1. MMA Medicare Modernization Act Richard Stefanacci, DO, MGH, MBA, AGSF, CMD Health Policy Institute

3. MMA

4. Enrollment Outreach Education Plan Selection Authority to Enroll Special Enrollment Period

5. Medicare Prescription Plans Fallback PDPAdm Fees PDPCost MA - PDPValue (Traditional Medicare)

6. $0 $250 $2250 $5100 $7000 Annual Initial Donut Hole Catastrophic Deductible Benefit No Coverage of Costs Coverage W/O W/ < 100% FPL - $1/3 <135% - $2/5 135%-150% ©Richard Stefanacci, DO, MGH, MBA, AGSF, CMD

7. Formulary Requirements Not CMS intention to build the operating framework of a sponsors formulary Formulary must include: –At least one drug in each of 209 therapeutic categories as published in regulation and solicitation –At least 55% of the 209 categories must include a generic offered for a discount

8. Non-Formulary Physician must determine that all drugs on the formulary for the treatment of the same condition: would not be as effective have adverse effects Definite exclusions: –OTC, weight-related, fertility, cosmetic, symptomatic relief cough or colds, vitamins (except prenatal), barbiturates, benzodiazepines –Drugs that would be covered under Medicare, including under Part B for that individual in that instance (Medicaid can cover with federal matched funds)

9. Transitioning Medicaid -> Medicare Community -> Hospital -> SNF -> NF Misalignment of formularies could result in: Inappropriate med changes Limited transition time between meds

10. Medication Therapy Management Services Sec 1860D-4(c) Beneficiaries targeted: Multiple chronic conditions Using multiple prescriptions Incur significant drug spending Services Include: Dispensing Monitoring covered under Part D through PDPs

11. Drug Therapy Quality SCRIPT: Study of Clinically Relevant Indicators for Pharmacologic Therapy Coronary Artery Disease –Beta Blockers –ACEI –Lipid Treatment –Lipid Testing Heart Failure –ACEI –Beta Blockers –Monitoring K, Renal Function Atrial Fibrillation –Warfarin –Monitoring K, Renal Function, INR CMS Funded Study 7/16/04

12. Specialized MA Plans Sec. 231 Special Needs: –Institutionalized –Dual Eligibles –Chronically ill Example Programs: EverCare Wisconsin Partnership Rx Factor

13. LTC Endorsed Sponsors Computer Sciences Corporation* National Community Pharmacist Association Senior Care Pharmacy Alliance PBM Plus, Inc* Omnicare Long Term Care Pharmacy Alliance, LLC Omnicare NeighborCare Pharmerica Kindred Health Care 170

14. Preparing for the Storm…. Education, Educations, Education…….. Preparation Collaboration

15. Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD r.stefan@usip.edu