group 3For consumers without drug coverage, inform them about the Part D Prescription Drug Program and the enrollment and extra help processes.

1. First, assist the consumer in completing an application for the limited income subsidy. Go to www.ssa.gov for an application or apply by phone at 1-800-772-1213.

2. Review the results of their subsidy application so that consumer knows the costs of the drug plan and that he/she has been approved for the limited subsidy.

3. Assist consumer in enrolling in an appropriate regional Prescription Drug Plan. With the consumer, compare their medication needs with the plans available in that region.

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Group 3

4. Following enrollment into a plan, review with the consumer their extra help allowance and co-pay charges for each medication. Also discuss the pharmacy in the consumer’s PDP network (name, address and telephone number, methods of transportation to the pharmacy) and make sure consumer has a new pharmacy card for that pharmacy.

5. Contact the local State Health Insurance Program (SHIP) for additional information which may be needed.

6. As with Groups 1-3 when needed accompany the consumer to the pharmacy to fill his/her first prescription under the new Medicare Part D Benefit.

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Medicare Beneficiaries in an Advantage Plan who do not Receive Medicaid

Group 4

How will their prescription drugs be covered as of January 1, 2006?

These individuals can stay in their current Medicare Advantage plan and get prescription drug coverage or enroll in a Part D Plan.

• Are they auto enrolled for subsidy assistance?• No. They must apply for this assistance.

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Medicare Beneficiaries in an Advantage Plan Who Do Not Receive Medicaid

Group 4

Provider Tasks

1. Meet with consumers to determine is he/she is in a plan without medication coverage. Some of the MA-PD plans do not have drug coverage.

2. If consumers are without medication coverage and are enrolled in a Medicare Advantage HMO, PPO or SNP, assist the consumer in signing up for a Medicare Advantage Prescription Drug (MA-PD) plan or Part D Plan.

3. For more information on how to enroll a consumer in the above plans, call 1-800-633-4227 or visit www.medicare.gov.

4. If needed, the provider should assist consumers with the application for limited income subsidy.Go to www.ssa.gov for an application or apply by phone at 1-800-772-1213.

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Case Study: Enrollment Procedures for Joe, a Man who receives Medicare

and Medicaid

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Case Study: Enrollment Procedures for Joe a Man who Receives Medicare and Medicaid

Consumer Event- June 2005, Joe receives an informational letter from CMS regarding his transition to a Medicare Prescription Drug Plan.

Provider Response- Provider identifies Joe as a consumer in Group 1 and meets with Joe to review Medicare prescription drug coverage and procedures.

Consumer Event- Fall 2005, Joe’s Medicaid agency mails him a letter to notify him that he will lose his Medicaid prescription drug coverage on January 1, 2006 and that he will be auto-enrolled in a Medicare plan. The letter tells Joe to call 1-800-MEDICARE if he has any questions.

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Consumer Event- October 27 – November 27, 2005, CMS notifies Joe of the Medicare Prescription Drug Plan he has been enrolled in.

Provider Response- Provider meets with Joe to confirm he has been auto-enrolled in a Prescription Drug Plan, review the contents of the CMS notification and compare the plan Joe has been enrolled in with his medication needs. During this meeting the provider and Joe will work together on the following:

– Review the specifics of the plan in which he has been enrolled and make sure that it is the most appropriate plan for him. He and the provider should compare the medical and mental health prescription drugs he needs with those covered by his assigned plan’s formulary.

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– If the assigned plan meets Joe’s needs, he and the provider will review how Joe will get to the participating pharmacy, as this pharmacy may be different from the one he normally uses.

– If the plan does not cover Joe’s prescribed medication needs, he should review other plans in his region to find a plan that does. He and the provider can go online at www.medicare.gov and access a software program provided by Medicare to identify the other plans that meet his medication needs. Remember, Joe must change his plan between November 15 and December 31, 2005 to avoid a lapse in coverage. After January 1, 2006, he can change plans every 30 days.

