The Part D Puzzle: Putting the Pieces Together
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1 The Part D Puzzle: Putting the Pieces Together Medicare Prescription Coverage & People with Medicaid: MassHealth/CommonHealth Programs Presented by: Lyn Legere, MS, CRC, CPRP legerechpr@mac.com Overview of Presentation General Overview - Duals Anatomy of a Formulary Steps to Successful Enrollment Getting Ready 2 1
2 A person on Medicare A Dual Eligible is Senior Retirement OR Disability (SSDI); Who also receives Medicaid MassHealth Standard MassHealth CommonHealth (MH/CH); May or may not have SSI Has been receiving medications via MassHealth. 3 Does NOT include 1. People with Only SSI & MassHealth or MassHealth CommonHealth 2. People with SSDI in 24-month Medicare waiting period 4 2
3 Major Concern for Dual Eligibles! Required by Part D to get medications via a Medicare Prescription Drug Plan as of 1/1/06. MassHealth medication coverage* ends on 12/31/05 for duals. Medicare Prescription Drug coverage begins on 1/1/06. * For most medications 5 2 Major Steps Identify and compare plans and coverage. 1. Enroll in a plan: 11/15/05-12/31/05 6 3
4 Identifying Plans Timeline for Prescription Drug Plan Info: *Oct. - Nov Medicare Website *Learn about and compare plans *Medicare & You, *Individual insurance company phone/websites 7 Step 2: Learning About Plans Important Factors in Choosing a Medicare Plan? Costs Type of plan Covered medications Formulary design Participating pharmacies Location of Pharmacies/Services Network providers (MA-PD only) 8 4
5 Subsidies apply to: Costs & Extra Help The Standard or Benchmark plan Plans that cost $30.27 or below in Massachusetts. Companies may offer enhanced plans with greater benefits. Person with subsidy pays the difference in cost of premium between the standard and enhanced plans. 9 Types of Medicare Plans PDP Original Medicare (Fee For-Service plan) + Private Prescription Drug Plan OR MA-PD Medicare Advantage Prescription Drug Plan Integrated Health Care HMO, PPO Medical & Prescription Drug Coverage 10 5
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7 Medications & Formularies Formulary = Covered drugs listed by class Anxiolytics BuSpar, 5mg, 10mg, 15mg, 30 mg Tabs BusPIRone HCI 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg Tabs Meprobamate 200 mg, 400 mg Tabs Miltown 200 mg, 400 mg Tabs Pexeva 10 mg, 20 mg, 30 mg, 40 mg TABS Vanspar 7.5 mg Tabs Adapted from Fallon Health Plan Formulary 13 Learning About Plans - Formulary Rules Must have minimum of 2 drugs per class. CMS: Formularies must include all or substantially all medications in the following classes: Antidepressant & Antipsychotic Anticonvulsants Antiretroviral (HIV/AIDS) - Immunosuppressants - Antineoplastics (Cancer) - Off-label use not required BUT must follow common medical practice (CHECK WITH PLAN)** 14 7
8 Learning About Plans - Formulary Rules 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 (O-T-C) Barbiturates (Phenobarbital) Benzodiazepines (Klonopin, Atavan) 15 MassHealth will continue coverage Of Barbiturates, Benzodiazepines and certain over-the-counter (O-T-C) medications 16 8
9 Formulary Restrictions Quantity Limitations (QL) - Only permitted to a certain number (e.g. 10 Ambien per month). get Prior Approval (PA) - must have permission for use to receive coverage. Generic Substitution - generic dispensed unless otherwise negotiated. Step Therapy: - May be required to start with another drug with a a longer/stronger track record. 17 Step-Therapy Formulary Example: Antidepressants 1st Line 2nd Line 3rd Line fluoxetine (g), citalopram (g), paroxetine (g), Sertraline (Zoloft) ST Buproprion (g), buproprion SR (g), mefazodone (g), venlafaxine XR (Effexor XR) ST Nortriptyline (g), desipramine (g) (g)= Generic available 18 9
10 Formulary Restrictions Co-Insurance Tier - Consumer responsible for percentage of drug cost; increases at each tier level. Co-Pay Tier - Each tier requires a higher co-pay (e.g. $10/$20/$30). These do not apply to duals in standard plans! Duals pay between $1 & $5 regardless of formulary design. 19 Formulary Changes Plans can change formularies during year: With CMS approval & provide 60 days notice Changes allowed: Medication coverage or tier placement Rules for use (i.e. prior approval) Not allowed: Changing drug classes or categories. Dual eligibles are allowed to change plans monthly on the 1st of the month
11 Enrollment and Auto-enrollment Dual Eligibles - Automatic (Auto) Enrollment October notification of assigned plan Enrolled on January 1st to assigned plan IF the person hasn t enrolled in another plan. May not match personal needs. Random assignment, not personalized. TO DO: Auto-enrollment should be viewed as a safety net only. Evaluate Plans and enroll in plan that best meets your personal needs. plan that best meets your personal needs 21 TO DO: Prepare worksheets for gathering formulary information (handouts). Worksheet 1 - My Medications NOW Worksheet 2 - Formulary Rating Sheet - As plans become available or through Medicare website Worksheet 3 - Plan Comparison - Which plan is the best match? Consult Resources (handout). - Other workbooks (NMHA), info in 7 languages (UnitedHealth), etc
12 TO DO Watch for auto-enrollment letter. Confirms that the person is categorized as a dual for extra help subsidies. Consult with medical providers Potential medication alternatives? Role in appeals (Donna will discuss) Consult with family, providers, supporters 23 TO DO: Pool Resources - Remember, there are many plans to evaluate!! Refer to the Medicare & You handbook and the CMS website. (
13 TO DO NOVEMBER 15 f zç hñ 25 Thank You!! Funded by: The Massachusetts Medicaid Infrastructure and Comprehensive Employment Opportunities Grant (MICEO) is a collaborative project of the Massachusetts Executive Office of Health and Human Services, the Institute for Community Inclusion at UMass Boston, and the Center for Health Policy and Research at UMass Medical School. This grant is funded by the Centers for Medicaid and Medicare Services (CFDA #93-768). For more information visit:
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