Pharmacy Outreach ProgramThe University of Rhode Island

College of Pharmacy

Updated October 2009

MEDICAREMedicare provides health insurance for…

Aged 65 years or olderAged 65 years or less with certain disabilitiesAll people with End-Stage Renal Disease (ESRD)All people with Lou Gehrig’s Disease (ALS)

THE PARTS OF MEDICAREPart A

Hospital insurancePart B

Medical insuranceMedicare Advantage Plans

Part D Prescription drug coverage

Medicare Part A Covers:

Inpatient hospital care Skilled nursing facilities (Under certain

conditions)

Typically doesn’t require a monthly payment (Premium)

Does require out-of-pocket deductible for hospital stays (in 2010): $1,100 of 1-60 days $275 per day co-pay for days 61-90 $550 per day co-pay for days 91-150 All costs beyond 150 days

For skilled nursing facilities: $137.50 per day for days 21 through 100

for each benefit period

Medicare Part B Helps cover:

Physician services Some physical and occupational

therapists Some home healthcare

Also covers other services and supplies: Glucose monitors Test strips Lancets

There is a monthly premium to enroll

The standard Part B premium for 2009 is $96.40 per month (income based)

In general, automatically deducted from social security checks

2010 annual deductible of $155.00 Once deductible is paid enrollee generally

pays a 20% co-payment for each service

Medicare AdvantageHealth 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)

Medicare Advantage12 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 PART DMEDICARE PART DStand-alone prescription drug coverageOpen to all people eligible for Medicare

Open enrollment begins November 15, 2009Enrollment for coverage of the year 2010

ends on December 31, 2009Coverage Begins on January 1st, 2010

Medicare Part D is VOLUNTARY!!

Re-enrollment begins November 15th, 2009!Your new plan will take effect January 1st, 2010

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 youBut be aware::::: your premiums, co-pays,

formulary, or deductible may be changed for the new year!

When Can I Enroll in a Part D Plan?

Enrollment InfoOpen enrollment is from

Nov.15-Dec 31st of each year

Coverage begins on January 1, 2010

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 nowPenalty 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 ApplyIf 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 InfoIf you did not enroll but were eligible to do so, when you

enroll now for coverage beginning on Jan.1, 2010- you will incur a penalty of 1% per month of average premium

Will have to wait until Nov 15- Dec 31, 2010 to join a Medicare drug plan if don’t do so now!

Average premium 2009 = $38.851% of $38.85 = $0.3912 months penalty= $4.66Therefore, $4.66 will be added unto your

monthly premium every month forever!

Penalty Info

You will not have this penalty enforced:If you were not previously

eligible for Medicare Part D

If you previously had creditable coverage

HOW PART D WORKSRemember::: this is just an explanation of the

template used as a general basis for the plans --there are options!

STANDARD PLAN (2010)$38.85 per month premium ($466.20/year)$310 deductible75% coverage from $310 to $2,830NO coverage from $2,830 to $6,440

This is called the coverage gap or “Donut Hole”95% coverage beyond $6,440

Equivalent to $4,550 dollars out of pocket spending

Over $6440

$2830 – 6440

$310 - 2830

$0 - 310

Think of it as Steps!Step #1 – The Deductible

You pay 100% and plan pays 0%

You receive $310 worth of medications

Step #2 – Co-insuranceYou pay 25% ($630) and

plan pays 75% ($1890)You receive $2520 worth

of medications(Total: Step 1 + Step 2 =

$2830)

Think of it as Steps!Step #3 – The Donut Hole

You pay 100% and plan pays 0%

You receive $3610 worth of medications

Total: Step 1 + Step 2 + Step 3 = $6440

Step #4 – Catastrophic CoverageYou pay 5% and plan pays

95%You receive unlimited drugs

for the remainder of calendar year

Remember! Even though you were

enrolled in a program last year, you start from the Step #1 all over again on January 1, 2010

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 deductibleSome have help during “donut hole” (coverage gap)

The Premium depends on the enhancements Mail order options may save costs on

maintenance medications (90 days)

How Do I Choose The Right Plan?

Rx Enrollment Check-Up:Cost

Will your premium and costs change in 2010?

CoverageWill you need more comprehensive coverage?Will your current meds be covered by your plan?

Customer ServiceAre you satisfied with your service from your current

plan?

Side Note: If you decide that your

current Med D plan will meet your needs in 2010 then you do not need to re-enroll

Coverage will continue through 2010 starting from Step 1

Plans Available in RI for 2010

Total of 48 plans offered19 plans available with NO deductible!38 Plans without gap coverage

Monthly premiums without gap coverage start at $10.80 & range from $10.80 – $77.70

12 PDPs have $0 premium if qualify for extra help

10 Plans with gap coverage Monthly premiums with gap coverage start at $59.30Lowest premiums have only generic coverage

All medicare patients are eligible for a medicare advantage plan

What is a Formulary?