– Review the extra help Joe will be receiving and discuss what pharmacy he will be using. The provider and Joe need to keep in mind that the extra help Joe and all other dual eligibles qualify only covers the premium for the lowest-cost plan in his area. Therefore, if Joe chooses a plan with a higher premium, Joe must pay the difference in the cost.

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– The provider and Joe should discuss any medications he needs that are not on the plan’s formulary. If these medications are medically necessary, Joe should be permitted to continue utilizing a non-formulary drug that is providing clinically beneficial outcomes. Joe’s plan should describe how consumers can continue to have access to a non-formulary drug, when there is a known risk for a negative clinical outcome associated with substituting another drug. Joe’s providers should understand the plan’s policy and ensure that the consumer’s coverage continues.

– Consumer Event- January or February 2006, Joe will receive a letter from his Medicaid agency when his prescriptions run out, reminding Joe that he will need to go to the participating pharmacy under his new drug plan to get his medications.

– Provider Response- The provider should accompany Joe to the pharmacy to fill his first prescription under the Part D Program.

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Potential problems Joe may encounter:1. Joe may not be auto-enrolled in a Medicare Prescription Drug Plan or

automatically qualify for extra help because of problems with the transmission of state eligibility records.

2. Joe’s cognitive impairment may prevent him from knowing what to do with the instruction letter her receives in October 2005, and/or from evaluating the plans in his region, including the specific formularies, co-payment amounts, pre-authorization processes, and available pharmacies.

3. The time frame for selecting the most appropriate Medicare Prescription Drug Plan (11/15/05- 12/31/05) may be too short.

4. Joe’s low income may create a situation where he won’t have sufficient funds to pay for co-payments every time he gets his medications refilled.

5. If Joe needs any drugs that require pre-authorization, he may need help with that process.

6. If there is an interruption in Joe’s medications, he may need help accessing an emergency supply.

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Frequently Discussed Topics

Common characteristics of Part D Prescription Drug Plan.

Concern about access to urgently needed medications.

Maintaining continuity of care during transitions

Accessing Part D drug benefits for persons in institutions.

Prescription Drug Plan Part D and Incarceration.

The impact of subsidy programs on other benefits.

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Characteristics of a Part D PDP:Organization

What is a PDP?PDP’s are Prescription Drug Plans offered by insurance and other private companies in 34 regions comprising the United States. Consumers who are eligible for these plans get health care benefits through the Original Medicare Fee-for-Service Plan or a private fee-for-service plan.

How are PDPs organized?There are 34 regions of coverage, some of which include more than one state. Each region must offer at least two plans.

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Characteristics of a Part D PDP: Regions & Participating Pharmacies

What pharmacies are participating in the PDP?

In Spring 2005, pharmacies participating in the PDPs were determined by the insurers

A list of participating pharmacies will be given to the consumer when they receive information about the assigned PDP

In October 2005, participating pharmacies will be one entity that will have information about the PDP a Medicaid and Medicare beneficiary has been auto-enrolled

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Characteristics of a Part D PDPDrug Coverage

• Prescription Drug Plans vary in what drugs are covered and how much a consumer has to pay.

• All plans must provide at least a standard level of coverage, set by CMS.

• All plans offering Medicare drug coverage must provide some drugs in all therapeutic classes, but they not required to cover all drugs in each class.

• It is important to make sure that most, if not all, a consumer’s medications are covered by their plan, as well as the correct dosages of those medications.

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Characteristics of a Part D PDPDrugs Included

The drugs that must be included in Prescription Drug Plans are “all or substantially all” of the brand name and generic drugs in the following categories:

Antidepressant

Antipsychotic

Anticonvulsant

Anticancer

Immunosuppressant

HIV/AIDS

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Characteristics of a Part D PDP: Drugs that may be Excluded

The drugs that are not required to be included in the Prescription Drug Plans are:

Over-the-counter drugs, weight gain & weight loss drugs.Fertility drugs and cosmetic drugs.Drugs to relieve cold and cough symptoms, vitamins and minerals (except prenatal vitamins and fluoride).Outpatient drugs for which associated tests or monitoring must be purchased exclusively from the manufacturer.Barbiturates (i.e.,pentobarbital and benzodiazepines (i.e., Xanax, Klonopin).

