Medicare Prescription Drug Coverage

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Medicare Prescription Drug Coverage

• Tim Cutler, Pharm.D.
• Assistant Clinical Professor of Pharmacy, UCSF
• Marilyn Stebbins, Pharm.D.
• Clinical Professor of Pharmacy, UCSF
• Osher Lifelong Learning Institute Presentation
  11/12/05

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Goals for Today Part I

• Describe the basic Medicare Prescription Drug
  Benefit
• Understand your current prescription drug
  coverage
• Understand your new options for prescription drug
  coverage
• Know important dates to remember

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Goals for Today Part II

• Determine if you are eligible for extra help to
  pay for the costs of your drugs
• Know where to go to compare plans
• Know your resources

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Medicare- What is it?

• Medicare is available to
• 65 and older
• Permanently disabled
• Medicare has 4 parts
• A Hospital coverage
• B Outpatient coverage (doctor visits)
• C Medicare Advantage (A and B coverage
  
  and often D)
• D Prescription Drug Coverage

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What is Medicare Part C

• Medicare Advantage Plans are part of Medicare
• Medicare-covered health care provided by that
  plan
• Plans can include prescription drug coverage
• Most plans have extra benefits and lower
  copayments than traditional Medicare
• You may have to use the plans doctors and
  hospitals
• There may be an additional premium for these
  plans
• Includes Managed Care Plans (i.e. Medicare HMOs)

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What is Medicare Part D

• New Prescription Drug Benefit from Medicare
• Starts January 1, 2006
• Offers Brand and Generic coverage
• Voluntary, must choose to enroll
• Stand alone benefit that can be combined with
  Part A and B and/or Medicare Supplements

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What is Medicare Prescription Drug Coverage?

• Covers drugs available only by prescription
• Prescription drugs, biologicals, insulin
• Medical supplies associated with injection of
  insulin
• A prescription drug plan (PDP) or Medicare
  Medicare Advantage prescription drug (MA-PD)
  plan may not cover all drugs
• Brand name and generic drugs will be in
• each formulary

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Excluded Drugs

• Drugs for
• Anorexia, weight loss, or weight gain
• Fertility
• Cosmetic purposes or hair growth
• Symptomatic relief of cough and colds
• Prescription vitamins and mineral products
• Except prenatal vitamins and fluoride
  preparations
• Non-prescription drugs
• Barbiturates
• Benzodiazepines

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What is the Cost of Part D?

• For minimum standard coverage in 2006,
• enrollees would pay
• Monthly premium of about 25
• First 250 per year for prescriptions
• (deductible)
• Part of the cost of prescriptions after 250
• 5 of the drug costs (or small copayment)
• after paying 3,600 out-of-pocket
• Cost 550 per year in deductible and premiums
  not including coinsurance

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Basic Benefit PackageEffective 2006

• 300 annual premium
• Patient pays 5 of drug costs
• Patient pays 100 of drug costs
• Patient pays 25 of drug costs
• 250 deductible

2,850 Gap (donut hole)
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The Penalty

• Assessed if no enrollment by May 15, 2006
• 1 per month of missed enrollment
• 5 for 2006, 12/year for all other years
• Penalty is based on the average premium (32
  nationally)
• 0.32 per month added to your premium
• No penalty for those with coverage equivalent to
  Medicare through the following
• VA or TRICARE
• Employer benefit or Union

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What Coverage Do You Currently Have?

• Traditional Medicare (Part A and B)
• Medicare Supplemental Insurance (Medigap)
• Retiree insurance coverage from a current or
  former employer or union
• Medicare Advantage (Secure Horizons, Health Net
  Seniority Plus, WHA Care Plus, Kaiser)
• Medicare and Medi-Cal
• Tricare and VA benefits

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I Have

• Original Medicare only or original Medicare and a
  Medigap supplement WITHOUT drug coverage
• I may choose to enroll in a Medicare
  Prescription Drug Plan
• And keep my original Medicare the way it is
• Or I may choose to join a Medicare Advantage
  Plan
• Covers doctor, hospital care, as well as
  prescriptions
• If I choose NOT to enroll by May 15, 2006
• I will pay a penalty when I do join

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I Have

• Original Medicare and a Medigap supplement WITH
  drug coverage
• I will receive a letter telling me whether my
  coverage is as good as Part D
• The new Medicare Prescription Drug Plan is likely
  to be better than your existing policy
• You can enroll in a Part D Prescription Drug Plan
  but you must tell your Medigap plan to remove the
  drug portion of your Medigap policy
• Or I may choose to join a Medicare Advantage Plan
• Covers doctor, hospital care, as well as
  prescriptions

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I Have

• Retiree benefits with drug coverage through my
  (or my spouses) former employer or union
• I will receive a letter from my former employer
  or union by November 15
• This letter will tell me whether my coverage is
  as good as Part D and what I need to do
• If you do not hear from them or have questions,
  call your benefits administrator
• Do not sign up for Part D IF your current
  coverage is equal to or better than your employer
  or union
• Some employers may not continue to offer a drug
  benefit or it may not be as good as Medicare
• If this is my situation, I may need to sign up
  with a Prescription Drug Plan to get medications
  covered

