Medicare Drug Benefit: IFAS Outreach

1
Part D INSERVICE PART 1

• Medicare Drug BenefitIFAS Outreach
• Traci Brooks, Senior Pharmacy Student
• University of Florida College of Pharmacy
• Carolyn S. Wilken, PhD, M.P.H
• Associate Professor Family Science
• University of Florida
• David M. Angaran MS, FASHP, FCCP
• Clinical Professor of Pharmacy
• University of Florida College of Pharmacy
• IFAS Program AEP 2006

2
Objectives Part I

• Prepare the IFAS agent for training and
  supporting volunteer Medicare Part D consultants
• Review Medicare Drug Benefit
• Describe the IFAS-Medicare Part D consultation
  process
• Explain the data collection and patient report
  instruments.
• Demonstrate navigating www.medicare.gov
• Part II - Practice

3
History of Medicare

• Medicare 1965
• Part A hospitalization
• Part B Physician visits and some drugs
• Part C (Old HMOs)
• Medicare Drug Benefit 2003
• Medicare Modernization Act
• Medicare Prescription Drug, Improvement and
  Modernization Act of 2003 (Pub l. 108-173)
• Medicare Part D

4
Why Sign UP?

• Save Money NOW
• Save Money LATER
• Insurance for the future
• Penalty if you dont
• 1 per month after May 15, 2006
• 5 yrs. 60 40.00 becomes 64.00
• Not everyone Low Income Subsidy

5
Medicare Prescription Drug Providers

• Prescription Drug Plan (PDP)
• Drugs only
• Medicare Health Plans Medical care drugs
• Medicare Advantage MA-PD
• HMOs Medicare Health Maintenance Organizations
• PPO Preferred Provider Organization
• PFFS Private Fee for Service
• SNP Special needs plan

6
Standard (Minimum) Government Benefit 2007
7
Prescription Drug PlansPrivate Companies

• Must offer at least standard benefit
• Can offer more benefit
• United Health Care/AARP Generic Benzodiazepines
  eg. alprazolam
• PDPs state wide
• MA-PDs
• County Specific
• Paid by Part B premiums /-health premiums and/or
  drug premiums

8
Florida PDPs2006 and 2007

• For 2007
• - Lost 3 companies - 12 PDPs increased their
  premiums
• - Gained 8 companies on average 6.48
• - Lost 11 PDPs - 20 PDPs decreased their
  premiums
• - Gained 25 NEW PDPs on average 8.67

9
What they Chose for 2006Lewin Group Beneficiary
choices in Medicare Part D and Plan Features in
2006 Sept 2006

• Lower premiums
• 88 NO Gap coverage
• Is it 3 million or 7 million in the Doughnut
  hole?
• Reduced or zero deductibles
• Broader Formularies
• 2,009 drugs vs. 1,161 average
• Avoided prior auth and step care
• PA 6.0 vs. 8.0
• Step care 1.6 vs. 2.0
• Lower tier 1 but higher tier 3

• Florida - 789,100      
• United Healthcare 34   
• Humana 18   
• WellCare 9   
• PacifiCare 8   
• Unicare 7   
• AmeriHealth 6   
• Blue Cross 5   
• AdvantraRx 4   
• CCRx 2   
• United American 2  
• www.cms.hhs.gov/PrescriptionDrugCovGenIn/02_Enroll
  mentData.asp 090906

10
Humanas PDP 2006
11
Humana PDPs 2007
12
Medicare AudienceBorn 1906 to 194123
Cognitively impaired 70 health literate

• 42.6 million Medicare beneficiaries
• CBO estimates 29 million to enroll in Medicare
  Part D
• 13.6 million will not participate because of
  other coverage
• Florida Medicare
• 3,135,438 
• www.cms.hhs.gov/medicarereform/stateinfo/

• June 2006 enrollment
• In 22.5 million
• 17.0 PDPs
• 5.5 MA PDs
• Not 4-5 million
• 3.3 million Low income subsidy
• FL 677,064 
• www.statehealthfacts.org accessed 091606

13
A Sense of Relief KRC Research Apr 06
4 out of 5 seniors who have enrolled in a
stand-alone Medicare Rx plan said they are
satisfiedwith majorities feeling theyre better
off than they were before and majorities saving
money
Overall, how satisfied are you with your
prescription drug coverage?

