MEDICARE PART D Are We Ready? Are We Ready?. Medicare Part D Overview Medicare Part A and B covers individuals Age 65 and older Age 65 and older Those

MEDICARE PART DMEDICARE PART D

Are We Ready?Are We Ready?

Medicare Part D Overview Medicare Part D Overview

Medicare Part A and B covers individuals Medicare Part A and B covers individuals • • Age 65 and older Age 65 and older

• • Those with a disability who have collected Social Security for a Those with a disability who have collected Social Security for a minimum of 2 years minimum of 2 years

• • Those with kidney failure or who need a kidney Those with kidney failure or who need a kidney transplant transplant

42 Million Medicare beneficiaries growing 42 Million Medicare beneficiaries growing


• • On 1/1/06, Medicare Part D – the largest Medicare On 1/1/06, Medicare Part D – the largest Medicare reform in 40 years began reform in 40 years began

• • Medicare Part D is a Medicare Part D is a voluntaryvoluntary Insurance program for Insurance program for prescription drugs through Medicare prescription drug prescription drugs through Medicare prescription drug plans and other health plan options. plans and other health plan options.

• • Insurance companies and other private companies will Insurance companies and other private companies will work with Medicare to provide a choice of plans that work with Medicare to provide a choice of plans that cover both brand name and generic drugs. cover both brand name and generic drugs.

Medicare Part D OverviewMedicare Part D Overview

Part D Drug Coverage Part D Drug Coverage • • Includes prescription drugs, biological products, Includes prescription drugs, biological products,

certain vaccines, insulin, and diabetic medical certain vaccines, insulin, and diabetic medical supplies supplies

• • Excludes, among other categories, OTC drugs, Excludes, among other categories, OTC drugs, barbiturates, benzodiazepines, weight loss or barbiturates, benzodiazepines, weight loss or weight gain meds, meds for relief of cough, and weight gain meds, meds for relief of cough, and any drug covered by Medicare Part A or B any drug covered by Medicare Part A or B


Part d is a voluntary program except for low income Part d is a voluntary program except for low income dual-eligible formerly on Medicaiddual-eligible formerly on Medicaid

• • Medicare eligible persons may remain on their currentMedicare eligible persons may remain on their current employer sponsored retiree Rx plans, participate in aemployer sponsored retiree Rx plans, participate in a

MA-PD plan or PDP plan, be auto-enrolled in a dual-MA-PD plan or PDP plan, be auto-enrolled in a dual- eligible plan, or not participate in any plan. eligible plan, or not participate in any plan.

Beginning 1/1/06, the current Medicaid Rx coverage for Beginning 1/1/06, the current Medicaid Rx coverage for dual-eligible will change to federally managed Medicare dual-eligible will change to federally managed Medicare Part D Rx Part D Rx


Dual-Eligibles (Medicare and Medicaid)Dual-Eligibles (Medicare and Medicaid)• • Dual-eligibles (eligible for Medicare and Medicaid) are Dual-eligibles (eligible for Medicare and Medicaid) are

covered. An estimated 60% of Medicaid prescriptions come covered. An estimated 60% of Medicaid prescriptions come from persons that are also eligible for Medicare from persons that are also eligible for Medicare

- At or below 135% of poverty level- At or below 135% of poverty level

• • Will be randomly auto-enrolled into one of the national plans Will be randomly auto-enrolled into one of the national plans that meets the benchmark pricing within a given area that meets the benchmark pricing within a given area

- - Plan may not meet their particular medication needs Plan may not meet their particular medication needs

- Over 6 million dual eligibles have already been randomly - Over 6 million dual eligibles have already been randomly auto-enrolled into a Part D plan auto-enrolled into a Part D plan

• • Medicaid prescription coverage will end beginning January 1, Medicaid prescription coverage will end beginning January 1, 2006 unless the drug is in a non-covered drug category 2006 unless the drug is in a non-covered drug category


Dual-Eligible (Medicare and Medicaid)Dual-Eligible (Medicare and Medicaid)• • No monthly premiumsNo monthly premiums • • No deductible No deductible • Low or no co-payments (may be higher than current Medicaid Low or no co-payments (may be higher than current Medicaid

program) program)

• • Possible differences in drug coverage and co-payments than Possible differences in drug coverage and co-payments than current Medicaid plan current Medicaid plan

