1 Pharmacy Outreach Program The University of Rhode Island College of Pharmacy Updated October 2014
2 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)
3 Part A Hospital insurance Part B Medical insurance Part C Medicare Advantage Plans Part D Prescription drug coverage
4 Covers: Inpatient hospital care Skilled nursing facilities (Under certain conditions) Usually doesn t require a monthly payment (Premium) Out-of-pocket deductible for hospital stays (in 2014): Days 1 60: $1,216 deductible Days 61 90: $304 coinsurance per day Days : $608 coinsurance per day Beyond day 151: patient pays all costs. For skilled nursing facilities: $152 per day for days 21 through 100 for each benefit period
5 Helps cover: Physician services Durable medical equipment Physical therapists Also covers other services and supplies: Glucose monitors Test strips Lancets Vaccines There is a monthly premium to enroll The standard Part B premium for 2014 is $ per month (income based) In general, automatically deducted from social security checks The Part B deductible is $147 Once deductible is paid enrollee generally pays a 20% co-payment for each service
6 Health insurance coverage, including preventative care PLUS prescription drug coverage in a single plan In exchange, typically must use a certain network of doctors, hospitals, and pharmacies (HMO, PPO)
7 9 plans available in Rhode Island with drug coverage 2 more plans without drug coverage 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 they offer it. If you obtain an independent standalone drug plan instead, your health coverage under the Medicare Advantage plan will stop and you will return to Original Medicare.
8 Annual Enrollment Period in 2014 October 15-December 7, 2014 Can choose to leave current Medicare Advantage plan to switch to an Original Medicare plan Can add prescription coverage - Part D
9 Stand-alone prescription drug coverage Open to all people eligible for Medicare Open enrollment begins October 15, 2014 Enrollment for coverage of the year 2015 ends on December 7, 2014 Coverage Begins on January 1 st, 2015 Medicare Part D is VOLUNTARY!!
10 Re-enrollment begins October 15 th, 2014! Your new plan will take effect January 1 st, 2015 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 the new year!
11 NEW Open enrollment is from Oct 15 Dec 7 th of each year Coverage begins on January 1, 2015 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 your 65 th birthday
12 People who are enrolled in a Med D plan right now but are 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: 1% increase in premium for every month not enrolled Enrolled in a Medicare Advantage Plan or Medigap 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
13 If you have CREDITABLE Coverage: Creditable Coverage = a plan that provides a prescription drug benefit that is EQUIVALENT or better than Medicare Part D coverage 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!**
14 If you did not enroll but were eligible to do so When you enroll now for coverage beginning on Jan.1, 2015 you will incur a penalty of a premium increase of 1% per month that you were eligible Will have to wait until 2015 enrollment period to join a Medicare drug plan if don t do so now! Average premium 2014 = $ % of $32.42 = $ months penalty= $3.89 rounded to nearest 0.10= 3.90 Therefore, $3.90 will be added on to your monthly premium every month forever!
15 You will not have this penalty enforced: If you were not previously eligible for Medicare Part D If you previously had creditable coverage
16 Those with Medicare Part D that have an annual income above a certain level will have an additional fee added to their monthly premium Penalty based on gross income reported on the income tax return from 2 years prior Paid directly to Medicare (aka the Federal government) It is not collected by Medicare Part D plans
17 The amount of an individual s IRMAA will be deducted from any government benefits (e.g. Social Security) If sufficient funds are not available, individuals will be billed directly from Medicare Medicare Part D beneficiaries will be contacted by the Social Security Administration if they are affected by the 2014 IRMAA
18 Beneficiaries who file individual tax returns with income that is: Less than or equal to $85,000 Greater than $85,000 and less than or equal to $107,000 Greater than $107,000 and less than or equal to $160,000 Greater than $160,000 and less than or equal to $214,000 Beneficiaries who file joint tax returns with income that is: Less than or equal to $170,000 Greater than $170,000 and less than or equal to $214,000 Greater than $214,000 and less than or equal to $320,000 Greater than $320,000 and less than or equal to $428,000 Medicare Part D Income Related Monthly Adjustment Amount $0.00 $0.00 $0.00 $12.30 $12.10 $11.60 $31.80 $31.10 $29.90 $51.30 $50.20 $48.10
19 Lower costs during donut hole : Patients pay 45% of brand name drugs Patients pay 65% of generic drugs Better Quality care: Bonus payments from the government will give incentives to Medicare Advantage plans with better quality care
20 Remember: this is just an explanation of the template used as a general basis for the plans-- there are options! STANDARD PLAN (2015) $31 per month premium $320 deductible (some plans don t have deductibles) 68% coverage until you ve paid $2,960 (copay varies by plan) Limited coverage until total of $4,700 spent Patient pays 45% of Brand Drugs and up to 65% of generic drugs This is called the coverage gap or Donut Hole 95% coverage beyond the coverage gap (% varies by plan)
21 HOW PART D WORKS Catastrophic Coverage > $4700 Donut hole - $2960 $4700 Medicare Pays 95% 45%-65% 5% Co-Insurance : $ % 25% 0 - $320 is your Deductible You Pay 100% New Change for Donut hole, will only spend 45% out of pocket for brand name and 65% maximum for generic drugs!!!