• 77 feel peace of mind
• 74 feel relief
• 67 feel better off now than before
• 59 lowered costs on medicines
• 20 no longer need to skip or reduce their
  medications

78
14
Choosing Total Cost and Coverage

• Is your drug covered
• Drug Cost
• Co pay and Co-insurance
• Tier
• Category
• Monthly premium
• Yearly deductible
• Doughnut hole coverage
• Mail Service
• Network pharmacy

15
Definitions

• Co-Pay
• Fixed amount you pay for each prescription.
  Difference between generic and brand.
• Co-Insurance
• Percentage of the actual sale price.
• 25 of 100 25.00
• 25 of 200 50.00
• Change with price increases

16
New concepts for cash paying customers

• Quantity limits
• How much of a drug you can receive at one time.
• Step Care
• Oldest cheapest before newest more expensive
• Prior Authorization
• Must meet certain criteria before prescribing
• Similar
• Different drug same results
• Lower cost
• Appeals, Exceptions, Determinations and
  Reconsiderations
• Make it work

17
Drug Benefit Paper Work

• TrOOP True out of pocket cost
• Monthly report of
• Out of their pocket spending
• Total Drug Cost
• List of all drugs being paid for and by whom
• Annual Notice of Change
• Yearly, in October
• Changes in
• Formulary
• Plan
• Premiums
• NOT person specific

18
Excluded Drugs Pay usual retail costs

• Do NOT count toward TrOOP
• Examples of these drugs are
• Benzodiapzepines Valium, diazepam, Xanax
• Anorexia, weight loss, or weight gain drugs
• Fertility drugs
• Drugs for cosmetic purposes or hair growth
• Symptomatic relief of cough and colds
• All Over-the-Counter (OTC) medications

19
7 Medication Regimen Tested

• AVANDIA 4 MG TABLET
• CELEBREX 200 MG CAPSULE
• CELEXA 40 MG TABLET
• COZAAR 50 MG TABLET
• GLUCOPHAGE XR 500 MG TAB SA
• NEXIUM 40 MG CAPSULE
• PLAVIX 75 MG TABLET

• Costs cvs.com accessed 022706
• Retail, 30 day supply, for one year.
• 8,210.00 -7,200
• Tested as
• PDP only
• No low income benefit
• Any pharmacy
• Any company
• Florida

20
7 Drug Retail Annual Cost Out of your
Pocketcopay premium deductible 2006

• Brand
• 1 Humana 3,755
• 61.70/month
• 2 Humana 3,844.
• 10.35/month
• 3 Humana 3,972
• 20.12/month

• Generic/Similar
• 1 Humana 2,432
• 2 AdvantraRx 3,414
• 3 MedicareRx 3,572
• 8 Humana (10.35/mo)
• 18 Humana (20.12/mo)

21
Extra Help Social Security

• Social Security Administration (SSA)
• Single Less than 14,700/Year
• Couple Less than 19,800/Year
• Assets test
• Reduce or eliminate
• Co pay or Coinsurance
• Premium
• Deductible
• Doughnut hole
• Social Security
• www.ssa.gov/prescriptionhelp
• 1-800-772-1213

22
Low-Income Benefits Under Part D for this
enrolment period.adapted form APhA monograph
Overview of Pharmacy issues
23
2006 HHS Poverty Guidelines
SOURCE  Federal Register, Vol. 71, No. 15,
January 24, 2006, pp. 3848-3849
24
Signing UP

• Annual Enrollment Period for PDPs MA-PDs.
• Once a year Nov 15 to Dec 31st.
• Turned 65. 7 months (3 before, 1 birthday, 3
  after)
• There are OTHER enrollment opportunities (see
  Medicare and You 2007)
• On Medicare and Medicaid No option
• All Medicare recipients A, B, Disability
• Dont Sign UP and No Penalty
• Employer retirement
• VA coverage
• Credible Coverage Letter

25
Enrollment Questions

• Switching Plans
• Just enroll (in theory) quote Medicare
• You dont have to notify FORMER plan
• Any other enrolment question
• Medicare and You 2007 on line