Agenda. Medicare Overview Medicare Part B Drug Coverage Medicare Part D: How to Find and Compare Medicare Part D Plans Summary Provider Contacts

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2 2 Medicare Part D

3 Agenda Medicare Overview Medicare Part B Drug Coverage Medicare Part D: Background Benefits of Medicare Part D Enrollment Coverage Specialty Medications Part D Costs How to Find and Compare Medicare Part D Plans Summary Provider Contacts 3

4 Medicare Overview Created in 1965 as Part of the SSA Part A: Automatically enrolled at age 65; provides hospital coverage Part B: Voluntary program; pay monthly premium; covers physician services and some items/supplies not covered by Part A Medicare Advantage: Created in 1997 as Medicare+Choice Medicare Part D: January 1,2006

5 Medicare Part B Drug Coverage There are significant limitations on Part B coverage of drugs and biologicals that do not apply under Part A Not usually self-administered Reasonable and necessary Administered as incident to service Not excluded as immunization Not found by the FDA as less than effective

6 Medicare Part B Statutory Exemptions Exemption to rule of self-administration for oral anti-cancer and oral anti-emetic drugs Covered, even when self-administered - If they contain the same active ingredients as intravenously administered anti-cancer drugs and anti-emetic drugs Must be used during the period that begins immediately before and ends within 48 hours after the time of administration of the anti-cancer drug Must be used as a full replacement for anti-emetic therapy that otherwise would be administered intravenously

7 Drug Coverage Prior to Part D Prior to creation of Part D, Medicare beneficiaries received drug coverage in the following ways: No coverage Medicare Part B Medigap Policy Medicare Advantage plan

8 Medicare Part D Background 8 Implemented in 2006 The original target for Part D was 29 million achieved nearly 24 million this year 9.5 million currently receiving Extra Help--about 1 in 3 beneficiaries More may be eligible for the Low Income Subsidy. Contact the Social Security Administration to apply

9 Benefits of Medicare Part D 9 Available to all people on Medicare Part D provides greater access to drugs that one can use to prevent complications of diseases and stay well. Enrollment is voluntary Auto-enrollment for dual eligible beneficiaries Estimated 1/3 of Medicare beneficiaries qualify for low-income subsidy, or Extra Help

10 Enrollment Period for Medicare Part D An individual may sign up for Medicare when they become eligible for Medicare (three months before they turn 65 and until three months after). If an individual applies for Medicare due to a disability, he or she can join as early as three months before and up to three months after the 25 th month of disability payments. If an individual does not enroll when first eligible then the next opportunity to enroll is November 15 thru December 31 each year. You will pay a penalty each year if you do not enroll when you are initially eligible

11 Medicare Part D Plans Coverage provided through two types of plans: Prescription Drug Programs (PDPs) Stand Alone Plans (FFS) Medicare Advantage Prescription Drug Plans (MA-PD) HMOs that cover drugs and other Medicare benefits 17 national plans in 2007 Plans available vary by region Listing of plans by state/region available at 11

12 Medicare Part D Coverage & Formularies Definition of a Part D Drug is a drug that is included in a Part D plans formulary Every plan has a formulary that is managed by the P&T committee Part D formularies must include drug categories and classes that cover all disease states USP Classification System American Hospital Formularies 12

13 Medicare Part D Formularies Each category or class must include at least two drugs Unless there is only one drug in the class Generic and brand do not count as two different drugs Must be 2 chemically distinct drugs Formulary changes must be sent to CMS for approval Defined process No changes prior to March 1 of each year Beneficiaries must be notified

14 Specialty Medications Specialty Medications are covered under both Medicare Part B and Part D. In order for them to be covered services thru Part B they must meet the Medicare Coverage Criteria requirements. If coverage criteria is not met and the patient elected Part D they will be covered if the medication is on the plan s formulary. 14 Oral medications are not covered under Part B and therefore are billable to Part D if they are on the plan s formulary

15 Standard Medicare Part D Benefit Cost Standard Medicare Prescription Drug Benefit, 2007 Enrollee Pays 5% Plan Pays 95% $5,451 in Total Rx Costs Enrollee Pays 100% $3,051 Coverage Gap Enrollee Pays 25% Plan Pays 75% $328 Average Annual Premium $2,400 in Total Rx Costs $265 Deductible 15 Kaiser Family Foundation, 2006 Figure available for download at

16 Part D Beneficiary Cost Chart Example Cost-Sharing % Beneficiary OOP Costs Plan Payment % Plan Payment Annual Deductible 100% $2655 0% $0 Initial Benefit ($265 - $2400) 25% $ % $ No Coverage of Costs $ $ % $ % $0 Catastrophic Coverage The greater of: 5% or flat copay -- 95%

17 Low Income Subsidy Extra Help Low Income Subsidy Level Monthly Premium Annual Deductible Co-payments Full Dual Eligible Beneficiaries $0 $0 $1-$2.15/generic $3-$5.35/brand No co-pays after spending reaches $5, Individuals with incomes <135% FPL and assets <$7,500; $12,000/couples $0 $0 $2.15/generic $5.15/brand No co-pays after total spending reaches $5, Individuals with incomes 135%-150% FPL and resources <$11,500; $23,000/couples Sliding scale $53 15% of total cost up to $5,451.25; $2.15/generic and $5.35 brand thereafter 17

