What you need to know about Medicare Part D - 2013

Pharmacy Outreach Program The University of Rhode Island College of Pharmacy Updated October 2012

MEDICARE  Medicare provides health insurance for…  Aged A d 65 years or older ld  Aged 65 years or less with certain disabilities  All people l with ith E End-Stage d St Renal R l Di 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 2012):  $1,156 of 1-60 days  $289 per d day co-pay for f days d 61-90 61 90  $578 per day co-pay for days 91-150  All costs beyond 150 days  For skilled nursing facilities:  $144.50 per day for days 21 through 100 for each benefit period

 Helps p cover:

Medicare Part B

Physician services  Durable medical equipment  Physical therapists 

 Also covers other services and

supplies: Glucose monitors  Test strips  Lancets 

 There is a monthly premium to enroll  The standard Part B premium for 2013 is

$120.20 per month (income based)  In general, automatically deducted from social security checks  Once deductible is paid enrollee generally pays a 20% co co-payment payment for each service

Medicare Advantage (Part C)  Health insurance

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

 In exchange, typically

must use a certain network t k off doctors, d t hospitals, and pharmacies (HMO, PPO)

Medicare Advantage  6 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 Advantage  Annual Enrollment Period in 2012  October 15‐December 7, 2012  Can choose to leave current Medicare Advantage plan to

switch to an Original Medicare plan  Can add prescription coverage ‐ Part D

MEDICARE PART D  Stand-alone prescription drug coverage  Open to all people eligible for Medicare  Open enrollment begins October 15, 2012  Enrollment for coverage of the year 2013

ends on December 7,, 2012  Coverage Begins on January 1st, 2013

 Medicare M di Part P t D is i VOLUNTARY!!

Wh C I E ll When Can I Enroll in a Part D Plan? in a Part D Plan?  Re-enrollment begins October 15th, 2012!  Your new plan will take effect January 1st, 2013  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  But be aware:::::

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

Enrollment Info  NEW Open enrollment is from

Oct 15 – Dec 7th 2012 of each year  Dates just changed

 Coverage begins on January 1, 2013  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,

but thinking about switching to another plan next year

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

last time around but you’re thinking of enrolling now  Penalty Penalt for e every er month without itho t co coverage erage

 Enrolled in a Medicare Advantage g Plan or Medigap g p

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

 People who have major changes in the medications

they take on a daily basis

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 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 J 1 2013 – you will Jan.1, ill iincur a penalty lt off 1% per month of average premium

 Will have to wait until 2013 enrollment period to

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

Average premium 2013 = $31 $31.17 17 1% of $31.17 = $0.31 12 months penalty= $3.74 Therefore, $3.74 will be added on to your monthly premium every month forever!

Penalty Info You will not have this penalty enforced: l f d 

If you were not y previously p y eligible for Medicare Part D



If you previously had y p y creditable coverage

Affordable Care Act Changes  Lower costs during donut hole:  Patients pay 47.5% of brand name drugs  Discount of generic drugs will raise from 21% this year  Better Quality care:  Bonus payments from the government will give p y g g incentives to Medicare Advantage plans with better quality care

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

template used as a general basis for the plans --there there are options!  STANDARD PLAN (2013)  $31.17 $31 17 per month premium ($374 ($374.04) 04)  $325 deductible  75% coverage g from $320 to $2,970  New limited coverage from $2,970 to $6,733.75  Patient pays 50% of Brand Drugs and up to 86% of generic drugs 

This is called the coverage gap or “Donut

 95% coverage beyond $6 $6,733.75 733 75

Hole”

HOW PART D WORKS HOW PART D WORKS Catastrophic C t t hi C Coverage > $6733.75

Medicare Pays 95% 5%

Donut hole - $2970 – $6733.75 $

47.5%-79%

Co-Insurance : $325-2970

75%

0 - $325 is your Deductible

You Pay 100%

25%

New Change for Donut hole, will only spend 47.5% out of pocket for brand name and 79% maximum for generic drugs!!!

Think of it as Steps!  Step #1 – The Deductible  You pay 100% and plan pays 0%  You Y receive i $325 worth h of medications

Medicare ed ca e Pays ays 95% 5%

C i  St Step #2 – Co-insurance  You pay 25% and plan pays 75%  You receive Yo recei e $2645 worth orth of medications (Total: Step 1 + Step 2 = $2970)

47.5%-79%

75%

You Pay 100%

25%

Think of it as Steps! o t as Steps!  Step #3 – The Donut Hole  New N changes h llett you pay  

47.5% of brand drugs Max of 79% generics

 You receive $3 $3,763.75 763 75

worth of medications  Total: Step 1 + Step 2 + Step p3=$ $6733.75  New discounts!

Medicare Pays 95% 5% 47.5%-79%

 Step #4 – Catastrophic

Coverage g  You pay 5% and plan

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

75%

You Pay 100%

25%

Remember! 

