Pharmacy Outreach Program University of Rhode Island C ll f Ph College of Pharmacy
Updated November 2008
MEDICARE y Medicare provides health insurance for… y Aged 65 years or older y Aged 65 years or less with certain disabilities y All people with End-Stage Renal Disease (ESRD) y All people with Lou Gehrig’s Gehrig s Disease (ALS)
THE PARTS OF MEDICARE y Part A y Hospital insurance y Part B y Medical insurance y Medicare M di Ad Advantage t Pl Plans y Part D y Prescription drug coverage
Medicare Part A y Covers: y Inpatient hospital care y Skilled nursing facilities (Under certain
conditions)
y Typically doesn’t require a monthly
payment (Premium) y Does require out-of-pocket out of pocket deductible for hospital stays: y $1,024 (in 2008) of 1-60 days y $256 per day co-pay (in 2008) for days
61-90 y $512 per day co-pay (in 2008) for days 91-150 y All cos costs s beyo beyond d 150 50 days
y For skilled nursing facilities: y $128.00 per day (in 2008) for days 21
through 100 for each benefit period
Medicare Part B y Helps cover: Physician services y Some physical and occupational therapists y Some home healthcare y
y Also covers other services and supplies: Glucose monitors y Test strips y Lancets y
y There is a monthly premium to enroll y The standard Part B premium for 2008 is y y y y
$96.40 per month Income based and will remain unchanged for 2009 In general, automatically deducted from social security checks Also has annual deductible of $135.00 Once deductible is paid enrollee generally pays a 20% co-payment for each service
MEDICARE PART D MEDICARE PART D y Stand-alone prescription drug coverage y Open to all people eligible for Medicare y Open enrollment begins November 15, 2008 y Enrollment for coverage of the year 2009 ends on December 31, 2008 y Coverage Begins on January 1st, 2009 y Medicare Part D is VOLUNTARY!!
Medicare Advantage y Health insurance
coverage, including preventative care PLUS prescription drug coverage in a single plan y In exchange, typically must use a certain network of doctors, hospitals, and pharmacies
Medicare Advantage y 13 plans available y Only 2 will provide some coverage for the coverage gap (donut hole)
y **If you already have a Medicare Advantage plan
and yyou want to add drug g coverage g yyou MUST obtain it through your Medicare Advantage provider. y If you obtain an independent standalone drug plan instead, your
health coverage under the Medicare Advantage plan will stop stop.
When Can I Enroll in a Part D Plan? y Re-enrollment begins November 15th, 2008! y Your new plan will take effect January 1st, 2009 y If you are happy with your current part D plan, you
don t need to do anything during the re don’t re-enrollment enrollment period! y Your Med D p plan will automatically y re-enroll yyou y But be aware::::: your premiums, co-pays, formulary,
or deductible may be changed for the new year!
Enrollment Info y Open enrollment is from Nov.15-Dec 31st of each year y Coverage begins on January 1, 2009 y If you become b eligible li ibl ffor M Medicare di P Part D after f the h
enrollment period, you have a 7 month period to enroll without incurring gap penalty y y
3 months before, the month of and 3 months after the month of your 65th birthday
Who Should Apply? y People who are enrolled in a Med D plan right now, but
thinking about switching to another plan next year y You didn’t sign up for a plan when eligible last time
around but you’re thinking of enrolling now y Penalty Penalt for every e er month without itho t co coverage erage
y Enrolled in a Medicare Advantage g Plan or Medigap g p
Supplemental Insurance Plan but you want to add or change your drug coverage
Who Doesn’t Need To Apply y If you have CREDITABLE Coverage: y This means that you already are enrolled in a plan that provides a
prescription drug benefit that is EQUIVALENT or better than that being offered through Medicare Part D
y You would have already been made aware of this by your
insurance p provider by y mail y KEEP THIS LETTER IN A SAFE PLACE** **If you are unsure if your coverage iis creditable dit bl or not, t ask k your employer or union for it!**
Penalty Info y If you did not enroll but were eligible to do so so, when you enroll now for
coverage beginning on Jan.1,2009… y You will incur a penalty of 1% of the national average premium FOR
EVERY MONTH YOU WERE ELIGIBLE AND DIDN’T NOT ENROLL!