22 Step #1 The Deductible You pay 100% and plan pays 0% You receive $320 worth of medications Step #2 Co-insurance You pay 25% and plan pays 75% You receive $2,640 worth of medications (Total: Step 1 + Step 2 = $2960) Medicare Pays 95% 75% 25% You Pay 100% 45%-65% 5%
23 Step #3 The Donut Hole New changes let you pay 45% of brand drugs Max of 65% generics Total: Step 1 + Step 2 + Step 3 = $4700 New discounts! Step #4 Catastrophic Coverage You pay 5% and plan pays 95% You receive unlimited drugs for the remainder of calendar year Medicare Pays 95% 75% 25% You Pay 100% 45%-65% 5%
24 Even though you were enrolled in a program last year, you start from the Step #1 all over again on January 1, 2015 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!
25 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)
26 A statement sent by your insurance company telling you which medical services were paid for by them. Includes: 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.
27 Get a complete list of your medications Include all prescriptions-eye drops, creams, inhalers, patches, etc. Go to and click on Formulary Finder Follow the prompts and enter your medications Can also call MEDICARE ( ) 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
35 Rx Enrollment Check-Up: Cost Will your premium and costs change in 2015? Coverage Will you need more comprehensive coverage? Will your current meds be covered by your plan? Now that donut hole is partially covered, is switching a better option? Customer Service Are you satisfied with your service from your current plan?
36 If you decide that your current Med D plan will meet your needs in 2015 then you do not need to re-enroll Coverage will continue through 2015 starting from Step 1
37 Total of 26 prescription plans offered 11 plans available with NO deductible! Monthly premiums start at $15.60 Humana Walmart Rx Plan 9 Medicare advantage plans Lowest premiums have only a few brands covered All Medicare patients are eligible for a Medicare advantage plan
38 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 (ex: $58)
39 Non-FDA approved drugs Weight loss or gain Erectile dysfunction Drugs for cosmetic purposes(hair growth) Non prescription drugs Cough & cold relief Fertility drugs Prescription vitamins, minerals Except prenatal vitamins and fluoride preparations
40 Generics: required to be covered by ALL plans Chemically identical to brand-name drugs and meet the same standards put forth by the FDA 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 by the Doctor explaining why you need the drug Step Therapy: may be required before certain medications will be covered ex: 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.
42 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
43 You SHOULD keep your RIPAE! It will provide assistance with the deductible & coverage gap It is not creditable coverage You need a Medicare Part D Plan to apply RIPAE is only 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
44 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!
45 Eligible: Single, income less than $45,991 per year Married, income less than $52,561 per year The lower the financial category, the higher percentage RIPAE will pay More information: The Point Wrong phone number on Medicare & You 2008 Booklet! Talk to SHIP counselor
46 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
47 Will automatically be eligible for: No premium No deductible No donut hole Minimum co-payments ($2.65 generic & $6.60brand at most) Have been automatically enrolled in a plan & will be automatically re-enrolled in a plan Part D plan for 2015 won t necessarily be the same plan as 2014 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!
48 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 Single* Married* Yearly Income <$17,505 <$23,595 Resources <$13,440 <$26,860 *Includes $1,500 per person burial expenses
49 Defined as those who had Low Income Subsidy (LIS) for 2014 & are not automatically eligible for 2015 Notifications being sent out with applications to re-enroll Does not mean that you are not eligible You need to reapply!!! Check with your SHIP counselor or The Point
50 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 Available from the pharmaceutical manufacturers Contact the Partnership for Prescription Assistance
51 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 or call
52 Changes in amount covered during the Coverage Gap! 45% for brand name prescriptions ( from 47.5%) 65% for generic prescriptions ( from 72%) Greater Coverage for preventive medical services Depression Cardiovascular Disease Alcohol Abuse Obesity
53 Options: Ask your pharmacist about therapeutic substitution Compare prescription vs. overthe-counter (OTC) options Celebrex $ Motrin OTC $10.99 Ibuprofen Rx- lowest cost or co-pay Always consult with your doctor regarding changes to your medications
54 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: 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
55 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! Especially if you did not call them.
57 October 1- Compare and Prepare October 15- Open Enrollment Begins December 7- Open Enrollment Ends January 1, Coverage Begins
58 No single plan is best for everyone You must pick the plan that s right for YOU! Make sure to enroll between Oct 15 Dec 7 th, 2014 Yes, it is confusing! Don t be afraid to ask for help: The Point!!! (401) SHIP counselors at your local Senior Center Dept. of Elderly affairs (401) Ask a relative or friend to help you navigate the Web Social Security Administration Pharmacy Outreach Program
59 THANK YOU!