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Transcript of Medicare PD
Oladayo Agboola - Deshonika Berry - Shannon Fitzgerald
Abdul Kamara - Sarah Nkeng - Hiwot Kesi WHO GETS IT? ELIGIBILITY WHAT DO YOU GET? WHO GIVES IT? Federal government – Centers for Medicare and Medicaid Services (CMS)
Benefit delivered exclusively through private health insurance plans People who already have Medicare Part A or Part B, and who have enrolled in a prescription drug plan People age 65 and older. Certain people younger than age 65 can qualify for Medicare, including those who receive Social Security Disability Income and those who have permanent kidney failure Health insurance that covers prescription drugs taken on an outpatient basis, subject to restrictions relating to deductibles, premiums, co-payments, coverage gap, utilization management, and which drugs are covered.Part D benefits can only be received through a private drug plan; the precise benefit structure varies from plan to plan TWO TYPES OF MEDICARE
PART D PLANS Prescription Drug Plans (PDPs) Medicare Advantage Plans (MA-PD) Prescription Drug Plans (PDPs) Also called “Stand-Alone Plans” – These are private insurance plans offered by private companies. They provide ONLY prescription drug coverage through Part D, and do not affect beneficiaries’ Parts A and B Medicare coverage. They are paid partially by the Federal government (through CMS) and partially by monthly premiums paid by members. Medicare Advantage Plans (MA-PD) “Medicare Health Plans” are generally HMOs, PPOs, or PFFS plans offered by private companies that provide Medicare Part A and B services in a managed care model, limiting the member’s choice of providers. Like PDPs, MA plans are paid partially by the Federal government, and partially by member premiums (although many MA plans have no premium). A Medicare Advantage plan that also offers Part D prescription drug coverage is called an MA-PD. COMBINATIONS OF PART D COVERAGE Some companies offer enhanced plans, which may cover a larger list of drugs, or reduced out-of- pocket costs; these generally have higher premiums. DEDUCTIBLE CO-PAYMENTS COVERAGE GAP CATASTROPHIC
COVERAGE All PDPs have a monthly premium. The 2010 premiums in New York range from $19.50/mo. to $117.50/mo. The median premium is $41.55/mo. The average premium for a PDP with basic coverage is $37.86/mo. There are ten PDPs in 2010 that will have $0 premiums for people with Full Extra Help. PREMIUM Some PDPs have an annual deductible, where the beneficiary must pay the full cost of their drugs until their drug costs (including what the plan pays) reach a certain threshold. After meeting the deductible, beneficiaries enter the Initial Coverage Period, when are responsible for co-payments or coinsurance. This means that they will have to pay a certain amount towards the cost of their drugs, and the plan pays the rest. All plans have something called a coverage gap (aka “donut hole”), which is like a second deductible that must be met once your drug costs reach a certain threshold. Once in the coverage gap, the beneficiary is responsible for 47.50% of the cost of brand-name drugs and 79% of generic drugs Once the beneficiary’s drug costs for the year (including the amount paid by the plan) reach $6,440, then they enter catastrophic coverage. From this point onward (until next January), the beneficiary is responsible for only about 5% of the cost of their drugs, and the plan pays the rest. Each PDP has a formulary. This is a list of drug classes covered. In other words, each plan has some drugs that it chooses not to cover. EXCLUDED DRUGS FORMULARLY CHANGES FORMULARY IN THE PHARMACY Formularies must include “all or substantially all” drugs in six classes of clinical concern: Antidepressants, Antipsychotics, Anticonvulsants, Antineoplastic (cancer) Immunosuppressant (for organ and tissue transplant patients), and Antiretroviral (for treatment of HIV/AIDS)
These must include generic drugs and older brand-name drugs. Plans may impose utilization management for these six classes of drugs, but are discouraged from doing so for HIV/AIDS drugs Plans may change their formularies at any time. If a plan removes a drug from their formulary or changes its cost-sharing, they must provide 60 days’ notice to members taking the affected drug, their prescribing physicians and pharmacists Certain drugs are excluded from and not covered by the Medicare drug benefit. This is different than those drugs that are simply not on a given plan’s formulary. If a drug is excluded, it means that no basic Part D plan can cover it, although some enhanced plans may. Drugs for anorexia, weight loss, or weight gain
Cosmetic or hair growth drugs
Prescription vitamins and minerals
Barbiturates (under certain circumstances)
Drugs for treatment of erectile dysfunction Once a beneficiary has enrolled in a Part D plan (either a PDP or MA-PD), they can only use their drug coverage at pharmacies that are in the plan’s network. If a beneficiary goes to a pharmacy that is not in their plan’s network, then the plan will not pay any portion of the cost. Thus, it is important, when selecting a plan, to ensure that one’s favorite pharmacy is in-network. The government sets rules about how many pharmacies any given Part D plan must have in their network in a given geographic area. EXTRA HELP? Deemed Eligible by receiving Medicaid, Medicare Savings Program, or Supplemental Security Income; OR Application approved by Social Security Administration under one of the following:
Full Extra Help
Income below $1,218/mo. (single), $1,639/mo. (couple) Resources below $8,100 (single), $12,910 (couple)
Partial Extra Help
Income below $1,353/mo. (single), $1,821/mo. (couple) Resources below $12,510 (single), $25,010 (couple) There are two types of Extra Help, Full and Partial, that differ in terms of eligibility and how much of a subsidy they provide.The amount of help provided by Extra Help depends upon a number of factors.
The following pages compare each cost component of a drug plan – premium, deductible, co-pays, coverage gap, and catastrophic coverage – between a basic plan with no extra help, with Full Extra Help, and with Partial Extra Help. What is the difference between
the two Medicare Part D plans? Who is eligible for Medicare Part D? Once you reach a donut hole, is the beneficiary only responsible for 47.5% of the cost of the generic drug? If a beneficiary has full coverage, will they be able to purchase over the counter(OTC) drug for the EXTRA HELP price? Can a beneficiary go to any pharmacy
to purchase drugs as long as it
is on the formulary? QUESTIONS CONCLUSION