y Will have to wait until Nov 15- Dec 31, 2009 to join a Medicare drug
plan if not enrolled and want to do so now! y Average premium 2009 = $31.74 y 1% of $31.74 $ =$ $0.31 y 12 months penalty= $3.72 y Therefore, $3.72 will be added unto your monthly premium every month
forever! y If you were eligible when the program first started in 2006 then you will be subject to 30 months of penalty y y y
So… 1% per month X 30 months = 30% penalty 30% off $31 $31.74 74 (2009 national ti l average)) = $9 $9.52 52 additional dditi l out-of-pocket t f k t expense every month on top of monthly premium $9.52 X 12 months = $114.26 each year
Penalty Info You will not have this penalty enforced: y
If you were not previously eligible for Medicare Part D
y
If If you previously had creditable coverage i l h d dit bl
HOW PART D WORKS y Remember::: this is just an explanation of the
template used as a general basis for the plans -there are options! y STANDARD PLAN (2009) y $31.74 p per month p premium (($380.88/year) y ) y $295 deductible y 75% coverage from $295 to $2700 y NO coverage from f $2700 tto $6153 $6153.75 75 y This is called the coverage gap or “Donut Hole” y 95% coverage g beyond y $6153.75 y Equivalent to $4350 dollars out of pocket spending
Over $6153.75 $6153 75 $2700 – 6153.75 $295 - 2700 $0 - 295
Think of it as Steps! y Step #1 – The Deductible y You pay 100% and plan pays 0% y You Y receive i $295 worth h of medications y Step #2 – Co-insurance y You Y pay 25% ($601 ($601.25) 25) and plan pays 75% ($1803.75) y You receive $2405 worth of medications (Total: Step 1 + Step 2 = $ $2700) )
Think of it as Steps! y Step #3 – The Donut Hole y You pay 100% and plan pays 0% y You Y receive i $3453 $3453.75 75 worth of medications y Total: Step 1 + Step 2 + Step 3 = $6153 $6153.75 75 y Step #4 – Catastrophic
Coverage y You pay 5% and plan
pays 95% y You receive unlimited d drugs ugs for o the e remainder e a de of calendar year
Remember! y
Even though you were enrolled in a program last year, you start from the Step #1 all over again on January 1 1, 2008
y
You will continue to pay y the premium everyy month regardless of what step that you are on y Even when in the “donut hole� a person still pays
the monthly premium!
Besides Standard Plan… y Must offer basic/standard drug benefit y May offer enhanced benefit y Some have no deductible y Some have help during “donut hole” (coverage gap) y The Premium depends on the enhancements y Mail order options may save costs on maintenance
medications (90 days)
How Do I Choose The Right Plan? Rx Enrollment Check-Up: ;Cost y Will your premium and costs change in 2009?
;Coverage C ; Will you need more comprehensive coverage? ; Will your current meds be covered by your plan? ;Customer Service y Are you satisfied with your service from your current plan?
Important y If you decide that your current Med D plan will meet
your needs in 2009 then you do not need to re-enroll y Coverage will continue through 2009 starting from
Step 1
Plans Available Plans Available in RI for 2009 in RI for 2009 y Total of 47 plans offered y 26 plans l offer ff enhanced h d benefit b fit or services i y 27 plans available with NO deductible! y Monthly premiums without gap coverage start at $19 $19.40 40 y Only 1 has premium less than $25 y 12 PDPs have $0 premium if qualify for extra help y Monthly premiums with gap coverage start at $50.60 $ y Lowest premiums have only generic coverage y All medicare p patients are eligible g for a medicare advantage g
plan
Formularies? y Formulary system y Each plan selects certain dr drugs gs from each dr drug g class that they will cover y May have a tier system y y y y y
May have up to 5 tiers Generic drugs = cheapest (ex: $5) Preferred e e ed brand b a d names a es = more o e expensive e pe s e (e (ex: $ $28) 8) Non-preferred brand names = most expensive (ex: $40) Certain injectable and specialty drugs= highest tiers (ex: $58)
Drugs Not Covered Under Most Drugs Not Covered Under Most Part D Formularies y Benzodiazepines
y Drugs for cosmetic
y Barbiturates
purposes or hair growth y Fertility promoting drugs y Prescription vitamins, minerals
y Weight W i ht lloss y Erectile dysfunction y Cough and cold relief y Non prescription drugs
y Except prenatal vitamins
and fluoride preparations
Definitions: y Generics: will be required to be covered by ALL plans y Chemically identical to brand‐name drugs and meet the same rigorous
standards put forth by the FDA (US Food and Drug Administration) for: y y y
Safety Purity Effectiveness
y Generic drugs can be legally produced in the US if a patent has expired, or for
drugs which have never been patented y Prior authorization: may be needed for some medications y Appeal process mandated by insurance company which includes
paperwork p p involving g the MD y Step Therapy: may be required before certain medications will be covered
y ex: Prilosec before Nexium or Motrin before Celebrex y Quantity limits: may be enforced
y 30 day quantities retail vs. 90 day mail-order y
Some plans DO allow 90 day quantities of maintenance medicines at community pharmacies.