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I Have

• A Medicare Advantage Plan (Secure Horizons,
  Health Net Seniority Plus, WHA Care Plus, Kaiser)
• Many of these plans will provide more coverage
  than Part D and at a lower cost
• The current Medicare Advantage Plans in our area
  will now have brand and generic coverage
• If you are an existing member and want to stay
  with your current plan, look for information in
  the mail about the new changes to your benefit
  and how you can sign up
• If you would like to join a Medicare Advantage
  Plan you can request an information packet from
  the specific plan

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I Have

• Medicare and MediCal.
• Starting January 1, 2006, you will get your
  prescription coverage from Medicare instead of
  MediCal
• You will have no premium, no deductable and pay
  1 for generic and 3 for brand name medications
  (30-90 day supply)
• You will be notified of the plan to which you
  have been assigned by Medicare.
• If you like the plan chosen, you will be
  auto-enrolled on January 1, 2006
• You may choose to enroll in a different plan but
  must enroll by December 31, 2005

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I Have

• TRICARE or VA benefits
• As long as you still qualify, your TRICARE, VA,
  or FEHB prescription drug coverage is not
  changing
• Contact your benefit administrator before making
  any changes
• If you lose your TRICARE of VA benefit and enroll
  in a Medicare Prescription Drug Plan, you will
  not have to pay a penalty

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Buyer Beware

• Every Prescription Drug Plan and Medicare
  Advantage Plan may vary
• Monthly premiums
• Deductible
• Copayment/Coinsurance
• Generic versus Brand versus Injectable versus
  non-covered
• Coverage Gap Donut Hole
• Coverage in the Coverage Gap

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Important Dates

• October 2005
• Medicare You handbook mailed
• Community outreach
• Medicare website and 1-800-Medicare for plan
  comparisons
• November 15, 2005
• First day you can join a plan
• January 1, 2006
• Coverage begins for those who join by December
  31, 2005
• May 15, 2006
• Last day to join a plan offering prescription
  drug coverage for 2006

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Medicare Prescription Drug Coverage Timeline

• Join November 15 December 31, 2005
• Coverage begins January 1, 2006
• Join January 1 May 15, 2006
• Coverage begins the month after you join
• Join when first eligible, to pay lowest monthly
  premium
• About 25/month in 2006

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Goals for Today Part II

• Determine if you are eligible for extra help to
  pay for the costs of your drugs
• Know where to go to compare plans
• Know your resources
• Mercy Medical Group
• Other

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Help for Those Who Need it Most

• It is estimated that 1 in 3 people will qualify
  for extra help with Medicare Drug costs
• Those with lowest incomes pay no premiums or
  deductibles small or no copayments
• Those with slightly higher incomes pay a little
  more
• Some people will automatically qualify
• Others will get an application from Social
  Security

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Eligibility for Extra Help

• Income
• Below 150 Federal poverty level
• 1,197 per month for an individual or
• 1,604 per month for a married couple
• Based on family size
• Resources
• Up to 11,500 (individual)
• Up to 23,000 (married couple living together)

2005 amounts
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Extra Help for Those with Limited Income and
Resources

• Level of help varies
• However, all should apply that meet criteria
• Call 1-800-SSA-1213 (1-800-772-1213) or go to
  www.socialsecurity.gov to apply
• Complete the application as soon possible
• If you qualify, you need to join a plan this fall
  for your coverage to start January 1, 2006

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Plan Comparison What You Will Need

• Your Medicare Number (on your Medicare Card)
• The date you first enrolled (on your card)
• Your zip code
• Your medication list
• Write out the names or get a printout from your
  pharmacy
• Your pharmacy

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Plan Comparison Where Do I Go?

• Go to www.medicare.gov if you use a computer and
  find Plan Comparison
• Find a family member, friend, or advocate to help
  if you need it
• Call 1-800-Medicare (1-800-633-4227) and a
  representative can assist you
• TTY users should call 1-877-486-2048
• Call HICAP 1-800-434-0222

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Confused?
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Take Home Message

• Gather information
• Know your current coverage
• Know how the changes will affect you
• Know if you qualify for extra help
• Know your options
• Gather resources
• Know who can help
• Family, Patient Advocates, HICAP, Medicare,
  library
• One step at a time
• Cannot enroll until November 15th
• Have until May 15th 2006 if needed

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Where Do I Go?

• Go to www.medicare.gov if you use a computer and
  find Plan Comparison
• Find a family member, friend, or advocate to help
  if you need it
• Medicare and You 2006 handbook
• Call 1-800-Medicare (1-800-633-4227) and a
  representative can assist you
• TTY users should call 1-877-486-2048
• Mercy Medical Group patients may make an
  appointment for assistance with PRICE clinic
• Call HICAP 1-800-434-0222