Pharmacy Outreach Program The University of Rhode Island

College of Pharmacy

Updated October 2011

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)

THE PARTS OF MEDICARE

Part A

Hospital insurance

Part B

Medical insurance

Medicare 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 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

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

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)

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.

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!

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!!

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?

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

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

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!**

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!

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

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

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

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%

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%

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%

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!

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)

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.

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?

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

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

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)

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

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 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

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

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!

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

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 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!

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

“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

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

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

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

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

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

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!

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

Important Dates to Remember

October 1- Compare and Prepare

October 15- Open Enrollment Begins

December 7- Open Enrollment Ends

January 1, 2012- Coverage Begins

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

THANK YOU!