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Medicare TodayMore Choices, Better Benefits


Medicare prescription drug coverage may help protect against high out-of-pocket costs ... Sources of Help Paying for Prescription Drugs. State Pharmaceutical ... – PowerPoint PPT presentation

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Title: Medicare TodayMore Choices, Better Benefits

Medicare TodayMore Choices, Better Benefits
Instructors Name Event Date
244375 9/06
  • Medicares Covered Preventive Care Services
  • Basics of Medicare Prescription Drug Coverage
  • Picking and Switching Medicare Plans
  • How to Get Extra Help with Costs
  • What Drugs Do Medicare Plans Cover? All About
  • What Is the Donut Hole?
  • Important Dates for Medicare

Medicares Covered Preventive Care Services
Medicare Has More to Offer
  • Preventive services
  • Prescription drug plan coverage
  • New Medicare Health Plan options
  • Extra help for those who need it most

Benefits and Options
  • Increased coverage of preventive services in 2005
  • Outpatient prescription drug coverage available
    January 1, 2006
  • Offered new Medicare Health Plan options in 2006

Covered Preventive Services
  • Designed to help you stay healthy
  • Began January 2005
  • Welcome to Medicare physical exam
  • Cardiovascular screening blood tests
  • Diabetes screening tests

Initial Preventive Physical Examination (IPPE)
  • Welcome to Medicare Physical
  • Who is eligible?
  • All Medicare beneficiaries whose Part B coverage
    began on or after January 1, 2005
  • When?
  • Once during the first 6 months of Part B coverage
  • Cost to beneficiary?
  • Part B deductible and copayment/coinsurance

Cardiovascular Disease Screening
  • Who is eligible?
  • All asymptomatic Medicare beneficiaries
  • When?
  • Every 5 years
  • Cost to beneficiary?
  • No deductible, no co-payment, no coinsurance

Elements of Cardiovascular Screening
  • Total Cholesterol
  • HDL
  • Triglycerides
  • Provides opportunity assess and discuss
    cardiovascular risk factors, such as
  • Family history - Smoking
  • Diet - Stress
  • Obesity - Diabetes

Diabetes Screening
  • Who?
  • Beneficiaries diagnosed with pre-diabetes and
    at-risk non-diabetic beneficiaries
  • When?
  • 2 tests per year for pre-diabetic beneficiaries
  • 1 test per year for undiagnosed, non-diabetic
  • Cost to beneficiary?
  • No deductible, no copay/coinsurance

Diabetes Self-Management Training (DSMT)
  • Who is eligible?
  • Beneficiaries recently diagnosed with diabetes or
    at risk for complications from diabetes or who
    were diagnosed with diabetes before becoming
    Medicare eligible
  • When?
  • A plan of care must be written to include number
    of sessions, frequency, and duration (up to 10
    hours for initial training, up to 2 hours per
    year thereafter)
  • Cost to beneficiary?
  • Part B deductible, copayment/coinsurance

Other Covered Screening Tests
  • Breast cancer
  • Colorectal cancer
  • Prostate cancer
  • Cervical vaginal cancer
  • Bone Density
  • Glaucoma

Covered Vaccinations
  • Influenza
  • Pneumococcal
  • Hepatitis B

Smoking Cessation Counseling
  • If diagnosed with a smoking related illness
  • Inpatient or Outpatient Counseling
  • Up to 8 face-to-face counseling sessions per 12
    month period

Basics of Medicare Prescription Drug Coverage
Medicare Prescription Drug Coverage Why Should
You Get It?
  • If you are going to join its important to join a
    plan when you are first eligible
  • Many people with Medicare need or likely will
    need prescription drugs to stay healthy
  • Medicare prescription drug coverage may help
    protect against high out-of-pocket costs
  • Enrolling when first eligible may mean that you
    pay a lower premium

Types of Medicare Prescription Drug Plans
  • There are two types of plans available
  • Prescription Drug Plans (PDPs)
  • Provide prescription drug coverage only
  • Medicare Advantage - Prescription Drug Plans
  • Formerly known as MedicareChoice
  • Provide Medicare Parts A B medical and hospital
    care and prescription drug coverage under the
    same plan

What Drugs Are Covered?
  • Medicare drug plans will cover most outpatient
    prescription drugs (and biologics)
  • The drug (or biologic) must be
  • Available by prescription only
  • Approved by the FDA
  • Drugs in clinical development will not be covered
  • Some vaccines, insulin and medical supplies used
    to inject insulin are also covered
  • Part B covers diabetes supplies. Part B does not

Pharmacies Under Part D
  • Part D plans must provide pharmacy options
  • Network of retail pharmacies
  • Long-term care pharmacies
  • Home infusion providers
  • Mail order pharmacies are permitted
  • 90-day supplies are available through retail and
    mail options

How to Sign Up for a Medicare Prescription Drug
  • There are several ways to enroll
  • Call the plan directly
  • Visit the plans website
  • Call 1-800-Medicare
  • Visit

