Medicare Part D
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Transcript of Medicare Part D
![Page 1: Medicare Part D](https://reader031.fdocuments.in/reader031/viewer/2022020320/568bd87e1a28ab2034a38c13/html5/thumbnails/1.jpg)
Pharmacy Outreach Program The University of Rhode Island
College of Pharmacy
Updated October 2011
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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)
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THE PARTS OF MEDICARE
Part A
Hospital insurance
Part B
Medical insurance
Medicare Advantage Plans
Part D Prescription drug coverage
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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 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
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Medicare Part B Helps cover:
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
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Medicare Advantage (Part C) 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)
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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.
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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!
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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!!
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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
But 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?
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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
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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
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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!**
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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!
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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
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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
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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 Hole” 95% coverage beyond $6657.50
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New Change for Donut hole, will only spend 50% out of pocket for brand name
and 86% maximum for generic drugs!!!
0 - $320 is your Deductible
Co-Insurance : $320-2930
Donut hole - $2930 –
$6657.50
Catastrophic Coverage
> $6657.50
You Pay 100%
75% 25%
5%
Medicare Pays
95%
HOW PART D WORKS
50%-86%
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Think of it as Steps! 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 $2610 worth of medications
(Total: Step 1 + Step 2 = $2930)
You Pay 100%
75% 25%
5%
Medicare Pays
95%
50%-86%
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50%-86%
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!
Step #4 – Catastrophic Coverage You pay 5% and plan
pays 95%
You receive unlimited drugs for the remainder of calendar year
You Pay 100%
75% 25%
5%
Medicare Pays
95%
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Remember!
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!
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Besides Standard Plan… 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)
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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.
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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?
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Side Note:
If you decide that your
current Med D plan will
meet your needs in 2012
then you do not need
to re-enroll
Coverage will continue
through 2012 starting
from Step 1
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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
advantage plan
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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)
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Drugs Not Covered Under Most Part D Formularies
Benzodiazepines
Barbiturates
Weight loss
Erectile dysfunction
Cough & cold relief
Non prescription
drugs
Drugs for cosmetic
purposes or hair
growth
Fertility drugs
Prescription
vitamins, minerals Except prenatal vitamins
and fluoride preparations
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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.
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Frequently Asked Questions
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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
Ex: tetanus
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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 information
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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!
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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
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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
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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!
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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* Married*
Yearly Income <$16,335 <$22,260
Resources <$12,640 <$25,260
*Includes $1,500 per person burial expenses
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“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
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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
1-888-477-2669
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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
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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
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What if I Like A Plan & One of My Drugs is Not Covered?
Options:
Ask your pharmacist about therapeutic substitution
Compare 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
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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
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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!
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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
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Important Dates to Remember
October 1- Compare and Prepare
October 15- Open Enrollment Begins
December 7- Open Enrollment Ends
January 1, 2012- Coverage Begins
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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
www.uri.edu/pharmacy/outreach
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THANK YOU!