Frequently Asked Questions
Who pays for my vaccines? y Now Medicare part D must cover all vaccines not
covered by part B y Ex: Zostavax (Shingles vaccine)
y Vaccines covered by part B y Pneumococcal y Influenza y Hepatitis B y Vaccines necessary to treat a disease or prevent one after direct
exposure y
Ex: tetanus
WHAT ABOUT MY RIPAE? y You SHOULD keep your RIPAE! y It will provide coverage throughout the deductible and coverage gap y BUT, it is not creditable coverage y You need a Medicare Part D Plan too y Starting January 2009, RIPAE will only be available for those enrolled in a Medicare part D plan y Must send in copy of enrollment letter or card y See your SHIP counselor or call The Point for
RIPAE information
RIPAE… y Provides extra benefit for those who don’t qualify
ffor extra t help h l ffrom Medicare M di y Applicable to all expenses that person is 100% responsible for y Deductible y Coverage g g gap p ((“Donut Hole”)) y Drugs not covered under your Part D Plan y
Only certain ones!
RIPAE‌ y Eligible: y Single, income less than $42,493 per year y Married,, income less than $48,563 $ , per p year y y
The lower the financial category, the higher percentage RIPAE will pay
y More information y 401 401-462-4444 462 4444 – The Point y
Wrong phone number on Medicare and You 2008 Booklet!
y Talk to SHIP counselor
What About My Tricare, VA, Pension Benefits? y They are creditable coverage, letters have have
been mailed! y Hold on to these letters! y Contact your pension benefits manager or union if you have any questions
Dual Eligibles (Medicare/Medicaid) y Will automatically be eligible for: y y y y
No premium No deductible No donut hole Minimum co-payments ($1.10 generic & $3.20 brand)
y Have been automatically y enrolled in a p plan & will be
automatically re-enrolled in a plan y Part D plan for 2008 won’t necessarily be the same plan as
2007 due to cost restraints!
y Reassignment notices will be sent out 10/30/08 y Enrollment confirmations will be sent 12/1/08 y If y you are “duallyy eligible,” g , yyou can change g yyour p plan at
any time during the year! Once per month!
What is Extra Help (Low Income Subsidy)? y Federal poverty limits determined by government each year y Best to apply pp y and be formally y denied y Many deductions, so apply!
y In order to be eligible, a person’s resources must be no greater
than the limits established
LIS level
Single*
Married*
Full Subsidy LIS Resource Limit
$ $8,100
$ $12,910
All Other LIS Resource Limit
$12,510
$25,010
*Includes $1,500 per person burial expenses
“Deemed” Population y Defined as those who had Low Income Subsidy
(LIS) for 2008 and are not automatically eligible for 2009 y Notifications have been sent out with applications to re-enroll y Does not mean that you are not eligible y Reapply!!!