• • Wrap around state public assistance programs Wrap around state public assistance programs (SPAPs) benefits or state Medicaid may apply to (SPAPs) benefits or state Medicaid may apply to non-covered categoriesnon-covered categories

•• Can switch plans monthly into another available Can switch plans monthly into another available Part D plan - during the first year Part D plan - during the first year


Non-Dual eligible (Medicare Only)Non-Dual eligible (Medicare Only)• • Voluntary enrollment Nov 15, 2005 thru May 15, 2006 Voluntary enrollment Nov 15, 2005 thru May 15, 2006

(1% per month premium penalty for enrollment after (1% per month premium penalty for enrollment after 5/15/06) 5/15/06)

• • Non-dual eligible must take action to enroll… many Non-dual eligible must take action to enroll… many choices between available Part D plans and plan choices between available Part D plans and plan designs designs

• • Some low income will qualify for extra assistance Some low income will qualify for extra assistance


Non-Dual eligible (Medicare Only)Non-Dual eligible (Medicare Only)• • Monthly premiums Monthly premiums

• • Deductible Deductible

• • Co-payments Co-payments

•• Can only switch plans once a year into Can only switch plans once a year into another available Part D plananother available Part D plan


Ability to Change PlansAbility to Change Plans • Non-dual-eligibles will have the opportunity to change Non-dual-eligibles will have the opportunity to change

between plans only once a year. between plans only once a year. • Dual-eligibles will have the opportunity to change Dual-eligibles will have the opportunity to change

between plans once a month, starting in November between plans once a month, starting in November 2005. 2005.


Standard Benefit Standard Benefit

• Monthly premiums from participants will be paid Monthly premiums from participants will be paid for most plans for most plans

- (Average premium is around $32.30 per month) - (Average premium is around $32.30 per month) • • $250 beneficiary deductible $250 beneficiary deductible • • For non-dual eligibles, Medicare will pay 75% ofFor non-dual eligibles, Medicare will pay 75% of drug costs up to $2,250. The beneficiary will paydrug costs up to $2,250. The beneficiary will pay 25% of these costs25% of these costs

• • Beneficiary will pay 100% of drug costs betweenBeneficiary will pay 100% of drug costs between $2,250 and $5,100 $2,250 and $5,100 • • After $3,600 in out-of-pocket spending, MedicareAfter $3,600 in out-of-pocket spending, Medicare will pay approximately 95% will pay approximately 95%


Drug Drug CostsCosts

Patient Patient PaysPays

Payment Payment up toup to

Cumulative Cumulative paymentpayment

Up to $250Up to $250 100%100% $250$250 $250$250

$250 - $250 - $2,250$2,250

25%25% $500$500 $750$750

$2,251 - $2,251 - $5100$5100

100%100% $2,850$2,850 $3,600$3,600

More than More than $5,100$5,100

5%5% $3,600$3,600 $36,00 plus 5% $36,00 plus 5% of additional of additional costscosts


82% Government

Contribution

13% PDP

5% co- ins

100% Enrollee Payment

“Coverage Gap”

75% PDP Contribution

($1,500 total)

25% co-ins

$250 Enrollee Deductible

Total Drug Expenditures

$5,100+

$2,250

$250

$0

$3,600+

$750

$250

$0

Beneficiary Out of Pocket Expenditures

Beneficiary Out of Pocket Expenditures

Medicare Part D OverviewMedicare Part D Overview Standard BenefitStandard Benefit

(dual eligibles & non-dual eligibles co-payments)(dual eligibles & non-dual eligibles co-payments)

Income TestIncome Test Asset TestAsset Test Premium/Premium/DeductibleDeductible

Co-paymentCo-payment

Under 100% of Under 100% of Federal Poverty Federal Poverty

Level (FPL)Level (FPL)

$6,000 individual $6,000 individual $9,000 couple$9,000 couple

$0/$0$0/$0 $1 generic/ $3 $1 generic/ $3 brand to Gap $0 brand to Gap $0

after Gapafter Gap

100% - 135% of 100% - 135% of FPLFPL


$0/$0$0/$0 $2 generic/ $5 $2 generic/ $5 brand to Gap $0 brand to Gap $0

after Gapafter Gap

135% - 150% of 135% - 150% of FPLFPL


Sliding scale Sliding scale premium/$50premium/$50

15% of Part D 15% of Part D costs from $50 -costs from $50 -

$3,600/$2 for $3,600/$2 for generic/ $5 brand generic/ $5 brand

after Gapafter Gap

Medicare Part DMedicare Part D

Beneficiary Enrollment Beneficiary Enrollment

Medicare Part DMedicare Part DGeneral EnrollmentGeneral Enrollment

• • Medicare Part D is an insurance product Medicare Part D is an insurance product

