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Medicare Prescription Drug Plans


... who have a Medigap prescription drug policy will receive ... coverage in place of Medicare prescription drug coverage and get a tax ... Prescription Drug ... – PowerPoint PPT presentation

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Title: Medicare Prescription Drug Plans


Changes in MedicareKeeping up with Todays
Health Care
  • Promoting a healthy lifestyle
  • Covering preventive services
  • Offering prescription drug coverage
  • Expanding coordinated care options
  • Including care for chronic conditions
  • Helping people with Medicare live longer,
    healthier lives

Medicare Prescription Drug Coverage
  • Begins January 1, 2006
  • Available for all people with Medicare
  • Part A, Part B, or both
  • For minimum standard coverage in 2006,
  • enrollees would pay
  • Monthly premium of about 32
  • 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

Savings in 2006
  • On average, for a person with Medicare and no
    drug coverage now
  • Total drug spending will go down by about 50
  • Over 1,100 per year saved
  • People with other drug coverage that, on average,
    is at least as good as the minimum standard
    Medicare prescription drug coverage also may save
  • These estimates do not include the extra help for
    people with limited incomes and resources

Protections for People with Medicare
  • Customer service
  • Pharmacy access
  • Medication therapy management
  • Generic drug information
  • Privacy
  • Uniform benefits and premiums
  • Formulary Protections

Extra Help With Drug Costs
  • Available for many people with limited income and
  • Those below Federal poverty level save over 95
    on average
  • People with lowest income and resources
  • Pay no premiums or deductibles
  • Have small or no copayments
  • Those with slightly higher income and resources
  • Have a reduced deductible
  • Pay a little more out-of-pocket

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)
  • Includes 1,500/person funeral or burial expenses
  • Counts savings and stocks
  • Does not count home the person lives in
  • Higher amounts for Alaska and Hawaii
  • -Not available in
    the U.S. territories

2005 amounts
Automatic Eligibility for Extra Help
  • Some people may automatically qualify
  • People with Medicare who
  • Get full Medicaid benefits
  • Get Supplemental Security Income (SSI)
  • Get help from Medicaid paying their Medicare
  • All others must apply

Ways to Get Coverage
  • Medicare prescription drug coverage is provided
  • Medicare Prescription Drug Plans
  • Medicare Advantage and other Medicare Health
  • Coverage is NOT automatic
  • People need to understand their options

Original MedicareAnd Medigap With Drug Coverage
  • People who have a Medigap prescription drug
    policy will receive important information in the
    mail this fall from their Medigap insurance
    company on how the new Medicare prescription drug
    coverage will affect their Medigap prescription
    drug coverage
  • Choices to make
  • Keep prescription coverage through the Medigap
  • Join a Medicare Prescription Drug Plan after they
  • Modify the Medigap policy to remove drug
    coverage, or
  • Change to a Medigap policy with no drug coverage
  • Drop Medigap policy and join a Medicare Advantage
    Plan or other Medicare Health Plan with
    prescription drug coverage

Employer/Union Coverage
  • Medicare is working with employers to help people
    with Medicare keep their current prescription
  • Employer/Union options
  • Offer coverage in place of Medicare prescription
    drug coverage and get a tax-free subsidy
  • Offer or contract with a Medicare drug plan to
    provide prescription drug coverage
  • Provide coverage that supplements the Medicare
    prescription drug coverage
  • Pay all or part of Medicare drug plan premiums

Employer/Union Coverage
  • People with Medicare and employer/union coverage
    will get important information in the mail this
    fall from their plan sponsor
  • They should contact their benefits administrator
    before making any changes
  • Choices to make
  • Keep coverage offered by employer/union
  • Join a Medicare Prescription Drug Plan
  • Join a Medicare Advantage Plan or other Medicare
    Health Plan with prescription drug coverage
  • NOTE If a Medicare beneficiary drops or loses
    their employer/union
  • coverage, they may not be able to get
    it back

Medicare and Medicaid
  • These people automatically qualify for the extra
  • They should watch the mail this fall
  • Letter about choosing a Medicare Prescription
    Drug Plan
  • Medicare You 2006 handbook
  • Choices to make
  • Compare prescription drug plan options and join
    in a plan
  • If not, Medicare will enroll them in one by
    December 31, 2005
  • Starting January 1, 2006, Medicare will pay for
    their prescription drugs
  • Can switch to another plan at any time

Other State/Federal Assistance Programs
  • These people automatically qualify for the extra
    help if they
  • Get help from Medicaid paying their Medicare
  • Get Medicare and Supplemental Security Income
    (SSI) benefits
  • They should watch the mail for Medicare You
    2006 handbook
  • Choices to make
  • Compare prescription drug plan options
  • Find a plan that meets their needs
  • If no choice made by May 15, 2006, will be
    enrolled on June 1, 2006
  • Also applies to people who applied and qualify
    for extra help

Late Enrollment
  • Most people will have to pay a penalty if they
    wait to join
  • Premium will go up 1 per month for every month
    the person was eligible but did not join
  • The person will have to pay this penalty as long
    as they have a Medicare Prescription Drug Plan
  • Unless they have other prescription drug coverage
    that is, on average, at least as good as the
    minimum standard Medicare prescription drug