Enrollment for Those Who Need Help Paying for a
  • People who have both Medicare and Medicaid
    coverage (dual eligibles) are automatically
    enrolled into a Medicare drug plan by CMS
  • They are notified of their enrollment
  • They can switch plans monthly if they are not
    satisfied or cannot get the medicines they need
  • Others with limited resources must apply for
    extra help to determine eligibility

Picking or Switching Medicare Prescription Drug
Decide What Kind of Plan You Want
  • Medicare Advantage with Prescription Drugs
  • New name for MedicareChoice plans
  • Medicare Managed Care Plans covering medical and
    hospital care and prescription drugs
  • Includes Medicare HMOs, Preferred Provider
    Organization Plans (PPOs)
  • Prescription Drug Plan (PDP)
  • Only covers drugs
  • Can be coupled with traditional Medicare Program

If you join a Medicare Advantage Plan
  • You are still in the Medicare program
  • You have all your Medicare rights and protections
  • You will get all the basic Medicare coverage
  • You may get more benefits

Pointers for Picking a Medicare Prescription Drug
  • Most people will want to pick a plan with low
    yearly costs considering all associated costs
  • Monthly Premiums Copays/Coinsurance
  • Other things to consider
  • Use of a preferred pharmacy or mail order
  • Getting prescriptions during travel (e.g.,
  • Limits such as prior authorization, step therapy
    requirements, and quantity limits on the
    patients medications
  • Reputation of the plan

Steps for Picking a Plan
  • Go to and click on Find and
    Compare Plans. Follow the instructions to use
    the Prescription Drug Plan Finder
  • OR
  • Call 1-800-MEDICARE and ask the representative
    to enter your information in the Prescription
    Drug Plan Finder

Steps for Picking a Plan (continued)
  • Choose if you want to do a Personalized or a
    General Plan Search. You will also need to
    pick the type of plan you want
  • Prescription Drug Plan only (PDP)
  • Medicare Advantage Plan (MA-PD)
  • (List your medications and strengths when

Steps for Picking a Plan (continued)
  • The Prescription Drug Plan Finder will list all
    the plans in your area. You can check up to
    three plans at one time to compare plan
  • 4. Select 3 or 4 possible plans from the
    Prescription Drug Plan Finder

Steps for Picking a Plan (continued)
  • 5. Contact each plan to get more information
  • How is the plans Customer Service? Are they
    quick to answer your call? Helpful in answering
    your questions? Courteous?
  • Are there restrictions on your medications, such
    as prior authorization requirements?
  • Can you get your drugs if you travel part of the
  • Is mail order available if you want it?

Steps for Picking a Plan (continued)
  • Decide on the right plan you want and sign up
    using the options below
  • Call the plan directly
  • Call 1-800-MEDICARE
  • Visit the web site of the plan sponsor
  • Visit
  • Submit a paper form provided by the plan sponsor

Comparing Plans
  • Why do some plans cost more than others?
  • Every plan is different and has different
    benefits that may increase its costs compared to
    other plans
  • For example, depending on the medications you
    take, some plans may be more expensive because
    your medicines are not on their preferred drug
  • Other plans may offer additional services
  • Paying more doesnt mean its a better plan!
  • You should find the plan that best fits your needs

Evaluating Your Current Plan
  • Open enrollment is a time to do a satisfaction
    check of your current plan
  • Ask yourself the following questions
  • Are the medicines my doctor prescribed on the
    plans formulary (drug list)?
  • If I hit the coverage gap (donut hole), am I
    still able to afford my medicines, or should I
    look for a plan with better coverage options
    during the gap?
  • Would enrolling in a Medicare Advantage plan be a
    better option than a stand-alone Prescription
    Drug Plan where I can get both medical and
    pharmaceutical coverage?

Pros and Cons of Switching to a Different Plan
  • Pros
  • You may
  • Save money if you pick a lower cost plan
  • Be more satisfied if you pick a plan that covers
    all your medications
  • Cons
  • It may require research and time to pick a new
  • You may have concerns about the new plan that are
    unknown at the time of enrollment

How to Get Extra Help with Medicare Part D Costs
Help for Those Who Need it Most
  • Those with the lowest incomes pay no premiums or
    deductibles and have small or no copayments
  • Those with slightly higher incomes pay a little
  • You may qualify if your annual income is less
    than 150 of the Federal Poverty Level and you
  • Single and annual income less than 14,700
  • Married and annual income less than 19,800
  • Some people will automatically qualify

Applying for Extra Help
  • Apply for Low Income Subsidy (LIS) through the
    Social Security Administration (SSA)
  • Online at
  • Look up the local SSA in your phone book for the
    local telephone number
  • Apply through your State Medical Assistance Office

Other Sources of Help Paying for Prescription
  • State Pharmaceutical Assistance Programs
  • Certain states have programs for people who meet
    age and income requirements
  • Examples EPIC (New York), PAAD (New Jersey),
    PACE (Pennsylvania)
  • Pharmaceutical Manufacturer Programs
  • Check with the company that makes your medication
    to see if you qualify for their assistance
    program or online at
  • Charitable Organizations

What Drugs Do Medicare Plans Cover? Information
About Formularies
Plan Formulary
  • Medicare Drug Plans
  • Do not cover every drug
  • Generally have a list of drugs they cover, called
    a formulary
  • Must cover prescription drugs in all defined
    categories and classes
  • Must include more than one drug in each class
  • Includes brand and generic drugs
  • Certain drugs are excluded by law
  • For example, Medicare cannot pay for
    benzodiazepines, barbiturates, drugs for weight
    loss or gain, and drugs for relief of colds.

