Pharmacy Outreach ProgramUniversity of Rhode Island

C ll   f PhCollege of Pharmacy

Updated November 2008

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)All people with Lou Gehrig s Disease (ALS)

THE PARTS OF MEDICAREPart A

Hospital insurancePart B

Medical insuranceM di Ad t PlMedicare Advantage PlansPart D

Prescription drug coveragePrescription drug coverage

Medicare Part ACovers:

Inpatient hospital careSkilled nursing facilities (Under certain conditions)conditions)

Typically doesn’t require a monthly payment (Premium)Does require out-of-pocket deductibleDoes require out of pocket deductible for hospital stays:

$1,024 (in 2008) of 1-60 days$256 per day co-pay (in 2008) for days 61-90 $512 per day co-pay (in 2008) for days 91-150All costs beyond 150 dayscos s beyo d 50 days

For skilled nursing facilities:$128.00 per day (in 2008) for days 21 through 100 for each benefit period

Medicare Part BHelps cover:

Physician servicesSome physical and occupational therapistsSome home healthcare

Also covers other services and supplies:Glucose monitorsTest stripsLancetsLancets

There is a monthly premium to enrollThe standard Part B premium for 2008 is $96.40 per monthIncome based and will remain unchanged for 2009In general, automatically deducted from social security checkssocial security checksAlso has annual deductible of $135.00Once deductible is paid enrollee generally pays a 20% co-payment for each service

MEDICARE PART DMEDICARE PART DStand-alone prescription drug coverageOpen to all people eligible for MedicareOpen enrollment begins November 15, 2008

Enrollment for coverage of the year 2009 ends on December 31, 2008Coverage Begins on January 1st 2009Coverage Begins on January 1st, 2009

Medicare Part D is VOLUNTARY!!

Medicare AdvantageHealth insurance coverage, including preventative care PLUSpreventative care PLUS prescription drug coverage in a single planplanIn exchange, typically must use a certain network of doctors, hospitals, and pharmaciespharmacies

Medicare Advantage13 plans available

Only 2 will provide some coverage for the coverage gap (donut hole)(donut hole)

**If you already have a Medicare Advantage plan and you want to add drug coverage you MUSTy g g yobtain it through your Medicare Advantage provider.

If you obtain an independent standalone drug plan instead, your health coverage under the Medicare Advantage plan will stophealth coverage under the Medicare Advantage plan will stop.

When Can I Enroll in a Part D Plan?

Re-enrollment begins November 15th, 2008!Your new plan will take effect January 1st, 2009

If you are happy with your current part D plan, you don’t need to do anything during the re enrollmentdon t need to do anything during the re-enrollment period!

Your Med D plan will automatically re-enroll youp y yBut be aware::::: your premiums, co-pays, formulary, or deductible may be changed for the new year!

Enrollment InfoOpen enrollment is from Nov.15-Dec 31st of each yearCoverage begins on January 1, 2009If b li ibl f M di P D f hIf you become eligible for Medicare Part D after the enrollment period, you have a 7 month period to enroll without incurring a penaltyg p y

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

Penalt for e er month itho t co eragePenalty for every month without coverage

Enrolled in a Medicare Advantage Plan or Medigap g g pSupplemental Insurance Plan but you want to add or change your drug coverage

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 mailp yKEEP THIS LETTER IN A SAFE PLACE**

**If if i dit bl t k**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 forIf you did not enroll but were eligible to do so, when you enroll now for coverage beginning on Jan.1,2009…

You will incur a penalty of 1% of the national average premium FOR EVERY MONTH YOU WERE ELIGIBLE AND DIDN’T NOT ENROLL!

Will have to wait until Nov 15- Dec 31, 2009 to join a Medicare drug plan if not enrolled and want to do so now!

Average premium 2009 = $31.74$ $1% of $31.74 = $0.31

12 months penalty= $3.72Therefore, $3.72 will be added unto your monthly premium every month forever!forever!If you were eligible when the program first started in 2006 then you will be subject to 30 months of penalty

So… 1% per month X 30 months = 30% penalty30% f $31 74 (2009 ti l ) $9 52 dditi l t f k t30% of $31.74 (2009 national average) = $9.52 additional out-of-pocket expense every month on top of monthly premium$9.52 X 12 months = $114.26 each year

Penalty InfoYou will not have this penalty enforced:

If you were not previously eligible for Medicare Part D

If    i l  h d  dit bl  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!there are options!STANDARD PLAN (2009)

$31.74 per month premium ($380.88/year)p p ( y )$295 deductible75% coverage from $295 to $2700NO f $2700 t $6153 75NO coverage from $2700 to $6153.75