18 More about Extra Help 18 Dual eligible beneficiaries automatically qualify for assistance Non-dual eligible beneficiaries have options too: Social Security Administration Pharmaceutical Assistance Programs State Pharmacy Assistance Programs (SPAP) As of June 2007, all LIS beneficiaries can change plan at any time during the year

19 Caring Voice Coalition for PAH The Caring Voice Coalition (CVC), Inc. is a national non-profit, charitable organization, established in 2003 to serve the comprehensive needs of individuals affected by serious, chronic disorders. Current CVC programs include: Insurance Reimbursement Program Financial Assistance Program Patient Support Program Public Advocacy Support Program

20 How To Research and Compare Medicare Part D Plans 20

21 Find and Compare Part D Plans To Find and Compare Plans go to s/searchoptions.asp Step 1 Choose a personal plan search or a general plan search 21

22 Find and Compare Part D Plans General Search Step 2 - Answer the questions as they apply to you and click continue 22

23 Find and Compare Part D Plans General Search Step 3 - Review current coverage entered and click continue 23

24 Find and Compare Part D Plans General Search Step 4 Decide if you want to enter your drugs to obtain specific drug costs for you 24

25 Find and Compare Part D Plans General Search Step 5 If you choose to enter your drugs, enter the drug name and click Search for Drug Next choose Add More Drugs until all are entered and click Continue Step 6 Enter your drug vial size, dose and days supply for each drug entered Click continue when finished 25

26 Find and Compare Part D Plans General Search Step 7 Choose to Save your drug list or skip this step 26

27 Find and Compare Part D Plans General Search Step 8 Indicate if you want to select a specific pharmacy 27

28 Find and Compare Part D Plans General Search Your Personalized Plan List is then displayed 28

29 Information Available on the Personalized Plan List The number of plans you can choose from in your zip code The Names and ID number of each plan You may select up to 3 plans to compare If you click on the payer name you will get the drug plan details Contact information for the payer Fixed costs Drug coverage information Estimated Annual cost Monthly drug premium Annual deductible Coverage in the Gap Number of Network Pharmacies 29

30 Information Available on the Personalized Plan List Drug Coverage Information The drug coverage information indicates: The formulary status (i.e. Tier 1, 2, 3 or Specialty) If prior authorization is required Any drug quantity limits If it is a step therapy (This specifies if another drug is necessary to try and fail before the drug you selected) 30

31 Medicare Part D Standard Model 31 Description Month 1 of new year Month 2 forward of New Year Sample Price of Drug $4,000 $4,000 Enrollee Pays Deductible $265 Paid Balance $3,735 $3,940 Enrollee Pays 25% of next $2,135 after deductible $534 NA Balance $3,201 $3,940 Enrollee Pays 100% of $3,051 (Donut Hole) $3,051 NA Balance $150 $3,940 Enrollee pays 5% $6 $197 Balance paid by plan $144 $3,743 Balance $0 $0 1. Part D starts over each January 1 st. 2. Medicare eligible patients, regardless of income, can participate in Part D plans. Income, however, will qualify patients for a higher range of assistance and less out of pocket costs. 3. The costs to the left do not include the Part D premiums or the Part D plans which lessen out of pocket expenses. 4. Plans have different formularies, co-pay arrangements.

32 Medicare Part D - Standard Model Pays one time each year, Some may be exempt (LIS) Amount varies per Individual case, plan Coverage, enrollee Income, time of year. Amount varies depending Upon enrollee eligibility, Plan, formulary. Brand co-pays can be $5.35 per month. 32

33 Summary Medicare Part D plans vary greatly Out-of-pocket costs may be substantial for many Medicare Part D beneficiaries with PAH Open enrollment will begin Nov. 15-Dec. 31, 2007 for 2008 coverage Non-LIS beneficiaries may change plan Review eligibility for LIS. Most companies have programs and resources for patients to get assistance

34 Provider Contacts for Part D Accredo Health Group Mission: Accredo Therapeutics is a national provider of innovative care dedicated to meeting the needs of patients with chronic conditions. We are committed to providing customized solutions to the unique needs of our patients, physicians, payers and manufacturers through our locally focused operations and staff of experienced professionals PAH Medications available: Flolan, Letairis, Remodulin, Revatio, Sildenafil, Tracleer, Ventavis Contact number: FIGHT-PH PAH Pathways Actelion Services & Support Mission: A central point of access and service to support patients and healthcare providers who use Actelion products Tracleer and Ventavis. Contact number: Gilead Sciences, Inc. Mission: To discover, develop and commercialize therapeutics that advance patient care, while challenging employees to make a difference and building a thriving worldwide enterprise. Contact number: LEAP 34

35 Good References t.asp Call Social Security at

36 Thank you Carla Monacelli Managing Partner, Argenta Reimbursement Advisors Sponsored by Actelion