Medicare Part D

Pharmacy Outreach Program The University of Rhode Island College of Pharmacy Updated October 2009

MEDICARE  Medicare provides health insurance for…  Aged 65 years or older  Aged 65 years or less with certain disabilities  All people with End-Stage Renal Disease (ESRD)  All people with Lou Gehrig’s Disease (ALS)

THE PARTS OF MEDICARE  Part A  Hospital insurance  Part B  Medical insurance

 Medicare Advantage Plans

 Part D  Prescription drug coverage

Medicare Part A  Covers:  Inpatient hospital care  Skilled nursing facilities (Under

certain conditions)

 Typically doesn’t require a monthly

payment (Premium)  Does require out-of-pocket deductible for

hospital stays (in 2010):  $1,100 of 1-60 days  $275 per day co-pay for days 61-90  $550 per day co-pay for days 91-150  All costs beyond 150 days  For skilled nursing facilities:  $137.50 per day for days 21 through 100 for each benefit period

 Helps cover:

Medicare Part B

Physician services  Some physical and occupational therapists  Some home healthcare 

 Also covers other services and

supplies: Glucose monitors  Test strips  Lancets 

 There is a monthly premium to enroll  The standard Part B premium for 2009 is

$96.40 per month (income based)  In general, automatically deducted from social security checks  2010 annual deductible of $155.00  Once deductible is paid enrollee generally pays a 20% co-payment for each service

Medicare Advantage ď‚— Health insurance

coverage, including preventative care PLUS prescription drug coverage in a single plan

ď‚— In exchange, typically

must use a certain network of doctors, hospitals, and pharmacies (HMO, PPO)

Medicare Advantage  12 plans available in Rhode Island

 **If you already have a Medicare

Advantage plan and you want to add drug coverage you MUST obtain it through your Medicare Advantage provider.  If you obtain an independent standalone

drug plan instead, your health coverage under the Medicare Advantage plan will stop.

MEDICARE PART D  Stand-alone prescription drug coverage  Open to all people eligible for Medicare  Open enrollment begins November 15, 2009  Enrollment for coverage of the year 2010

ends on December 31, 2009  Coverage Begins on January 1st, 2010

 Medicare Part D is VOLUNTARY!!

When Can I Enroll in a Part D Plan?  Re-enrollment begins November 15th, 2009!  Your new plan will take effect January 1st, 2010  If you are happy with your current part D plan, you

don’t need to do anything during the re-enrollment period!  Your Med D plan will automatically re-enroll you

your premiums, co-pays, formulary, or deductible may be changed for the new year!

 But be aware:::::

Enrollment Info  Open enrollment is from

Nov.15-Dec 31st of each year  Coverage begins on January 1, 2010  If you become eligible for Medicare

Part D after the enrollment period, you have a 7 month period to enroll without incurring a penalty  3 months before, the month of and 3 months after the month of your 65th birthday

Who Should Apply?  People who are enrolled in a Med D plan right now,

year

but thinking about switching to another plan next

 You didn’t sign up for a plan when eligible

now

last time around but you’re thinking of enrolling

 Penalty for every month without coverage

 Enrolled in a Medicare Advantage Plan or Medigap

Supplemental Insurance Plan but you want to add or change your drug coverage

Who Doesn’t Need To Apply  If you have CREDITABLE Coverage:  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

 You would have already been made aware of

this by your insurance provider by mail  KEEP THIS LETTER IN A SAFE PLACE**

**If you are unsure if your coverage is creditable or not, ask your employer or union for it!**

Penalty Info  If you did not enroll but were eligible to do so,

when you enroll now for coverage beginning on Jan.1, 2010- you will incur a penalty of 1% per month of average premium

 Will have to wait until Nov 15- Dec 31, 2010 to

join a Medicare drug plan if don’t do so now!    

Average premium 2009 = $38.85 1% of $38.85 = $0.39 12 months penalty= $4.66 Therefore, $4.66 will be added unto your monthly premium every month forever!

Penalty Info You will not have this penalty enforced: ď‚—

If you were not previously eligible for Medicare Part D

ď‚—

If you previously had creditable coverage

HOW PART D WORKS  Remember::: this is just an explanation of the

template used as a general basis for the plans --there are options!

 STANDARD PLAN (2010)  $38.85 per month premium ($466.20/year)  $310 deductible  75% coverage from $310 to $2,830  NO coverage from $2,830 to $6,440 

This is called the coverage gap or

“Donut Hole”

 95% coverage beyond $6,440  Equivalent to $4,550 dollars out of pocket spending

Over $6440 $2830 – 6440 $310 - 2830 $0 - 310

Think of it as Steps!  Step #1 – The Deductible  You pay 100% and plan pays 0%  You receive $310 worth of medications  Step #2 – Co-insurance  You pay 25% ($630) and plan pays 75% ($1890)  You receive $2520 worth of medications (Total: Step 1 + Step 2 = $2830)

Think of it as Steps!  Step #3 – The Donut Hole  You pay 100% and plan pays 0%  You receive $3610 worth of medications  Total: Step 1 + Step 2 + Step 3 = $6440  Step #4 – Catastrophic

Coverage

 You pay 5% and plan

pays 95%  You receive unlimited drugs for the remainder of calendar year

Remember! 

