Prescription Drug Improvement and Modernization Act

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Prescription Drug Improvement and Modernization
Act

• Dorothy Della Sherwood, M.D.
• Presbyterian Hospital of Dallas
• 2/22/2006

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• This year, Medicare introduced the prescription
  drug benefit-the most significant change in
  Medicare coverage since the programs
  inceptionwhich will help patients and doctors
  work together to alleviate symptoms and reduce
  the rate of complications from serious illness.
• Mark B. McClellan, M.D., PhD., NEJM 12/05

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• Americas older citizens have been barraged with
  educational and marketing initiatives for various
  drug plans.an October poll indicated that 61
  did not understand the program and 54 did not
  intend to sign up.
• Richard L. Kravitz, M.D. NEJM 12/05 UC Davis

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• CMS Goal for the Drug Benefit
• 1. Ensure all beneficiaries have access to
  high-quality, affordable drug coverage
• 2. Provide continuous access to drugs needed by
  the chronically ill
• 3. Create a competitive, transparent marketplace

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• Competitive/Transparent
• Medicare Prescription Drug Plans ( MPDP)
  negotiate with drug companies to purchase drugs
  at a discounted price which they pass on to the
  beneficiary.
• CMS is counting on this competition to hold down
  prescription prices

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• When choosing a PDP, one should compare
• Deductible
• Monthly Premium
• Co-pay for Rx
• Formulary
• Gap Coverage
• Mail-in or local pharmacy

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• The minimum prescription-drug benefit required by
  Medicare
• No more than 250.00 deductible
• A monthly premium ( average of 37.00/mo)
• Pay 25 of the next 2000.00 in costs (500.00)
• Pay 100 of the next 2,850.00 the gap
• Total out of pocket costs could reach
  3,600.00/yr
• Catastrophic coverage begins and beneficiary pays
  only 5

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• Competition has resulted in better coverage than
  those that have been mandated.
• WWW.CMS.GOV

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• Help for People with Limited Incomes
• People with lowest income and resources
• Pay no premiums or deductibles
• Have small or no co-payments
• Eligibility
• lt1,197 per month for an individual with lt11,500
  in assets (excluding house)
• lt1,604 per month for a couple with lt23,000 in
  assets (excluding house)

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• How to apply for extra help.
• SSA mailed applications to those who may be
  eligible
• www.ssa.gov
• All dual eligible ( Medicare and Medicaid) are
  automatically enrolled

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• What about Medigap?
• Information was sent to people with Medigap
  giving them the following choices
• Keep Medigap
• Join Medicare Prescription Drug Plan and delete
  drug coverage from Medigap
• Drop Medigap and join Medicare Advantage

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• What about Employer/Union Coverage?
• Choices include
• Keep coverage offered by employer/union
• Join MPDP
• Join Medicare Advantage Plan
• Advise to contact Employers/Union
• There is a tax free subsidy provided by Medicare
  to the Employers who offer coverage
• Employers may contract with a MPDP to provide
  coverage

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• Specific Drug Coverage mandated by MMA
• Cancer medications
• HIV/AIDS treatments
• Antidepresssants
• Antipsychotics
• Anticonvulsants
• Immunosuppressants

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• Excluded Drugs
• Weight Loss Drugs
• Fertility Drugs
• Cosmetic hair growth products
• Cough suppressants
• Benzodiazepines
• Barbituates
• Vitamins
• Non-prescription drugs

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• Formularies
• Most MPDP have formularies
• All formularies must include at least 2 drugs
  from every category of drug
• The formulary must be approved by CMS
• Tier 1 drugs have the lowest cost sharing
• There must be an exception procedure for tiered
  formularies to obtain a drug at a more
  favorable cost or obtain a drug not on formulary

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• PDP Formulary Available at
• www.epocrates.com
• http//formularyfinder.medicare.gov/formularyfi
  nder/selectstate.asp

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• Perils
• Exception Request
• Patient is unable to take a statin due to
  myopathy and therefore requires Zetia
• PDP considers Zetia a Step Drug after
  maximizing statin
• The enrollee can request an exception to the
  plans step-therapy requirement

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• Process
• PDP pharmacy initiates with fax entitled Request
  for Prescription Information or Change
• Physician initiates request to the PDP with a
  Request for Prescription Exception
• Exceptions should be reviewed in 24 hours if the
  need is immediate

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• Plan Contacts for appeal
• www.cms.hhs.gov/PrescriptionDrugCovGenIn
• There are 5 levels of appeal and it may indeed
  end up in the Federal Courts!
• Redetermination by plan
• Reconsideration by a Medicare drug coverage QIC
• Administrative Law judge
• Medicare Appeals Council
• Federal District Court

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• Why should the Medicare beneficiary enroll now?
• Late enrollment results in a 1 increase in
  premium per month for every month the person was
  eligible but did not join.
• This penalty will be paid forever!
• This penalty does not apply to individuals with
  prescription drug coverage that equals the
  Medicare coverage

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• Individual Choice
• Last date for enrollment is May 15th, 2006
• All Medicaid beneficiaries were automatically
  enrolled by Jan 1st if they had not chosen a plan.

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• So what will this cost? BILLIONS over the next
  8 years.
• Payments to MPDP 448 to 479
• Low Income Subsides 192 to 239
• 35 of the Medicare Population
• Spending on health care is expected to increase
  from 1.8 trillion dollars in 2003
• to 3.6 trillion dollars in 2014

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• Web sites for your patients
• www.medicare.gov
• www.cms.hhs.gov
• www.ssa.gov
• Phone
• 1-800-MEDICARE (800-633-4227)
• SS 1-800-772-1213