1 Medicare Today…More Choices, Better Benefits Instructor’s Name Event Date /06

2 Topics/Modules Medicare’s 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 Formularies What Is the “Donut Hole?” Important Dates for Medicare

Medicare’s Covered Preventive Care Services

4 Medicare Has More to Offer Preventive services Prescription drug plan coverage New Medicare Health Plan options Extra help for those who need it most

5 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

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

7 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

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

9 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

10 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 beneficiaries Cost to beneficiary? –No deductible, no copay/coinsurance

11 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

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

13 Covered Vaccinations Influenza Pneumococcal Hepatitis B

14 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

16 Medicare Prescription Drug Coverage: Why Should You Get It? If you are going to join it’s 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

17 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 (MA-PDs) –Formerly known as Medicare+Choice –Provide Medicare Parts A & B medical and hospital care and prescription drug coverage under the same plan

18 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 change.

19 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

20 How to Sign Up for a Medicare Prescription Drug Plan There are several ways to enroll: Call the plan directly Visit the plan’s website Call Medicare Visit

21 Enrollment for Those Who Need Help Paying for a Plan 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 Plans

23 Decide What Kind of Plan You Want Medicare Advantage with Prescription Drugs (MA-PD): –New name for Medicare+Choice 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

24 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

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

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

27 Steps for Picking a Plan (continued) 2.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 prompted)

28 Steps for Picking a Plan (continued) 3.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 information 4. Select 3 or 4 possible plans from the Prescription Drug Plan Finder

29 Steps for Picking a Plan – (continued) 5.Contact each plan to get more information: –How is the plan’s 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 year? –Is mail order available if you want it?

30 Steps for Picking a Plan – (continued) 6.Decide on the right plan you want and sign up using the options below: –Call the plan directly –Call MEDICARE –Visit the web site of the plan sponsor –Visit –Submit a paper form provided by the plan sponsor

31 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 lists Other plans may offer additional services Paying more doesn’t mean it’s a better plan! –You should find the plan that best fits your needs

32 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 plan’s 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?

33 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 plan 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

35 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 more You may qualify if your annual income is less than 150% of the Federal Poverty Level and you are –Single and annual income less than $14,700 –Married and annual income less than $19,800 Some people will automatically qualify

36 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

37 Other Sources of Help Paying for Prescription Drugs 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

39 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.

40 Plan Formulary Using drugs on a plan’s 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

41 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 through –Transition supply –Exceptions process –Appeals process

42 Plan Formulary Plans must fill prescriptions that are not on the plan’s 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

43 Plan Formulary Exception requests may be warranted if a: –Patient has tried covered drugs and they don’t work, or –Physician believes the patient requires a specific non-covered drug If a request is approved, the plan will cover the drug

44 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

45 Appeals Process A person can appeal a Medicare drug plan’s 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?”

47 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

Drug Plan Cost Sharing Source:Kaiser Family Foundation Medicare Part D benefit Out-of-pocket spending Catastrophic coverage Partial coverage up to limit Deductible 5% $3,051 Gap “Donut hole” 25% $5,451 $2,400 $265 95% 75% Percent of Rx spend “Medicare Part D benefit” “Out-of-pocket” Actuarial Equivalence 100% Beneficiary Responsibility

49 What Can You Do About Costs in the Coverage Gap? Apply for Medicare’s 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 Plan’s 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

51 Important Dates January New preventive services began…

52 Important Dates October/ November 2006 Watch your mail for the Medicare & You handbook, which will have information about the plans in your area

53 Important Dates October 2006 You can begin to compare Medicare prescription drug plans… – – MEDICARE – Local SHIP office – Local community groups

54 Important Dates November 15 through December 31 each year You can enroll in a Medicare prescription drug plan, or change plans!

55 Important Dates January 1 Medicare prescription drug coverage begins for those who are enrolled…

56 For More Information Medicare & You 2007 handbook MEDICARE ( ) –TTY users call (Spanish) State Health Insurance Program (SHIP) Community groups (Local Agency on Aging)