MMAMedicare

Modernization Act

Richard Stefanacci, DO, MGH, MBA, AGSF, CMD

Health Policy Institute

MMA

Enrollment Outreach

• Education

• Plan Selection

• Authority to Enroll

• Special Enrollment Period

Medicare Prescription Plans

Fallback PDP Adm Fees

PDP Cost

MA - PDP Value

(Traditional Medicare)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$1

$184

$367

$550

$733

$916

$1,099

$1,282

$1,465

$1,648

$1,831

$2,014

$2,197

$2,380

$2,563

$2,746

$2,929

$3,112

$3,295

$3,478

$3,661

$3,844

$4,027

$4,210

$4,393

$4,576

$4,759

$4,942

$5,125

$5,308

$5,491

$5,674

$5,857

$6,040

$6,223

$6,406

$6,589

$6,772

$6,955

W/o

W/

$0 $250 $2250 $5100 $7000

Annual Initial Donut Hole Catastrophic Deductible Benefit No Coverage of Costs Coverage

W/O

W/

< 100% FPL - $1/3 <135% - $2/5

135%-150%

©Richard Stefanacci, DO, MGH, MBA, AGSF, CMD

Formulary Requirements

• Not CMS’ intention to build the operating framework of a sponsor’s formulary

• Formulary must include:– At least one drug in each of 209 therapeutic

categories as published in regulation and solicitation

– At least 55% of the 209 categories must include a generic offered for a discount

Non-Formulary

• Physician must determine that all drugs on the formulary for the treatment of the same condition:

• would not be as effective

• have adverse effects

• Definite exclusions: – OTC, weight-related, fertility, cosmetic, symptomatic relief cough or

colds, vitamins (except prenatal), barbiturates, benzodiazepines

– Drugs that would be covered under Medicare, including under Part B for that individual in that instance

(Medicaid can cover with federal matched funds)

‘Transitioning’

Medicaid -> MedicareCommunity -> Hospital -> SNF -> NF

Misalignment of formularies could result in:Inappropriate med changes

Limited transition time between meds

Medication Therapy Management ServicesSec 1860D-4(c)

Beneficiaries targeted:Multiple chronic conditions

Using “multiple prescriptions” Incur significant drug spending

Services Include:DispensingMonitoring

coveredunder Part Dthrough PDPs

Drug Therapy QualitySCRIPT: Study of Clinically Relevant Indicators for Pharmacologic Therapy

• Coronary Artery Disease– Beta Blockers– ACEI– Lipid Treatment– Lipid Testing

• Heart Failure– ACEI– Beta Blockers– Monitoring K, Renal Function

• Atrial Fibrillation– Warfarin– Monitoring K, Renal Function, INR

CMS Funded Study 7/16/04

Specialized MA PlansSec. 231

Special Needs:– Institutionalized – Dual Eligibles– Chronically ill

Example Programs:• EverCare

• Wisconsin Partnership

Rx Factor

LTC Endorsed Sponsors

• Computer Sciences Corporation*• National Community Pharmacist Association • Senior Care Pharmacy Alliance

• PBM Plus, Inc*• Omnicare

• Long Term Care Pharmacy Alliance, LLC• Omnicare• NeighborCare• Pharmerica• Kindred Health Care

170

Preparing for the Storm….

• Education, Educations, Education……..

• Preparation

• Collaboration

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD r.stefan@usip.edu