This is called the coverage gap or “Donut Hole”95% coverage beyond $6153.75g y

Equivalent to $4350 dollars out of pocket spending

Over $6153 75Over $6153.75

$2700 – 6153.75

$295 - 2700

$0 - 295$0 295

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

You pay 100% and plan pays 0%Y i $295 hYou receive $295 worth of medications

Step #2 – Co-insuranceY 25% ($601 25)You pay 25% ($601.25) and plan pays 75% ($1803.75)You receive $2405 worthYou receive $2405 worth of medications

(Total: Step 1 + Step 2 = $2700)$ )

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

You pay 100% and plan pays 0%Y i $3453 75You receive $3453.75 worth of medicationsTotal: Step 1 + Step 2 + Step 3 = $6153 75Step 3 = $6153.75

Step #4 – Catastrophic Coverage

You pay 5% and planYou pay 5% and plan pays 95%You receive unlimited drugs for the remainder d ugs o e e a deof 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 2008January 1, 2008

You will continue to pay the premium every month y yregardless of what step that you are on

Even when in the “donut hole” a person still pays the monthly premium!the monthly premium!

Besides Standard Plan…Must offer basic/standard drug benefit

May offer enhanced benefitSome have no deductibleSome have no deductibleSome have help during “donut hole” (coverage gap)The Premium depends on the enhancementsThe 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 2009?CCoverage

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

Customer ServiceAre you satisfied with your service from yourAre you satisfied with your service from your current plan?

ImportantIf you decide that your current Med D plan will meet your needs in 2009 then you do not need to re-enroll

Coverage will continue through 2009 starting from Step 1Step 1

Plans AvailablePlans Available in RI for 2009in RI for 2009 

Total of 47 plans offered26 l ff h d b fit i26 plans offer enhanced benefit or services27 plans available with NO deductible!Monthly premiums without gap coverage start at $19 40Monthly premiums without gap coverage start at $19.40

Only 1 has premium less than $2512 PDPs have $0 premium if qualify for extra help

$Monthly premiums with gap coverage start at $50.60Lowest premiums have only generic coverage

All medicare patients are eligible for a medicare advantage p g gplan

Formularies?

Formulary systemEach plan selects certain dr gs from each dr g classEach plan selects certain drugs from each drug class that they will coverMay have a tier system

May have up to 5 tiersGeneric drugs = cheapest (ex: $5)Preferred brand names = more expensive (ex: $28)e e ed b a d a es o e e pe s e (e $ 8)Non-preferred brand names = most expensive (ex: $40)Certain injectable and specialty drugs= highest tiers (ex: $58)$58)

Drugs Not Covered Under MostDrugs Not Covered Under Most Part D Formularies 

BenzodiazepinesBarbituratesW i ht l

Drugs for cosmetic purposes or hair growthFertility promoting drugsWeight loss

Erectile dysfunctionCough and cold relief

Fertility promoting drugsPrescription vitamins, mineralsCough and cold relief

Non prescription drugsExcept 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: 

SafetySafetyPurityEffectiveness

Generic drugs can be legally produced in the US if a patent has expired, or for drugs which have never been patented drugs which have never been patented 

Prior authorization: may be needed for some medicationsAppeal process mandated by insurance company which includes paperwork involving the MDp p g

Step Therapy: may be required before certain medications will be coveredex: Prilosec before Nexium or Motrin before Celebrex

Quantity limits: may be enforced30 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)Ex: Zostavax (Shingles vaccine)

Vaccines covered by part BPneumococcalInfluenzaHepatitis BVaccines necessary to treat a disease or prevent one after directVaccines 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 and coverage gapand 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 planplanMust 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 f t h l f M difor extra help from MedicareApplicable to all expenses that person is 100% responsible forresponsible for

DeductibleCoverage gap (“Donut Hole”)g g p ( )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, $ , p y

The lower the financial category, the higher percentage RIPAE will pay

More information401-462-4444 – The Point401 462 4444 The Point

Wrong phone number on Medicare and You 2008 Booklet!Talk to SHIP counselor

What About My Tricare, VA, Pension Benefits?

They are creditable coverage, letters have have been mailed!been mailed!Hold on to these letters!Contact your pension benefits manager or union ifContact your pension benefits manager or union if you have any questions

Dual Eligibles (Medicare/Medicaid)Will automatically be eligible for:

No premiumNo deductibleNo deductibleNo donut holeMinimum co-payments ($1.10 generic & $3.20 brand)

Have been automatically enrolled in a plan & will be y pautomatically re-enrolled in a plan

Part D plan for 2008 won’t necessarily be the same plan as 2007 due to cost restraints!