Ways to Lower Your Drug Costs Ways to Lower Your Drug Costs During the Coverage Gap y
Ask your doctor about generic and less expensive brand name drugs (therapeutic substitutions) y y
y y
Ask your doctor for samples National & Community Based Charitable Programs y
y
Cheaper p in the g gap p Less likely to hit the gap if avoid brand names from the beginning
For specialty drugs
Pharmace tical Assistance Programs Pharmaceutical y y
Available from the pharmaceutical manufacturers Contact the Partnership for Prescription Assistance y
1-888-477-2669
Ways to Lower Your Drug Costs Ways to Lower Your Drug Costs During the Coverage Gap y
State Pharmaceutical Assistance Programs y
RIPAE y
y
Based on your income, RIPAE will pay 15%, 30%, or 60% of drug cost during coverage gap
Apply for Extra Help y
y
If you have limited income and resources, y you may yq qualify y for extra help For more information go to www.socialsecurity.gov or call 1-800-772-1213
h f k l d f What If I Like A Plan And One Of My Drugs Is Not Covered? y Options: y Ask your pharmacist about therapeutic substitution y Compare prescription vs vs. over the counter options y y y
Nexium $158.00 Prilosec OTC $21.99 Omeprazole Rx- lowest cost or co-pay
y Always consult with your doctor regarding changes
to your medications
Drugs that are Not Covered by ANY Part D Plan y Can still get these drugs but must pay the retail price
( cash ) and it does not count towards out of pocket (“cash”) expenses or total drug costs Examples: p y Benzodiazepines y
alprazolam, lorazepam, diazepam
y Drugs for weight loss, hair loss, and fertility y Drugs covered under Medicare parts A and B y
Example: Drugs received while in the hospital hospital, diabetic testing supplies
Medicare Fraud y It is important to remember that the vast majority of your
health care providers are committed to providing you with high g q quality y care. y However, there are some individuals who cheat the system out of millions of dollars, which results in higher premiums for its members members. y It is important to be very conscious when dealing with your
Medicare information, and to never share it with a medical professional unless yyou are absolutely p y certain that they y need it. y Never share your Medicare information over the phone with someone else
Medicare Fraud y Medicare fraud is purposely billing Medicare for services
that were never provided or received. y Billling Medicare or another insurer for services or items you
never got. y Billing Medicare for services or equipment which are different from what you got got. y Use of another person’s Medicare card to get medical care, supplies, or equipment. y Billing Billi Medicare M di for f home h medical di l equipment i t after ft it h has b been returned.
www.medicare.gov
Medicare Fraud ‐ Do’s and Don’ts y Don't Health D ' give i out your Medicare M di H l h Insurance I
Claim Number (on your Medicare card) except to your physician or other Medicare provider. y Don’t give out social security or credit card numbers y Don't allow anyone, except appropriate medical
professionals, to review your medical records or recommend services. y Don't contact your physician to request a service that
yyou do not need. www.medicare.gov
Medicare Fraud ‐ Do’s and Don’ts y Do be careful in accepting Medicare services that are
represented as being free. y Do be cautious when you are offered free testing or screening in exchange for your Medicare card number. y Do be cautious of any provider who maintains they have been endorsed by the Federal government or by Medicare. y Do avoid a provider of health care items or services who t ll you th tells thatt the th item it or service i iis nott usually ll covered, d but they know how to bill Medicare to get it paid.
www.medicare.gov
Avoiding Telephone Scams y Never give out personal information over the phone unless
you are certain the other person is legitimate y Simply tell the person that you are too busy to talk at the moment and you would like to call them back at a more convenient time y Request the following information: y Name y Title (if appropriate) y Phone number
y Find the customer service number for the business the person
on the phone said they represented (on a bill, internet, or other piece of mail) y Call the customer service line and ask if the person that called you was indeed i d d partt off th the company
Using the Internet y Get a complete list of your medications and the cash price
from the pharmacy y Be sure to include all prescriptions-eye drops, creams, inhalers,
patches, etc.
y Go to www.Medicare.gov and click on “Formulary Finder” y Follow the prompts and enter your medications
y Can also call 1-800-MEDICARE (1-800-633-4227) y Can enroll on line—have your Medicare card ready y CVS and Walgreens both have websites to condense your
search of possible plans y Rite Aid has plan finding software, just call your Rite Aid pharmacist and schedule a time to choose a plan
Important Dates to Remember October- Compare and Prepare November 15- Open Enrollment Begins D December b 8 8- Don’t D ’t B Be L Late t December 31- Open Enrollment Ends January 1, 1 2008- Coverage Begins ***Next Open p Enrollment Period is not until November 15- December 31, 2008***
In summary…. y No single plan is best for everyone y You must pick the plan that’s right for YOU!
y Yes, Yes it is confusing confusing, so don’t don t be afraid to ask for help: y The Point!!! (401) 462-4444 y SHIP counselors at your local Senior Center y Dept. Dept of Elderly affairs (401) 462 462-4000 4000 y Ask a relative or friend to help you navigate the Web y Social Security Administration 1-800-772-1213 y Pharmacy Outreach Program 1-800-215-9001 1 800 215 9001 y
www.uri.edu/pharmacy/outreach
THANK YOU!