• • Pharmacists and pharmacy staff members Pharmacists and pharmacy staff members may not may not enrollenroll participants in any plan but participants in any plan but may offer information and advice may offer information and advice

toto participants participants • • In pharmacies choosing to endorse a particular plan, there mightIn pharmacies choosing to endorse a particular plan, there might be opportunities for insurance brokers to enroll participants withinbe opportunities for insurance brokers to enroll participants within their pharmacies or clinics. their pharmacies or clinics. • • Endorsement also requires agreement to promote the plan,Endorsement also requires agreement to promote the plan, provide enrollment information, explain the benefits of enrollment,provide enrollment information, explain the benefits of enrollment, describe the rules that apply to enrollees, explain how servicesdescribe the rules that apply to enrollees, explain how services are covered, communicate with individuals on operational policies,are covered, communicate with individuals on operational policies, rules and procedures, provide marketing and informationalrules and procedures, provide marketing and informational materials to participantsmaterials to participants

Medicare Part DMedicare Part DGeneral EnrollmentGeneral Enrollment

• • Voluntary enrollment Voluntary enrollment

• • Non-dual eligibles will have an opportunity to enroll in Non-dual eligibles will have an opportunity to enroll in one of a number of PDP or MA-PD Medicare Part D one of a number of PDP or MA-PD Medicare Part D plans in their area beginning November 15, 2006 plans in their area beginning November 15, 2006

• • Non-dual eligibles have financial penalties (1% per Non-dual eligibles have financial penalties (1% per month after May 15, 2005) for late enrollment month after May 15, 2005) for late enrollment

• • Non-dual eligible participants are only able to change Non-dual eligible participants are only able to change from the plan in which they participate, once a year from the plan in which they participate, once a year

• • Must consider the plan’s formulary coverage of the Must consider the plan’s formulary coverage of the medications they are taking, the deductible, the co-medications they are taking, the deductible, the co-payment structure, and the monthly premium before payment structure, and the monthly premium before selecting a plan in their area. selecting a plan in their area.

Medicare Part DMedicare Part DAuto-EnrollmentAuto-Enrollment

Limited to only the dual-eligibles Limited to only the dual-eligibles

Randomly assigned to selected prescription plans within Randomly assigned to selected prescription plans within their local areas their local areas

Plans selected to participate in auto-enrollment process Plans selected to participate in auto-enrollment process were at or less than benchmark in the Medicare Part D were at or less than benchmark in the Medicare Part D bid process bid process

May change plans monthly http://May change plans monthly http://www.medicare.govwww.medicare.gov or or http://http://www.id-health.comwww.id-health.com

Plan coverage begins January 1, 2006 Plan coverage begins January 1, 2006

Medicare Part DMedicare Part DPrescription Drug Plans (PDP)Prescription Drug Plans (PDP)

• • There are 10 approved nationwide PDPsThere are 10 approved nationwide PDPs• • Aetna Life Insurance Company Aetna Life Insurance Company

• • Connecticut General Life Insurance CompanyConnecticut General Life Insurance Company• • Coventry Health & Life Insurance/First Health Life & Health Coventry Health & Life Insurance/First Health Life & Health

Insurance/ Cambridge Life Insurance Insurance/ Cambridge Life Insurance • • Medco Containment Life Insurance CompanyMedco Containment Life Insurance Company• • MemberHealth, Inc MemberHealth, Inc • • Pacificare Life and Health Insurance CompanyPacificare Life and Health Insurance Company• • Silverscript Insurance Company Silverscript Insurance Company • • Wellpoint Wellpoint • • United Health Care Insurance Company United Health Care Insurance Company • • Wellcare Health Plans Wellcare Health Plans


There are hundreds of regional, state, and county PDP There are hundreds of regional, state, and county PDP and MA-PD plans in addition to thousands of employer and MA-PD plans in addition to thousands of employer sponsored equivalent plans sponsored equivalent plans

- - A list of the regional PDP and MA-PD plans designated toA list of the regional PDP and MA-PD plans designated to

receive auto-enrollees within each state is available on thereceive auto-enrollees within each state is available on the

on the http://on the http://www.tachc.orgwww.tachc.org web site. web site.