Reassignment notices will be sent out 10/30/08Enrollment confirmations will be sent 12/1/08If you are “dually eligible,” you can change your plan at y y g , y g y pany time during the year! Once per month!

What is Extra Help (Low Income Subsidy)?

Federal poverty limits determined by government each yearBest to apply and be formally deniedpp y y

Many 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 $12,510 $25,010Resource Limit*Includes $1,500 per person burial expenses

“Deemed” PopulationDefined as those who had Low Income Subsidy(LIS) for 2008 and are not automatically eligible for 20092009Notifications have been sent out with applications to re-enrollDoes not mean that you are not eligible

Reapply!!!

Ways to Lower Your Drug CostsWays 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 gapp g pLess likely to hit the gap if avoid brand names from the beginning

Ask your doctor for samplesAsk your doctor for samplesNational & Community Based Charitable Programs

For specialty drugsPharmace tical Assistance ProgramsPharmaceutical Assistance Programs

Available from the pharmaceutical manufacturersContact the Partnership for Prescription Assistance

1-888-477-2669

Ways to Lower Your Drug CostsWays to Lower Your Drug Costs During the Coverage Gap

State Pharmaceutical Assistance Programs

RIPAEBased on your income, RIPAE will pay 15%, 30%, or 60% of drug cost during coverage gap

Apply for Extra HelpIf you have limited income and resources, you may qualify for y y q yextra helpFor more information go to www.socialsecurity.gov or call 1-800-772-1213

h f k l d fWhat If I Like A Plan And One Of My Drugs Is Not Covered?

Options: Ask your pharmacist about therapeutic substitutionCompare prescription vs over the counter optionsCompare prescription vs. over the counter options

Nexium $158.00Prilosec OTC $21.99Omeprazole Rx- lowest cost or co-pay

Always consult with your doctor regarding changes to your medicationsto 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( cash ) and it does not count towards out of pocket expenses or total drug costsExamples:p

Benzodiazepinesalprazolam, lorazepam, diazepam

Drugs for weight loss, hair loss, and fertilityDrugs covered under Medicare parts A and B

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

Medicare FraudIt is important to remember that the vast majority of your health care providers are committed to providing you with high quality care.g q yHowever, there are some individuals who cheat the system out of millions of dollars, which results in higher premiums for its memberspremiums for its members.

It is important to be very conscious when dealing with your Medicare information, and to never share it with a medical professional unless you are absolutely certain that they need it.p y y yNever 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 youBillling Medicare or another insurer for services or items you never got.Billing Medicare for services or equipment which are different from what you gotfrom what you got.Use of another person’s Medicare card to get medical care, supplies, or equipment.Billi M di f h di l i t ft it h bBilling Medicare for home medical equipment after it has been returned.

www.medicare.gov

Medicare Fraud ‐ Do’s and Don’tsD ' i M di H l h IDon'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.y

www.medicare.gov

Medicare Fraud ‐ 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 orDo 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 bybeen endorsed by the Federal government or by Medicare.Do avoid a provider of health care items or services who t ll th t th it i i t ll dtells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid.

www.medicare.gov

Avoiding Telephone ScamsNever give out personal information over the phone unless you are certain the other person is legitimateSimply tell the person that you are too busy to talk at the moment and you would like to call them back at a moremoment and you would like to call them back at a more convenient timeRequest the following information:

NameNameTitle (if appropriate)Phone number

Find the customer service number for the business the personFind the customer service number for the business the person on the phone said they represented (on a bill, internet, or other piece of mail)Call the customer service line and ask if the person that called

i d d t f thyou was indeed part of the company

Using the InternetGet a complete list of your medications and the cash price from the pharmacy

Be sure to 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 readyCan 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 RememberOctober- Compare and PrepareNovember 15- Open Enrollment BeginsD b 8 D ’t B L tDecember 8- Don’t Be LateDecember 31- Open Enrollment EndsJanuary 1 2008- Coverage BeginsJanuary 1, 2008- Coverage Begins

***Next Open Enrollment Period is not until November p15- December 31, 2008***

In summary….No single plan is best for everyone

You must pick the plan that’s right for YOU!Yes it is confusing so don’t be afraid to ask for help:Yes, it is confusing, so don t be afraid to ask for help:

The Point!!! (401) 462-4444SHIP counselors at your local Senior CenterDept of Elderly affairs (401) 462 4000Dept. 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 9001Pharmacy Outreach Program 1-800-215-9001

www.uri.edu/pharmacy/outreach

THANK YOU!