Pharmacy Outreach Program The University of Rhode Island College of Pharmacy Updated October 2011
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
Typically doesn’t require a monthly
payment (Premium) Does require out-of-pocket deductible for
hospital stays (in 2011): $1,132 of 1-60 days $283 per day co-pay for days 61-90 $566 per day co-pay for days 91-150 All costs beyond 150 days For skilled nursing facilities: $141.50 per day for days 21 through 100 for each benefit period
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 2011 is
$115.40 per month (income based) In general, automatically deducted from social security checks Once deductible is paid enrollee generally pays a 20% co-payment for each service
2012 deductible $162
Medicare Advantage (Part C) 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 7 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 New Annual Enrollment Period in 2011 October 15-December 7, 2011 Can choose to leave current Medicare Advantage plan to
switch to an Original Medicare plan Can add prescription coverage - Part D
Will run from January 1, 2011 through February 14, 2012 Remember! Can only disenroll during this period!
MEDICARE PART D Stand-alone prescription drug coverage Open to all people eligible for Medicare Open enrollment begins October 15, 2011 Enrollment for coverage of the year 2012
ends on December 7, 2011 Coverage Begins on January 1st, 2012
Medicare Part D is VOLUNTARY!!
When Can I Enroll in a Part D Plan? Re-enrollment begins October 15th, 2011! Your new plan will take effect January 1st, 2012 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 NEW Open enrollment is from
Oct 15 – Dec 7th 2011 of each year Dates just changed
Coverage begins on January 1, 2012 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 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 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 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, 2012 – you will incur a penalty of 1% per month of average premium Will have to wait until 2012 enrollment period to
join a Medicare drug plan if don’t do so now!
Average premium 2012 = $36.92 1% of $36.92 = $0.37 12 months penalty= $4.44 Therefore, $4.44 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
If you previously had creditable coverage
Affordable Care Act Changes Lower costs during donut hole: Patients pay 50% of brand name drugs Discount of generic drugs will raise from 7-14% this year Better Quality care: Bonus payments from the government will give 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 are options! STANDARD PLAN (2012) $36.92 per month premium ($443.04) $320 deductible 75% coverage from $320 to $2,930 New limited coverage from $2,930 to $6657.50
Patient pays 50% of Brand Drugs and up to 86% of generic drugs This is called the coverage gap or “Donut
95% coverage beyond $6657.50
HOW PART D WORKS Catastrophic Coverage > $6657.50
Medicare Pays 95% 5%
Donut hole - $2930 â€“ $6657.50
Co-Insurance : $320-2930
0 - $320 is your Deductible
You Pay 100%
New Change for Donut hole, will only spend 50% out of pocket for brand name and 86% maximum for generic drugs!!!
Think of it as Steps! Step #1 – The Deductible You pay 100% and plan pays 0% You receive $320 worth of medications
Medicare Pays 95% 5%
Step #2 – Co-insurance You pay 25% and plan pays 75% You receive $2610 worth of medications (Total: Step 1 + Step 2 = $2930)
You Pay 100%
Think of it as Steps! Step #3 – The Donut Hole New changes let you pay
50% of brand drugs Max of 86% generics
You receive $1770 worth
of medications Total: Step 1 + Step 2 + Step 3 = $6657.50 New discounts!
Medicare Pays 95% 5% 50%-86%
Step #4 – Catastrophic
Coverage You pay 5% and plan
pays 95% You receive unlimited drugs for the remainder of calendar year
You Pay 100%
Even though you were enrolled in a program last year, you start from the Step #1 all over again on January 1, 2012
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 hole‖
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: 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.
How Do I Choose The Right Plan? Rx Enrollment Check-Up: Cost Will your premium and costs change in 2012?
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?
Side Note: ď‚— If you decide that your
current Med D plan will meet your needs in 2012 then you do not need to re-enroll ď‚— Coverage will continue
through 2012 starting from Step 1
Plans Available in RI for 2012 Total of 30 prescription plans offered 14 plans available with NO deductible! 23 Plans without gap coverage Monthly premiums start at $15.10 (Humana Walmart Preferred plan)
7 Plans with gap coverage Monthly premiums start at $65.80 and go up to $110.20 Lowest premiums have only generic coverage All Medicare patients are eligible for a Medicare
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 (ex: $58)
Drugs Not Covered Under Most Part D Formularies Benzodiazepines
Drugs for cosmetic
purposes or hair growth Fertility drugs Prescription vitamins, minerals
Weight loss Erectile dysfunction
Cough & cold relief Non prescription
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
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 your SHIP counselor or call The Point for RIPAE
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 $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: 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 2012 won’t necessarily
be the same plan as 2011
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 Single*
*Includes $1,500 per person burial expenses
“Deemed” Population Defined as those who had Low Income Subsidy
(LIS) for 2011 & are not automatically eligible for 2012 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 Pharmaceutical Assistance Programs Available from the pharmaceutical manufacturers Contact the Partnership for Prescription Assistance
Ways to Lower Your Drug Costs During the Coverage Gap
State Pharmaceutical Assistance Programs
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
New Medicare Changes Cut in half the prescription drug
expenses of those who fall into the dreaded Part D donut hole! This means you only pay 50% of the
cost of brand-name medications in the gap – instead of the 100% in previous years 14% discount for covered generic drugs Earlier enrollment: Oct 15 – Dec 7 2011
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!
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 Aid has plan finding software, just call your Rite Aid pharmacist and schedule a time to choose a plan
Important Dates to Remember October 1- Compare and Prepare October 15- Open Enrollment Begins December 7- Open Enrollment Ends January 1, 2012- 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 1-800-772-1213 Pharmacy Outreach Program 1-800-215-9001