Even though you were enrolled in a p program g last yyear,, you start from the Step #1 all over again on January 1, 2013



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 premium!

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

 Some have no deductible  Some have help during “donut donut hole” hole (coverage gap)  The Premium depends on the enhancements  Mail order options may save costs on

maintenance medications (90 days)

Explaination of Benefits  A statement sent by your insurance company telling

you which medical services were paid for by them.  Includes: I l d  The service: date/place service provided  Doctors fee and what was paid by them  Remainder that the patient is responsible for

 To show you what portion the insurance is paying for

and which portion you are. p y

How Do I Choose The Right Plan?

Rx Enrollment Check-Up: C Cost  Will your premium i and d costs t change h iin 2013?

Coverage  Will you need more comprehensive coverage?  Will your current meds be covered by your plan?  Now No that don donutt hole is partiall partially co covered, ered is sswitching itching a better option? Customer Service  Are you satisfied with your service from your current plan?

Side Note:  If you decide that your

current Med D plan will meet your needs in 2013 then you do not need to re-enroll  Coverage will continue

through 2013 starting from Step 1

Plans Available Plans Available in RI for 2012 in RI for 2012  Total of 30 prescription plans offered  14 plans l available il bl with ith NO deductible! d d tibl !  20 Plans without gap coverage  Monthly premiums start at $15 AARP MedicareRx Saver Plus

 10 Plans with gap coverage  Monthly y premiums p with g gap p coverage g start at $ $39 and g go up p to $114  Lowest premiums have only generic coverage  All Medicare patients are eligible for a Medicare

advantage plan

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

from each drug class that they will cover  May have a tier system  May y have up p to 5 tiers  Generic drugs = cheapest (ex: $5)  Preferred brand names = more expensive (ex: $28)  Non Non-preferred preferred brand names = most expensive (ex: $40)  Certain injectable and specialty drugs= highest tiers (ex: $58)

Drugs Not Covered Under Most Part D Formularies Part D Formularies  Benzodiazepines

 Drugs for cosmetic

 Barbiturates

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

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

drugs

 Except prenatal vitamins

and fluoride fl oride 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  RIPAE is only available for those enrolled in a Medicare

part D plan  Must send in copy of enrollment letter or card

 See y your SHIP counselor or call The Point for RIPAE

information

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

qualify lif ffor extra t h help l from f Medicare M di  Applicable to all expenses that

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

Onlyy certain ones!

RIPAE…  Eligible:  Single, income less than $45,991 per year  Married,, income less than $52,561 $ , per p year y 

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,

l tt letters have h been b sentt in i mail! il!  Hold H ld on tto th these lletters! tt !  Contact your pension benefits

manager or union if you have any yq questions

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

No premium N d No deductible d tibl 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 2013 won’t necessarily

b th be the same plan l as 2012

 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) (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, eligible a person’s person s resources

must be no greater than the limits established Single*

Married*

Yearly Income

<$16,335

<$22,260

Resources

<$12 640 <$12,640

<$25 260 <$25,260

*Includes $1,500 per person burial expenses

“Deemed” Population  Defined as those who had Low Income Subsidy

(LIS) for 2012 & are not automatically eligible for 2013  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 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 Pharmaceutical Assistance Programs  A il bl ffrom th Available the pharmaceutical h ti l manufacturers f t  Contact the Partnership for Prescription Assistance 

1-888-477-2669

Ways to Lower Your Drug Costs 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 y 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

New Medicare Changes  Changes in amount covered during

the Coverage Gap!  47.5% 47 5% ffor b brand d name prescriptions i ti (↓ from f

50%)  79% for generic prescriptions (↓ from 86%)

 Greater G t Coverage C ffor preventive ti

medical services  Depression  Cardiovascular Disease  Alcohol Abuse  Obesity

What if I Like A Plan & One 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 N i $158 $158.00 00 Prilosec OTC $21.99 Omeprazole Rx- lowest cost or co-pay

 Always consult with your doctor

regarding changes to your medications

D th t N tC db 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, p , lorazepam, p , diazepam p

 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 itt d to t providing idi you with ith high hi h quality lit care…  However, there are some individuals who cheat the

system t outt off millions illi off dollars, d ll which hi h results lt in i higher premiums for its members.  Be very cautious when dealing with your Medicare information, &

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

Using the Internet  Get a complete list of your medications  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 e Aid d has as plan p a finding d g so software, a e, jus just ca call you your Rite e Aid d pharmacist and schedule a time to choose a plan

Important Dates Important Dates to Remember to Remember October 1 1- Compare and Prepare October 15- Open Enrollment Begins p Enrollment Ends December 7- Open January 1, 2013- Coverage Begins

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 1-800-772-1213 800 772 1213  Pharmacy Outreach Program 1-800-215-9001 

www.uri.edu/pharmacy/outreach

THANK YOU!