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Characteristics of a Part D PDP Plans: Medications that may be Excluded

Other drugs which may be excluded are:Iressa - not required on formularies (for locally advanced or metastatic non-small-cell lung cancer).Fuzeon – (HIV medication) must be on formularies, but may require prior authorization for new users.Escitalopram or citalopram – (antidepressants) one may be left off the formulary, since escitalopram is the component of citalopram responsible for the antidepressant effects.Fosphenytoin - may be left off formularies. This is for seizures. It is only available as IM or IV.It is not required that multi-source brands of identical molecular structure be included, that extended release products be included, or that all dosages of covered drugs be included.

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Characteristics of a Part D PDP Medications that may be Excluded

The State Pharmaceutical Assistance Program could cover any of the above medications that may be excluded form the PDPs.

The State Medicaid Programs can cover barbiturates and benzodiazepines and for those consumers who are full benefit dual eligible States can receive federal financial participation.

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How are Urgently Needed Medications Obtained?

Medications needed urgently are covered while a prompt exception process is completed.

A physician or authorized representative can help the consumer with the exception process.

A one-time emergency supply of a medically necessary, non-formulary drug may be available for at least 30 days.

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Characteristics of a Part D PDP Formularies

Plans can have different formulariesIt is important to make sure that the majority of the consumer’s medications are included on their plans formulary.

Within a formulary, medications can be tiered. A medication can be Tier 1, 2, or 3. Medications on Tier 1 and 2 are considered preferred and have a lower co-payment.

Medications on Tier 3 are covered by the plan but are not preferred and have the most expensive co-payments. In most cases, generic medications will be Tier 1 and brand name drugs will be Tier 2 or 3.

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Is There an Appeals Process to Obtain Medications Not on the Formulary?

Consumers can obtain off-formulary medications.A consumer or his/her physician may file a request for an exception to the formulary.

All exception requests must be accompanied by the prescribing physician’s oral or written statement supporting the request.

The physician’s request must demonstrate that the drug is medically necessary because all of the covered drugs on any tier of the plan’s formulary used to treat the same condition would not be as effective for the consumer as the non-formulary drug and/or would have adverse effects.

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Characteristics of a Part D PDP Formularies

Who decides what medications are on the formulary?Formularies are developed and reviewed by a pharmacy and therapeutic (P&T) committee.

What is the process for changes in the formulary? The PDP may only change the therapeutic categories and classes on the formulary at the beginning of each year.

Plans must provide direct written notification to affected consumers at least 60 days prior to a formulary change becoming effective. This includes both removal of a drug from a formulary and any change in the preferred or tiered cost-sharing status of a drug.

Specific changes in the formulary under a plan, including changes to tiered or preferred status, shall be made available through on a website: www.cms.hhs.gov?mmu?hrl/PL108-173summary.asp.

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Grievances and AppealsConsumers can get off-formulary medications.

Consumer or his/her physician may file a request for an exception to the formulary.

Exception requests must be accompanied by the prescribing physician’s oral or written statement supporting the request.

The physician’s request must demonstrate that the drug is medically necessary because all of the covered drugs on any tier of the plan’s formulary used to treat the same condition would not be as effective for the consumer as the non-formulary drug and/or would have adverse effects.

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What Should the Consumer do if the Pharmacist says the Drug is not on the

Formulary?

Assist the consumer in contacting their plan to request an exception. If the plan denies an exception, then the consumer can appeal the plan’s decision.

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Maintaining Continuity of CareDuring Transitions?

Provider GuidelinesIf a consumer is currently stabilized on a non-formulary drug, the plan must describe in detail how it will ensure the consumer will continue to have access to that drug when there are known risks for negative clinical outcomes associated with its substitution.

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Maintaining Continuity ofCare During Transitions?

All PDPs must have transition plans for new enrollees to ensure that emergency drugs are supplied.Generally, If a service provider anticipates a problem with drug coverage, a supply of drugs determined by the physician to be medically necessary may be available. It appears that at least a 30 day supply of medications may be the standard used for emergencies.Some states may also be able to prevent a lapse in coverage by filling a 90-day extended supply of prescriptions in December 2005 and still receive federal matching funds.