So some of the questions are:So some of the questions are:

““What if I don’t take any prescription drugs?”What if I don’t take any prescription drugs?”

““How do I chose a Medicare Part D plan that meets myHow do I chose a Medicare Part D plan that meets my

needs?”needs?”

““How do I enroll?”How do I enroll?”

““What happens to my Medicare-approved drug discountWhat happens to my Medicare-approved drug discount

card when I enroll and can I still use any credits left on thecard when I enroll and can I still use any credits left on the

card?”card?”


““What if I don’t take any prescription What if I don’t take any prescription drugs?”drugs?”

Even if you don’t use any or a lot of prescription drugsEven if you don’t use any or a lot of prescription drugs

now, you should still consider joining a Medicarenow, you should still consider joining a Medicare

prescription drug plan. As we age, most people needprescription drug plan. As we age, most people need

prescription drugs to stay healthy. For most people,prescription drugs to stay healthy. For most people,

joining as soon as possible means you will pay the lowestjoining as soon as possible means you will pay the lowest

monthly premium. monthly premium.


““How do I chose a Medicare Part D plan that How do I chose a Medicare Part D plan that meets my needs?”meets my needs?”

This is not an easy question to answer, because it involvesThis is not an easy question to answer, because it involves

determining the plans available, what medications theirdetermining the plans available, what medications their

plans have on the formulary, costs, what pharmacyplans have on the formulary, costs, what pharmacy

contracts with them, etc.contracts with them, etc.

Later we will look at a website http://www.Later we will look at a website http://www.MyMedicareMattersMyMedicareMatters and and

show you how to select a plan.show you how to select a plan.


““How do I enroll?”How do I enroll?”

Paper applications through the drug planPaper applications through the drug plan

On the Plan’s web siteOn the Plan’s web site

http://www.medicare.govhttp://www.medicare.gov

1-800-MEDICARE (1-800-633-4227) TTY 1-800-486-1-800-MEDICARE (1-800-633-4227) TTY 1-800-486-20482048


““What happens to my Medicare-approved drugWhat happens to my Medicare-approved drug

discount card when I enroll and can I still usediscount card when I enroll and can I still use

any credits left on the card?”any credits left on the card?”

You can use your Medicare-approved drug discount cardYou can use your Medicare-approved drug discount card

until May 15, 2006 or until you join a Medicare Prescriptionuntil May 15, 2006 or until you join a Medicare Prescription

Drug Plan, whichever is first. Drug Plan, whichever is first.


For Additional Details and Information on Medicare, For Additional Details and Information on Medicare, please refer to the following web sites: please refer to the following web sites:

• Centers for Medicare and Medicaid (CMS) website: Centers for Medicare and Medicaid (CMS) website: http://www.cms.hhs.govhttp://www.cms.hhs.gov OR OR http://www.cms.govhttp://www.cms.gov

• Official US Government Medicare website Official US Government Medicare website http://www.medicare.govhttp://www.medicare.gov

• NACDS website: NACDS website: http://www.nacds.org/wmspage.cfm?http://www.nacds.org/wmspage.cfm?parm1=3899parm1=3899

• Kaiser foundation website on Medicare: Kaiser foundation website on Medicare: http://www.kff.org/medicare/index.cfmhttp://www.kff.org/medicare/index.cfm

• US Department of Health and Human Services website US Department of Health and Human Services website http://www.dhhs.gov/http://www.dhhs.gov/

• Office of Pharmacy Affairs: Office of Pharmacy Affairs: http://www.hrta.gov.opa/ http://www.hrta.gov.opa/


Most helpful web site:Most helpful web site:

MyMedicareMattersMyMedicareMatters

http://mymedicarematters.org/http://mymedicarematters.org/

http://mymedicarematters.org/ZipFinder/http://mymedicarematters.org/ZipFinder/


RememberRemember

Medicare Part D Medicare Part D

Pharmacy benefit coverage Pharmacy benefit coverage

begins in all states on begins in all states on

January 1, 2006 January 1, 2006


““Questions?”Questions?”

Documents

MEDICARE PART D Are We Ready? Are We Ready?. Medicare Part D Overview Medicare Part A and B covers individuals Age 65 and older Age 65 and older Those