Formulary systemEach plan selects certain drugs

from each drug class that they will coverMay 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

BenzodiazepinesBarbituratesWeight loss Erectile dysfunctionCough & cold reliefNon prescription

drugs

Drugs for cosmetic purposes or hair growth

Fertility drugsPrescription

vitamins, mineralsExcept 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 BEx: Zostavax (Shingles vaccine)

Vaccines covered by part BPneumococcal InfluenzaHepatitis BVaccines necessary to treat a disease

or prevent one after direct exposure Ex: tetanus

WHAT ABOUT MY RIPAE?You SHOULD keep your RIPAE!

It will provide coverage throughout the deductible & coverage gap

BUT, it is not creditable coverageYou need a Medicare Part D Plan tooStarting January 2009, RIPAE will only be

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

RIPAE…Provides extra benefit for those who don’t

qualify for extra help from MedicareApplicable to all expenses that

person is 100% responsible for:DeductibleCoverage gap (“Donut Hole”)Drugs not covered under your Part D Plan

Only certain ones!

RIPAE…Eligible:

Single, income less than $42,493 per yearMarried, income less than $48,563 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 premiumNo deductibleNo donut holeMinimum co-payments ($1.10 generic & $3.30 brand)

Have been automatically enrolled in a plan & will be automatically re-enrolled in a planPart D plan for 2010 won’t necessarily

be the same plan as 2009

Reassignment notices are being sent outEnrollment confirmations will followIf 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 deniedMany deductions, so apply!

In order to be eligible, a person’s resources must be no greater than the limits established

LIS level Single* Married*Full Subsidy LIS Resource Limit

$8,100 $12,910

All Other LIS Resource Limit

$12,510 $25,010

*Includes $1,500 per person burial expenses

“Deemed” PopulationDefined as those who had Low Income Subsidy

(LIS) for 2009 & are not automatically eligible for 2010

Notifications being sent out with applications to re-enroll

Does not mean that you are not eligibleReapply!!!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 National & Community Based Charitable Programs

For specialty drugs Pharmaceutical Assistance Programs

Available from the pharmaceutical manufacturers Contact the Partnership for Prescription Assistance

1-888-477-2669

Ways to Lower Your Drug Costs During the Coverage Gap

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 www.socialsecurity.gov or call 1-800-772-1213

President Obama’s PlanProposed to cut in half the

prescription drug expenses of those who fall into the dreaded Part D doughnut hole!This means you would only pay

50% of the cost of brand-name medications in the gap – instead of the 100%you pay now!

If passed, it would go into effect in July 2010…

What if I Like A Plan & One of My Drugs is Not Covered?

Options: Ask your pharmacist about

therapeutic substitutionCompare prescription vs. over-the-

counter (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, diazepamDrugs for weight loss, hair loss, and fertilityDrugs covered under Medicare parts A and B

Example: Drugs received while in the hospital, diabetic testing supplies

Medicare FraudThe 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!

Medicare FraudMedicare fraud is purposely billing Medicare for

services that were never provided or received.Billling Medicare or another insurer for

services or items you never got.

Billing Medicare for services or equipment which are different from what you got.

Use of another person’s Medicare card to get medical care, supplies, or equipment.

Billing Medicare for home medical equipment after it has been returned. www.medicare.gov

Medicare Fraud The Do’s and Don’tsDon't give out your Medicare Health Insurance

Claim Number (on your Medicare card) except to your physician or other Medicare provider.

Don’t give out social security or credit card numbers

Don't allow anyone, except appropriate medical professionals, to review your medical records or recommend services.

Don't contact your physician to request a service that you do not need.

www.medicare.gov

Medicare FraudThe Do’s and Don’tsDo be careful in accepting Medicare services

that are represented as being free.

Do be cautious when you are offered free testing or screening in exchange for your Medicare card number.

Do be cautious of any provider who maintains they have been endorsed by the Federal government or by Medicare.

Do avoid a provider of health care items or services who tells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid.

www.medicare.gov

Using the InternetGet a complete list of your medications & the cash price

from the pharmacy 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 readyCVS and Walgreens both have websites to condense your

search of possible plansRite Aid has plan finding software, just call your Rite Aid

pharmacist and schedule a time to choose a plan

Important Dates to Remember

October- Compare and PrepareNovember 15- Open Enrollment BeginsDecember 8- Don’t Be LateDecember 31- Open Enrollment EndsJanuary 1, 2010- Coverage Begins

***Next Open Enrollment Period is not until November 15- December 31, 2010***

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) 462-4444SHIP counselors at your local Senior CenterDept. of Elderly affairs (401) 462-4000Ask a relative or friend to help you navigate the WebSocial Security Administration 1-800-772-1213Pharmacy Outreach Program 1-800-215-9001

www.uri.edu/pharmacy/outreach

THANK YOU!