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How do Individuals in Institutions Apply for Medicare Part D Prescription Drug Plan ?

Eligible persons residing in nursing homes will be expected to enroll in a new Medicare Part D Prescription Drug Plan (PDP) (or be automatically enrolled if they are dual eligible). The new plans are expected to contract with long- term care pharmacies.For eligible persons temporarily residing in a psychiatric facility follow the appropriate group 1-4 enrollment procedures previously discussed. If a consumer is hospitalized during the Fall 2005 enrollment period, then providers need to coordinate with the institutional staff to ensure that the consumer is enrolled the most appropriate PDP for their needs.

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Do Individuals Who are Incarcerated Qualify for Medicare

Individuals who are incarcerated are not eligible for Medicare prescription Drug Coverage because they are not considered to reside in a prescription drug service areas.

Providers will need to help these individuals upon re-entry into the community and as eligible enroll in a PDP and apply for extra help.

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What is the Impact of Participation in the Part D Prescription Drug Plan on Food Stamps?

With the extra help to defer prescription drug costs, a consumer may see his/her Food Stamps benefit go down as they spend less on drugs. Using the extra help means consumers will have more cash to spend on things they need other than medications.Changes in medical expenses should be reported when the consumer files to renew his/her Food Stamps benefit.Providers should give consumers who are receiving Food Stamps and are eligible for extra help a copy of the CMS Tip Sheet “Information Partners Can Use on: Food Stamps.

Source: CMS Tip Sheet “Information Partners Can Use on: Food Stamps, 5/25/05, http://www.cms.hhs.gov/medicarereform/factsheets.asp

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What is the Impact of Participation in the Part D Prescription Drug Plan on Housing Assistance?

Consumers will not lose housing assistance eligibility if they qualify for subsidy help in paying for the Prescription Drug Plan.With extra help to defer prescription drug costs, the portion of the rent that a consumer pays may increase, but their expenditures on prescription drugs will decrease. The increase in the consumer’s rent cost will be more than the offset by Medicare’s extra help.

Source: CMS Tip Sheet “Information Partners Can Use on: Housing Assistance from the Department of Housing and Urban Development (HUD), 6/25/05, http://www.cms.hhs.gov/medicarereform/factsheets.asp

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What is the Impact of Participation in the Part D Prescription Drug Plan on Housing Assistance?

After the consumer knows the amount of extra help they qualify for, the provider and the consumer should discuss with the agency that handles the consumer’s rent determination the impact of extra help on the portion of the rent that the consumer will be responsible for.By doing this, the consumer will know whether or not their rent will increase at the next recertification. Participation in a Medicare PDP does not need to be reported until the consumer’s family income and composition is recertified.Review with consumers who are receiving housing assistance and are eligible for extra help the CMS Tip Sheet “Information Partners Can Use on: Housing Assistance from the Department of Housing and Urban Development (HUD).

Source: CMS Tip Sheet “Information Partners Can Use on: Housing Assistance from the Department of Housing and Urban Development (HUD), 6/25/05, http://www.cms.hhs.gov/medicarereform/factsheets.asp

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What is the Impact of Participation in the Part D Prescription Drug Plan on Medicaid Spend Down?

Consumers will not lose Medicaid Spend Down if they qualify for subsidy help in paying for the new Medicare prescription drug plan costs.If a consumer does “spend down” to Medicaid because they have high drug costs, they may find that the new Medicare Prescription Drug Plan covers their drug spending but they no longer “spend down” as quickly to become Medicaid-eligible.Providers should review with consumers who are utilizing the Medicaid Spend Down process and are eligible for subsidy assistance the CMS Tip Sheet “Information Partners Can Use on: Medicaid Spend Down.

Source: CMS Tip Sheet “Information Partners Can Use on: Medicaid Spend Down, 5/25/05http://www.cms.hhs.gov/medicarereform/factsheets.asp

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