1	Introducing Medicare Part D Beginning the Prescription Drug Coverage Journey
2	In This Presentation This presentation provides a review of: Overview Information (slides 3-4) Medicare Part D and PH (slides 5-8) Enrollment questions: What, who, when, why, & how? (slides 9-16) Coverage questions (slides 17-19) Cost questions (slides 20-27) Dual eligibility (slides 26-28) Tools for the road (slides 29-35) Important Terms/Glossary (slides 36-41) How to receive a copy of these slides (slide 42)
3	In This Presentation The titles at the top of each slide will help you keep track of what portion of the presentation you are in. Throughout the presentation, words defined in the glossary are in italics the first time they are used. This presentation is intended for both PH patients and physicians with questions about Medicare. For consistency, presentation material is addressed to a fictional patient, however, physicians should find answers to their general questions as well. The information provided here is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.
4	Overview Medicare Part D is new prescription drug coverage provided by Medicare through private companies. Anyone eligible for Medicare is eligible for Part D. Although there are some national Part D plans, most plans are regional or local. Within your state, you may have 50+ plans to choose from. There are many things you should consider when making decisions about Medicare Part D...
5	Medicare Part D and PH Different PH drugs are covered by different parts of Medicare. Part B (outpatient coverage) covers drugs with special delivery systems. These include Remodulin, Flolan, and Ventavis. Part B also covers oxygen costs. Part B coverage will continue to cover these drugs under most circumstances.
6	Medicare Part D and PH Part D covers Revatio and Tracleer. As new oral medications are developed, they will fall under Part D. Part D also covers other drugs important to PH patients such as oral diuretics, calcium channel blockers, and birth control pills. Many plans will cover PH drugs, but some will not. Try to choose a plan that covers most of your drugs on their formulary (a plan’s list of covered drugs), particularly the most expensive ones.
7	Medicare Part D and PH Different plans will charge different co-pays or co-insurance for PH drugs. That is, the amount you must pay out of pocket when you receive your drugs may vary from plan to plan. Different plans may also place PH drugs on different tiers. Tiers are levels of cost for a prescription. For example, most plans list generic brand drugs in tier I, the least expensive tier. Brand-name drugs may be in one of several more expensive tiers. Many plans place PH drugs in tier 4 or 5, their most expensive tier.
8	Medicare Part D and PH If you are currently part of the Medicare Replacement Drug Demonstration or a Patient Assistance Program, remember… The Medicare Replacement Drug Demonstration (MRDD) ends on December 31, 2005. In order to continue your drug coverage under Medicare, you must sign up for Medicare Part D. Patient Assistant Programs will be impacted by Part D. Many programs will no longer offer assistance to those eligible for Medicare Part D.
9	Enrollment Questions: What? The first step to understanding Part D coverage is to decide whether or not to enroll in a plan. The next 7 slides outline the answers to some basic enrollment questions. Medicare Part D is new prescription drug coverage provided by Medicare through private companies.
10	Enrollment Questions: Who? Who is eligible? Everyone who is eligible for Medicare is eligible for Part D coverage. Who should join? Many people with Medicare will benefit from signing up for a Part D plan. However, if you have existing prescription coverage through a retirement plan, spouse, union, or other source, you should get more information.
11	Enrollment Questions: Who? If you already have prescription drug coverage, you need to know if it is credible. Credible coverage is deemed by Medicare to be at least as good as what they are offering. If your coverage IS at least as good as Medicare’s you can: Keep the coverage as long as it is offered and join a Medicare plan later. You will not pay a penalty. Switch to a Medicare Part D plan. However, if you drop your employer coverage, you may not be able to get it back. You also may not be able to drop your employer drug coverage without dropping your employer health coverage.
12	Enrollment Questions: Who? If your coverage is NOT as good as Medicare’s you can: Keep your current plan and join a Medicare drug plan to give you more complete prescription drug coverage. Only keep your current plan. If you decide to join a Medicare plan after May 15, 2006 you will have to pay a penalty. Drop your current coverage and join a Medicare plan. Remember that you may not be able to drop employer or union drug coverage without also dropping your health care coverage.
13	Enrollment Questions: When? The first day to enroll in a Part D plan was November 15, 2005. The last of this enrollment cycle is May 15, 2006. If you enroll by December 31, 2005, your coverage will start on January 1, 2006. If you enroll between January 1 and May 15, 2006, your coverage will begin on the first day of the month after you enroll. It is important to enroll promptly to avoid a penalty. However, if you have other prescription drug coverage, be sure to get the information you need before you enroll.
14	Enrollment Questions: Why? Enrolling in Medicare Part D may save you money. Even if you do not have many prescription drug needs now, you may want to enroll in order to avoid a penalty in the future. The Medicare penalty for late enrollment is 1% of the plan’s premium for every month after your initial enrollment period ends. If you enroll 4 months late you pay a 4% penalty. You will pay that penalty for as long as you are part of Medicare Part D.