Even though you were enrolled in a program last year, you start from the Step #1 all over again on January 1, 2010



You will continue to pay the premium every month regardless of what step that you are on  Even when in the “donut hole” a

person still pays the monthly

Besides Standard Plan…  Must offer basic/standard drug benefit  May offer enhanced benefit 

 Some have no deductible  Some have help during “donut hole”

(coverage gap)

 The Premium depends on the enhancements  Mail order options may save costs on

maintenance medications (90 days)

How Do I Choose The Right Plan?

Rx Enrollment Check-Up: Cost  Will your premium and costs change in 2010?

Coverage  Will you need more comprehensive coverage?  Will your current meds be covered by your plan?

Customer Service  Are you satisfied with your service from your

current plan?

Side Note: ď‚— If you decide that your

current Med D plan will meet your needs in 2010 then you do not need to re-enroll ď‚— Coverage will continue

through 2010 starting from Step 1

Plans Available in RI for 2010  Total of 48 plans offered  19 plans available with NO deductible!  38 Plans without gap coverage  Monthly premiums without gap coverage start at $10.80

& range from $10.80 – $77.70  12 PDPs have $0 premium if qualify for extra help

 10 Plans with gap coverage  Monthly premiums with gap coverage start at $59.30  Lowest premiums have only generic coverage  All medicare patients are eligible for a medicare

advantage plan

What is a Formulary?  Formulary system  Each plan selects certain drugs

from each drug class that they will cover

 May have a tier system  May have up to 5 tiers  Generic drugs = cheapest (ex: $5)  Preferred brand names = more expensive (ex: $28)  Non-preferred brand names = most expensive (ex: $40)  Certain injectable and specialty drugs= highest tiers

Drugs Not Covered Under Most Part D Formularies  Benzodiazepines

 Drugs for cosmetic

 Barbiturates

purposes or hair growth  Fertility drugs  Prescription vitamins, minerals

 Weight loss  Erectile dysfunction  Cough & cold relief  Non prescription

drugs

 Except prenatal vitamins

and fluoride preparations

Definitions:  Generics: will be required to be covered by ALL plans  Chemically identical to brand-name drugs and meet the same rigorous standards put

forth by the FDA (US Food and Drug Administration) for: Safety, Purity, Effectiveness  Generic drugs can be legally produced in the US if a patent has expired, or for drugs which have never been patented

 Prior authorization: may be needed for some medications  Appeal process mandated by insurance company which includes paperwork

involving the MD

 Step Therapy: may be required before certain medications will be covered  ex: Prilosec before Nexium, or Motrin before Celebrex

 Quantity limits: may be enforced  30 day quantities retail vs. 90 day mail-order 

Some plans DO allow 90 day quantities of maintenance medicines at community pharmacies.

Frequently Asked Questions

Who pays for my vaccines?  Now Medicare part D must

cover all vaccines not covered by part B  Ex: Zostavax (Shingles vaccine)

 Vaccines covered by part B  Pneumococcal  Influenza  Hepatitis B  Vaccines necessary to treat a

disease or prevent one after direct exposure 

Ex: tetanus

WHAT ABOUT MY RIPAE?  You SHOULD keep your RIPAE!  It will provide coverage throughout the deductible & coverage gap  BUT, it is not creditable coverage  You need a Medicare Part D Plan too  Starting January 2009, RIPAE will only be

available for those enrolled in a Medicare part D plan  Must send in copy of enrollment letter or card

 See your SHIP counselor or

call The Point for RIPAE information

RIPAE…  Provides extra benefit for those who don’t

qualify for extra help from Medicare  Applicable to all expenses that

person is 100% responsible for:  Deductible  Coverage gap (“Donut Hole”)  Drugs not covered under your Part D Plan 

Only certain ones!

RIPAE…  Eligible:  Single, income less than $42,493 per year  Married, income less than $48,563 per year 

The lower the financial category, the higher percentage RIPAE will pay

More information: 401-462-4444 The Point Wrong phone number on Medicare & You 2008 Booklet!

Talk to SHIP counselor

What About My Tricare, VA, Pension Benefits?  They are creditable coverage,

letters have been sent in mail!  Hold on to these letters!  Contact your pension benefits

manager or union if you have any questions

Dual Eligibles (Medicare/Medicaid)  Will automatically be eligible for:    

No premium No deductible No donut hole Minimum co-payments ($1.10 generic & $3.30 brand)

 Have been automatically enrolled in a plan

& will be automatically re-enrolled in a plan

 Part D plan for 2010 won’t necessarily

be the same plan as 2009

 Reassignment notices are being sent out  Enrollment confirmations will follow  If you are “dually eligible,” you can change your

plan at any time during the year! Once per month!