Important Dates
  • September 15 November 15, 2005
  • Medigap insurance companies will mail information
    to Medigap policy holders who have a policy that
    covers prescription drugs
  • October 13, 2005
  • Begin comparing prescription drug plans
  • 1-800-MEDICARE (1-800-633-4227)
  • TTY users should call 1-877-486-2048

Important Dates
  • October 2005
  • Medicare You 2006 handbook mailed
  • Medicare notifies people with Medicare and
    Medicaid of the plan they will be automatically
    enrolled in on January 1, 2006, if they do not
    enroll on their own
  • Employer plans send coverage information to
  • November 15, 2005
  • Initial Enrollment Period begins

Important Dates
  • January 1, 2006
  • Medicare Prescription Drug Plan coverage begins
    for those enrolled
  • May 15, 2006
  • Last day of Initial Enrollment Period
  • June 1, 2006
  • Facilitated enrollment of people entitled to
    extra help who did not enroll by May 15, 2006

Information For Your Patients
  • See Medicare You 2006 handbook
  • To be mailed October 2005
  • Read about prescription drug plans in the area
  • For help in choosing a plan
  • Visit on the web
  • To get personalized information
  • Visit or call the local State
    Health Insurance Assistance Program (SHIP)
  • For assistance with enrollment
  • Call 1-800-MEDICARE (1-800-633-4227)
  • TTY users call 1-877-486-2048
  • Attend local community events

How to Apply For Extra Help
  • Social Security Administration (SSA) is mailing
    applications to those who may be eligible
  • Throughout the summer of 2005
  • Those who think they may qualify should
  • Complete this application
  • Mail it to the address on the back of the
  • Use the enclosed postage-paid envelope
  • Use original forms only (do not photocopy)
  • People who are not sure should still apply
  • can help people decide

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
  • Advantage prescription drug (MA-PD) plan
  • may not cover all drugs
  • Brand name and generic drugs will be in
  • each formulary

Medicare Prescription Drug Coverage Plans Must
  • Cancer medications
  • HIV/AIDS treatments
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for epilepsy and other
  • Immunosuppressants

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
  • Non-prescription drugs
  • Barbiturates
  • Benzodiazepines

  • Prescription drug plans (PDP) and Medicare
    Advantage prescription drug (MA-PD) plans may
    have a formulary
  • CMS will ensure formularies do not
  • discourage enrollment among certain groups of
  • Formulary review requirements are posted at on the web
  • CMS will approve formularies in advance for plans
    to complete their bid

Exception Process
  • Ensures access to medically necessary Medicare
    covered prescription drugs
  • Provides process for enrollee to
  • Obtain a covered Medicare prescription drug at a
    more favorable cost-sharing level
  • Obtain a covered Medicare prescription drug not
    on the formulary

Exception Requests
  • Enrollees may request an exception if
  • The enrollee is using a drug that has been
    removed from the formulary
  • A non-formulary drug is prescribed and is
    medically necessary
  • The cost-sharing status of a drug an enrollee is
    using changes
  • A drug covered under a more expensive
    cost-sharing tier is prescribed because the drug
    covered under the less expensive cost-sharing
    tier is medically inappropriate

Exception Procedures
  • Adjudication timeframes A plan must notify an
    enrollee of its determination no later than 24 or
    72 hours as appropriate
  • Failure to meet adjudication timeframes Forward
    enrollees request to Independent Review Entity
  • Generally, plans are prohibited from requiring
    additional exceptions requests for refills and
    from creating a special formulary tier or other
    cost-sharing requirement applicable only to
    Medicare-covered prescription drugs approved
    under the exceptions process

5-Level Appeals Process
  • Redetermination by plan sponsor
  • Reconsideration by Independent Review Entity
  • Review by Administrative Law Judge
  • Review by Medicare Appeals Council
  • Review by Federal District Court

Long-Term Care Facilities
  • Residents
  • Obtain drug benefits from pharmacy chosen by the
  • Can change plans at any time if they have both
    Medicare and full Medicaid benefits
  • Will have convenient access
  • Those persons who are dually eligible for
    Medicare and Medicaid have no deductibles and no

More Information for Health Care Professionals
  • Toolkit for healthcare professionals
  • Medicare Prescription Drug Coverage Information
    for Providers Page
  • Official U.S. government website for people with

More Information for Health Care Professionals
  • Social Security Administration (SSA) posters
  • Directs limited income Medicare beneficiaries
    where to call to determine eligibility for help
    with prescription drug costs
  • http//
  • Hard copies of the posters, for display in your
    office, may be ordered from the Medlearn Product
    Ordering Page
  • http//

Encourage Your Medicare Patients
  • Learn about the Medicare prescription drug
    program by visiting on the web
    or by calling 1-800-MEDICARE
  • (1-800-633-4227). TTY users should call
  • 1-877-486-2048.
  • Complete and mail back material that they may get
    from the Social Security Administration
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