15	Enrollment Questions: How? You can join Medicare Part D in one of the following ways: By going to Medicare’s website. You will also be able to join a drug plan at www.medicare.gov on the web using Medicare’s online enrollment center. By calling 1-800-MEDICARE. You can join a drug plan by calling 1-800-MEDICARE (1-800-633-4227) and talking to a Medicare customer service representative. TTY users should call 1-877-486-2048.
16	Enrollment Questions: How? By paper application. Contact the company offering the drug plan you choose and ask for an application. Once you fill out the form, mail or fax it back to the company. By going to the plan’s website. Some companies will offer the option of joining online. Check to see if your plan provider offers this service.
17	Coverage Questions: Exceptions If you decide to enroll in Medicare Part D, you will need to select a plan. Coverage questions are important to finding a plan that fits your needs. Choose a plan that covers most of your drugs, or at least the most expensive ones. If you need a drug that is not on your plan’s formulary, or that is covered at a co-pay you cannot afford, you can apply for an exception. An exception is a formal decision by your prescription drug plan to cover your medications or reduce your co-payments. If the plan does not approve the exception, you have the right to appeal.
18	Coverage Questions: Exceptions The company that sells your plan must provide you with information about the exceptions and appeals processes. They must provide this information in writing and in electronic format (online) at your request.
19	Coverage Questions: Formulary Changes Medicare prescription drug plans may change their formularies as long as they continue to meet Medicare’s basic requirements. Your plan must let you know at least 60 days before a drug you use is to be removed from the list, or before the costs change.
20	Cost Questions: How much will I pay? Cost issues are also important in selecting a plan. Unfortunately, there is no easy answer to the question of how much an individual will pay for Medicare drug coverage. If you choose to sign up for a Part D plan, you will still have some costs. These costs may include: A premium (The monthly amount you pay to maintain your coverage) A deductible (The initial costs you cover each year before your plan kicks in) Co-insurance (A percentage of the cost each time you purchase a prescription) The “doughnut hole” (100% of your total drug costs between $2,250 and $5,100)
21	Cost Questions: How Much Will I Pay? Medicare has issued “standard coverage” guidelines. These are the expenses that all plans must cover. Some plans will provide additional coverage, often for a higher premium. Individuals with limited resources may be eligible for additional help to cover the drug plan costs.
22	Cost Questions: How Much Will I Pay? Standard coverage costs look like this: Premium: $32/month Deductible: $250/year • You pay 25% of your yearly drug costs from $250 to $2,250, and your plan pays the other 75% of these costs. You pay 100% of your next $2,850 in total drug costs. • You pay 5% of your drug costs (or a small co-payment) for the rest of the calendar year after you have reached $5,100 total drug costs. Your plan pays the rest.
23	Cost Questions: How Much Will I Pay?
24	Cost Questions: How can I pay? You can choose to pay your Part D premium in one of three ways: The company that offers the plan can deduct the premium automatically from your bank account. The premium can be deducted each month from your Social Security benefits. You can pay your premium directly by mailing a check each month to the plan provider.
25	Cost Questions: Additional Assistance Additional assistance to cover Part D costs is based on your income and assets in relation to the size of your household. For example, you may get assistance if your income is less than or equal to $14,355 for a single person or $19,245 for a married couple living together and you have limited assets. Most people must apply to receive additional assistance. If you are uncertain about your eligibility, call Medicare! If you are still uncertain—apply anyway! There is no risk or cost.
26	Dual Eligibility and Cost If you currently receive Medicare and Medicaid, your are “dual eligible.” Medicaid is a federal program administered and operated on the state level that provides medical benefits to eligible low-income persons needing health care. Dual eligible individuals automatically receive additional assistance to cover their Part D costs. They do not need to apply.
27	Dual Eligibility and Cost Dual eligible individuals will have: $0 monthly premium and $0 deductible Co-pays between $1 and $5 $0 “doughnut hole” $0 additional costs Medicaid will no longer cover drug costs for dual eligible individuals, but Medicare will.
28	Dual Eligibility: Additional Points Dual eligible individuals are automatically enrolled in a Part D plan if they do not select one themselves. If you are dual eligible, selecting a plan yourself will increase the likelihood that your medications will be covered right away. Dual eligible individuals may change their plan at any time. Dual eligible individuals should sign up for a Medicare prescription drug plan even if they live in a nursing home or other institution.
29	Tools for the Road Medicare Part D can be quite confusing. Sometimes, even the options for getting help can be confusing…
30	Tools for the Road Here are some phone numbers and web addresses to help you along the Part D path: www.medicare.gov Medicare’s website provides fact sheets and web-based tools to get you started selecting a plan. These tools will work better for some individuals than others. 1-800-MEDICARE (1-800-633-4227) If you would prefer to talk with someone directly, Medicare has committed to having thousands of individuals staffing their hotline 24/7. If you are able to call during “off” hours, you may get through more quickly.
