Access Denied The Medicare Part D Benzodiazepine Challenge and Maines Coverage Solution.

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Access Denied?The Medicare Part D Benzodiazepine
Challenge and Maines Coverage Solution.

• Stacie Sparkman
• Medicare Prescription Drug Specialist
• Eastern Agency on Aging

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Medicare Prescription Drug, Improvement and
Modernization Act of 2003

• Signed into law December 8, 2003.
• Implemented outpatient prescription drug coverage
  for seniors and the disabled population.
• Is a voluntary program. If a person has state
  Medicaid and wants to continue to receive
  prescription assistance, they must be enrolled
  into a Part D plan.

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Medication Coverage

• Prescription Drug Plan (PDP) formularies must
  include drugs within each therapeutic category
  and class of covered Part D drugs, though not
  necessarily all the drugs in each category or
  class.
• The legislation excludes from coverage the
  following drugs or classes of drugs, or their
  medical uses

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Excluded Medications

• Agents when used for anorexia, weight loss, or
  weight gain
• Agents when used to promote fertility
• Agents used for cosmetic purposes or hair growth
• Agents when used for the symptomatic relief of
  cough and colds
• Prescription vitamins and mineral products,
  except prenatal vitamins and fluoride
  preparations
• Non-prescription drugs
• Outpatient drugs for which the manufacturer seeks
  to require associated tests or monitoring
  services be purchased exclusively from the
  manufacturer or its designee as a condition of
  sale
• Barbiturates
• Benzodiazepines

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All of the classes of excluded medications have
the potential to impact medical care in the
elderly or disabled population. Continuity of
care issues could include the use of

• Benzodiazepines, widely used for management of
  acute anxiety, panic attacks, seizure disorders,
  and muscle spasms in those with cerebral palsy or
  other disorders like Ativan, Xanax and Valium.
• Over-the-counter medications, including agents
  for pain, constipation, and other common
  conditions.
• Medications used to treat weight loss, such as in
  those persons who lose weight due to cancer or
  AIDS.
• Barbiturates like Phenobarbital, which is widely
  used in the elderly for treatment of seizures.

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Maines Coverage Solution

• The Centers for Medicare and Medicaid Services
  authorized states to provide coverage of and
  receive federal matching funds for-medications
  the Medicare Modernization Act excludes.1
• Before Medicare Part D started on 1/1/06, the
  State of Maine made the decision to continue
  coverage of excluded medications already on the
  states preferred drug list. This coverage
  included members who received prescription
  assistance under state Medicaid and the Low Cost
  Drug Program.
• 1 Policy Guidance Regarding Medicaid Coverage of
  Prescription Drugs Excluded from the New Medicare
  Prescription Drug Benefit, http//www.cms.hhs.gov/
  letters/smd060305.pdf

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Low Income Subsidy

• The Medicare Modernization Act gave three groups
  automatic Low Income Subsidy.
• Individuals with State Medicaid.
• Individuals with Supplemental Security Income.
• Individuals with their states Medicare Savings
  Program.

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Medicare Savings Program

• Pays for the Medicare Part B Premium-93.50 in
  2007 and 96.40 in 2008
• Enrollment into the MSP will deem a person
  eligible for full Low Income Subsidies for Part D
  which includes
• Payment of the part D premium for approved plans
• Payment of the deductible
• Small co-pays of between 1 and 5.35
• No Coverage Gap
• Catastrophic Coverage

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Medicare Savings Program

• Each state sets the income and asset levels for
  the MSP.
• The state of Maine did away with the asset test
  on 1/1/06 and raised the income limit to 185 of
  the federal poverty limit on 4/1/07.
• The Department of Health and Human Services
  determines eligibility and countable income.
  There are some instances where individuals or
  couples may be eligible for the MSP even if their
  income is higher than 185 of the federal poverty
  limit.
• Maine also provides a wrap benefit through the
  states Low Cost Drug program. This program
  continues to provide coverage for excluded
  medications listed on the states preferred drug
  list. This benefit helps those transitioning,
  from the Low Cost Drug Program and Mainecare into
  Medicare and Medicare Part D, continue to receive
  their medications without interruption.

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Direct Savings

• Since Medicare Part D started in 2006 Maine has
  covered benzodiazepine and barbiturate
  prescriptions.
• The estimated total savings for the consumer is
• We will never know the total cost of savings
  related to hospitalizations and mass confusion,
  but we know it is priceless.

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Resources

• Legal Services for the Elderly, Inc. Part D
  Appeals Unit 1-877-774-7772
• Maine Area Agencies on Aging/State Health
  Insurance Assistance Program (SHIP)
• 1-877-353-3771
• Maine Department of Health and Human Services
  Regional Offices
• Maine Office of Elder Services 1-800-262-2232
• TTY 1-800-606-0215
• Maine Pharmacy Helpdesk 1-866-796-2463
• Medicare 1-800-Medicare or 1-800-633-4227
• TTY 1-877-486-2048
• Social Security Office 1-800-772-1213
• TTY 1-800-325-0778