Plan Formulary
  • Using drugs on a plans list will save money
  • You will pay lower prices for drugs that are
    preferred by the plan
  • Choosing a covered generic drug instead of a
    brand-name medication may also save money
  • You should always check with your doctor before
    agreeing to have your medicines changed or to
    have your prescription filled with a generic

Plan Formulary
  • Plans manage drug use with the following
  • Prior authorization requiring plan approval
    before a Rx can be filled
  • Step therapy encouraging the use of generic or
    less expensive drugs first
  • Quantity limits
  • Processes are available to you that can help you
    get the medicines your doctor feels you need
  • Transition supply
  • Exceptions process
  • Appeals process

Plan Formulary
  • Plans must fill prescriptions that are not on the
    plans list
  • For new enrollees
  • For residents of Long-term Care (LTC) facilities
  • This will allow time for you and your doctor
  • To find another acceptable formulary drug
  • To request an exception so the plan will cover
    your drug, even if it is not on their formulary

Plan Formulary
  • Exception requests may be warranted if a
  • Patient has tried covered drugs and they dont
    work, or
  • Physician believes the patient requires a
    specific non-covered drug
  • If a request is approved, the plan will cover the

Exception Requests
  • Anyone can request an exception
  • Contact the drug plan and they will advise
  • How to submit a request
  • What information needs to be submitted
  • Physician must submit supporting documentation
  • Must demonstrate that requested drug is
    medically necessary
  • Plan must notify patient of its decision within
  • 72 hours for standard processing (after receiving
    physicians statement), or
  • 24 hours for expedited processing

Appeals Process
  • A person can appeal a Medicare drug plans
    unfavorable exception decision
  • First level appeal is to the plan
  • Expedited appeals take only a few days
  • An appointed representative may appeal
  • Generally, appeals must be made in writing
  • You should get information about the appeals
    process upon enrollment
  • You may have as many as 5 levels of appeal/review

What Is the Coverage Gap or Doughnut Hole?
What is the Coverage Gap or Doughnut Hole?
  • The coverage gap is that time when beneficiaries
    must pay 100 of their drug costs
  • Medicare is set up as a cost sharing benefit. In
    2007, beneficiaries will pay
  • A deductible (if applicable)
  • A monthly premium
  • A co-pay for each prescription drug
  • 25 of the first 2,400 of total drug spend
  • 100 of the next 3,051 of total drug spend
  • 5 of any additional drug spend beyond 5,451

2007 Drug Plan Cost Sharing
Out-of-pocket spending
Medicare Part D benefit
Catastrophic coverage
Medicare Part D benefit
100 Beneficiary Responsibility
3,051 Gap Donut hole
Actuarial Equivalence
Partial coverage up to limit
Medicare Part D benefit
Percent of Rx spend
Source Kaiser Family Foundation
What Can You Do About Costs in the Coverage Gap?
  • Apply for Medicares Low Income Subsidy (LIS) if
    you have not already done so
  • If your State has a Pharmaceutical Assistance
    Program (SPAP), apply for it
  • Check with the pharmaceutical companies that make
    your medications about whether they have a
    Patient Assistance Program to help you with costs
  • Talk with your pharmacist or doctor about
    applying to charitable organizations for
    medication assistance
  • Continue to use your Medicare Plans card when
    you pay for prescriptions - your payments will be
    counted toward the amount you must spend before
    catastrophic coverage begins

Important Dates for Medicare Services
Important Dates
New preventive services began
January 1 2005
Important Dates
Watch your mail for the Medicare You handbook,
which will have information about the plans in
your area
October/ November 2006
Important Dates
  • You can begin to compare Medicare prescription
    drug plans
  • 1-800-MEDICARE
  • Local SHIP office
  • Local community groups

October 2006
Important Dates
You can enroll in a Medicare prescription drug
plan, or change plans!
November 15 through December 31 each year
Important Dates
Medicare prescription drug coverage begins for
those who are enrolled
January 1
For More Information
  • Medicare You 2007 handbook
  • 1-800-MEDICARE (1-800-633-4227)
  • TTY users call 1-877-486-2048
  • (Spanish)
  • State Health Insurance Program (SHIP)
  • Community groups (Local Agency on Aging)
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