31	Tools for the Road State Health Insurance Assistance Programs (SHIPs) http://www.phassociation.org/insurance/ ships.asp SHIP representatives should be able to talk with you one-on-one and assist you in selecting a plan. See PHA’s website for a list of SHIP phone numbers by state. Your specialty pharmacy may also be able to assist you in finding plans that cover your PH medications.
32	Tools for the Road ACCESS 1-888-700-7010 The goal of ACCESS is to “reduce the time and effort required to obtain the benefits to which you may be entitled so that you may concentrate your efforts on managing your care and providing for you loved ones.” They have a dedicated team and will take the time to help you understand your options. All their services are provided free of charge to individuals with pulmonary hypertension.
33	Conclusion: Important Questions Sometimes, knowing what questions to ask can be the hardest part of getting the care you need. Here are some important questions to ask as you review the plans in your area. Remember to start by making a list of the names and dosages of all of your medications. 1. Which of my medications are covered on the plan formulary? Is the dosage I need covered? Are my most expensive medications covered? 2. Are there drugs my physician feels I will be likely to be placed on in the future? Are these drugs covered? 3. Which of my medications are not covered?
34	Conclusion: Important Questions 4. What are the premium and deductible for this plan? 5. What is the co-pay structure for this plan? What tiers will my drugs fall into? 6. Does this plan work with pharmacies that I can get to easily? 7. Does this plan offer mail-order services? (If you use them) 8. Does this plan require my doctor to get prior authorization before providing any of my medications?
35	Conclusion: Important Questions 9. Does this plan require me to try a different, less expensive treatment before I can receive a medication I need? (This is called step therapy) 10. Does this plan limit the number or amount of prescriptions I can receive? Don’t Forget! Before signing up for a Medicare prescription drug plan ask: Do I have existing prescription drug coverage? Does Medicare think my coverage is better or worse than what they will be offering?
36	Glossary These slides provide some definitions to help you understand the language used by Medicare and other health care providers. Sections of Medicare: Original Medicare: Parts A (inpatient care) Part B (outpatient care—premium required). Participants can see any Medicare provider. Medicare Advantage Plans (Part C): HMO or other managed care plans are offered through Medicare. Participants must see physicians in-network but may receive other benefits. Some Medicare Advantage plans include prescription drug coverage, others do not.
37	Glossary Medigap: Medigap policies are also called Medicare supplements. They are supplemental insurance policies sold by private insurance companies to fill in the gaps in Traditional Medicare coverage. Premium: The monthly amount you pay to maintain insurance. Deductible: The amount of money that you pay before your insurance plan pays for any medical care or prescriptions.
38	Glossary Co-pay: A set amount determined by the insurance company that you pay when you receive covered services. Co-insurance: A set percentage of the total amount determined by the insurance company that you pay when you receive covered services. Formulary: An approved list of prescription drugs. Formularies vary from plan to plan. Some plans may include a drug on their formulary, but only in specific dosages.
39	Glossary Doughnut Hole: A point at which Medicare stops covering any portion of drug costs and you must cover the entire amount out of pocket. Once you pay a certain out of pocket cost, Medicare begins coverage again. In many Medicare plans you must pay 100% of your total drug costs between $2,250 and $5,100 annually. This is the doughnut hole. Exception: A formal decision by your Medicare prescription drug plan to cover your medications or reduce your co-payment.
40	Glossary Credible coverage: Drug coverage that is at least as good as the new Medicare drug benefit. Credible coverage is also called comparable coverage and may include coverage from current or former employers, Veteran’s benefits, or other sources. If you have credible coverage you can enroll in a Medicare prescription drug plan without a penalty after the initial enrollment period. Prior authorization: Some insurance plans require that services be pre-approved before you receive them, otherwise the plan will not cover them. In many Medicare plans, some prescriptions require prior authorization but others do not.
41	Glossary Tiers: Levels of cost for a prescription. For example, most plans list generic brand drugs in Tier I, the least expensive tier. Brand-name drugs may be in one of several more expensive tiers. Penalty: The Medicare penalty for late enrollment is 1% of the plans premium for every month that you could have enrolled but didn’t. If you enroll 4 months late you pay a 4% penalty. You will pay that penalty for as long as you maintain the insurance. PDP: “Prescription Drug Plan” PDP’s are private insurance plan that offer coverage for prescription drugs under Medicare. MA-PD: A Medicare Advantage Prescription Drug plan.
42	For More Information If you have questions about this presentation, or wish to receive a copy of these slides by mail or e-mail, contact Katie, PHA’s Advocacy and Awareness Associate, at 301-565-3004 X109 or awareness@phassociation.org. Please take a moment to complete the brief survey at the end of this presentation. Thank you!
43	Thank You! This presentation was made possible by generous support from CoTherix and Myogen.