What is Extra Help?

(Low Income Subsidy)  Federal poverty limits determined by government each year  Best to apply and be formally denied  Many deductions, so apply!

 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  Defined as those who had Low Income Subsidy

(LIS) for 2009 & are not automatically eligible for 2010

 Notifications being sent out with applications to re-enroll

 Does not mean that you are not eligible  Reapply!!!  Check with your SHIP counselor or The Point

Ways to Lower Your Drug Costs During the Coverage Gap 

Ask your doctor about generic and less expensive brand name drugs (therapeutic substitutions)  

  

Cheaper in the gap Less likely to hit the gap if avoid brand name medications from the beginning!

Ask your doctor for samples National & Community Based Charitable Programs  For specialty drugs Pharmaceutical Assistance Programs  Available from the pharmaceutical manufacturers  Contact the Partnership for Prescription Assistance 

1-888-477-2669

Ways to Lower Your Drug Costs During the Coverage Gap 

State Pharmaceutical Assistance Programs 

RIPAE 



Based on your income, RIPAE will pay 15%, 30%, or 60% of drug cost during coverage gap

Apply for Extra Help 



If you have limited income and resources, you may qualify for extra help For more information go to www.socialsecurity.gov or call

1-800-772-1213

President Obama’s Plan  Proposed to cut in half the

prescription drug expenses of those who fall into the dreaded Part D doughnut hole!  This means you would only pay

50% of the cost of brand-name medications in the gap – instead of the 100%you pay now!

 If passed, it would go into

effect in July 2010…

What if I Like A Plan & One of My Drugs is Not Covered?  Options:  Ask your pharmacist about therapeutic substitution  Compare prescription vs. over-thecounter (OTC) options   

Nexium $158.00 Prilosec OTC $21.99 Omeprazole Rx- lowest cost or co-pay

 Always consult with your doctor

regarding changes to your medications

Drugs that are Not Covered by ANY Part D Plan  Can still get these drugs but must pay the retail

price (“cash”) and it does not count towards out of pocket expenses or total drug costs Examples:  Benzodiazepines 

alprazolam, lorazepam, diazepam

 Drugs for weight loss, hair loss, and fertility  Drugs covered under Medicare parts A and B 

Example: Drugs received while in the hospital, diabetic testing supplies

Medicare Fraud  The vast majority of your health care providers are

committed to providing you with high quality care…

 However, there are some individuals who cheat the

system out of millions of dollars, which results in higher premiums for its members.

 Be very cautious when dealing with your Medicare information, &

never share it with a medical professional unless you are absolutely certain that they need it.  Never share your Medicare information over the phone with someone else!

Medicare Fraud  Medicare fraud is purposely billing Medicare for

services that were never provided or received. 

Billling Medicare or another insurer for services or items you never got.



Billing Medicare for services or equipment which are different from what you got.



Use of another person’s Medicare card to get medical care, supplies, or equipment.



Billing Medicare for home medical equipment after it has been returned.

www.medicare.gov

Medicare Fraud The Do’s and Don’ts  Don't give out your Medicare Health Insurance

Claim Number (on your Medicare card) except to your physician or other Medicare provider.

 Don’t give out social security or credit card numbers  Don't allow anyone, except appropriate medical

professionals, to review your medical records or recommend services.

 Don't contact your physician to request

a service that you do not need.

www.medicare.gov

Medicare Fraud The Do’s and Don’ts  Do be careful in accepting Medicare services

that are represented as being free.

 Do be cautious when you are offered free

testing or screening in exchange for your Medicare card number.

 Do be cautious of any provider who

maintains they have been endorsed by the Federal government or by Medicare.

 Do avoid a provider of health care items or

services who tells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid. www.medicare.gov

Using the Internet  Get a complete list of your medications & the cash price

from the pharmacy  Include all prescriptions-eye drops, creams, inhalers, patches, etc.

 Go to www.Medicare.gov and click on “Formulary Finder”  Follow the prompts and enter your medications

 Can also call 1-800-MEDICARE (1-800-633-4227)  Can enroll on line—have your Medicare card ready  CVS and Walgreens both have websites to condense your

search of possible plans  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 December 8- Don’t Be Late December 31- Open Enrollment Ends January 1, 2010- Coverage Begins

***Next Open Enrollment Period is not until November 15December 31, 2010***

In summary….  No single plan is best for everyone  You must pick the plan that’s right for YOU!

 Yes, it is confusing! Don’t be afraid to ask for help:  The Point!!! (401) 462-4444  SHIP counselors at your local Senior Center  Dept. of Elderly affairs (401) 462-4000  Ask a relative or friend to help you navigate the Web  Social Security Administration 1-800-772-1213  Pharmacy Outreach Program 1-800-215-9001 

www.uri.edu/pharmacy/outreach

THANK YOU!