Download Medicare Part D - 2 - Academy of Managed Care Pharmacy

Medicare Part D Prescription
Drug Benefit
Highlights
Presentation Developed for the
Academy of Managed Care Pharmacy
Updated: February 2015
Medicare – The Basics
• Federal health insurance program
administered by the Centers for Medicare &
Medicaid Services (CMS)
• Program covers individuals:
– 65 years of age and older
– under age 65 with qualifying disabilities
– under age 65 with End Stage Renal Disease (ESRD)
– Under age 65 with Lou Gehrig’s disease
Original Medicare
• Medicare Part A:
– free premium for most people
– covers hospital stays, skilled nursing facility, home
health care, hospice
– limited drug coverage (drugs given during Medicarecovered stays)
Original Medicare (continued)
• Medicare Part B:
– premium, deductibles and coinsurance paid by
member
– covers doctors’ visits, outpatient medical and
surgical services, durable medical equipment
(DME)
– provides benefits for some drugs, including certain
chemotherapy drugs, certain drug injections given
during an office visit, and drugs that are given at a
dialysis facility
Medigap
• Insurance sold to individual members
• Fills in the gaps (i.e. deductibles & coinsurance) of
Original Medicare plan
• Often referred to as supplemental or complementary
to the Original Medicare plan
Medicare Modernization Act of 2003
• Federal legislation signed into law on
December 8, 2003
• Created a new prescription drug benefit
(Medicare Part D) beginning in January 2006
– available to those members eligible for Medicare
Part A or Part B and elderly Medicaid beneficiaries
– voluntary benefit
– coverage available through private insurance
companies and Managed Care Organizations
Medicare Part D Overview
• PDP: Stand-alone Prescription Drug Plan
(provides drug coverage only)
• MA-PD: Medicare Advantage + Prescription
Drug (provides medical and drug coverage)
• Members select and enroll in plans annually
(open enrollment Oct – Dec)
• Monthly premiums paid to plan
Medicare Part D – Late enrollment penalty
• Calculated by multiplying 1% of the “national
base beneficiary premium” ($ 32.42 in 2014)
times the number of full, uncovered months that
a beneficiary was eligible but didn't sign up for
Part D.
• National base premium may increase each year
and penalty may concurrently increase
• Extra help beneficiaries do not need to pay
penalties
Medicare Part D – Formulary
• CMS set guidelines
– formularies must cover beneficiaries in both
community and long-term care settings
– minimum coverage criteria: two drugs per
therapeutic category/class (based on USP or other
model formulary)
– majority of drugs in 6 key classes are covered:
antidepressants, antipsychotics, anticonvulsants,
antiretroviral, immunosuppressant,
antineoplastics
– some drug classes are specifically excluded
Medicare Part D – Formulary (continued)
• Per CMS, the following drug classes are excluded from coverage under
Part D:
– OTC
– Part B drugs
– Excluded drug categories:
•
•
•
•
•
•
•
•
weight loss/weight gain
fertility agents
agents for cosmetic purposes or hair growth
agents for symptomatic relief of cough and colds
prescription vitamins and minerals (except prenatal and fluoride preparations)
erectile dysfunction
barbiturates
benzodiazepines
• Enhanced plans can provide additional coverage for select barbiturates
and benzodiazepines
Medicare Part D – Formulary (continued)
• Drug formularies are specific to each plan (i.e.
coverage will vary from plan to plan)
• Copayment or co-insurance set by each plan
• Restrictions on coverage set by plan
– prior authorization (PA)
– step therapy (ST)
– quantity limits (QL)
• Upcoming drug maintenance and negative formulary
changes (CMS requires 60 day member notification)
– Includes PA, QL, and ST notifications
Medicare Part D – 2015 Standard Benefit Limits
• Members responsible for:
monthly premium (set by
plan)
annual deductible
health plan drug coverage
(co-pay/co-insurance set by
plan)
Initial Coverage or
Total Drug Cost (TDS) of
$2,960 (set by CMS).
Made up of deductible,
cost share, allowed drug
amount. Once TDS
Is met, member falls into
Coverage gap where
member pays 45% of
plan’s cost for Brand
name drugs
Medicare Part D – 2012 Standard Benefit Limits
• Coverage gap*: member responsible for 45% of
approved cost for brand drugs and 65% of approved
cost for generic drugs
• Member continues to pay out-of-pocket until True
Out-Of-Pocket (TrOOP) reaches $4700 (set by CMS).
Deductible, cost share and member spend in
coverage gap all contribute to TrOOP.
• Once TrOOP is met, member falls into Catastrophic
Coverage where member pays greater of 5% or $2.60
(generic) or $6.50 (brand)
*An enhanced benefit may provide for additional coverage in the gap
Medicare Part D – Low income
• Dual eligible: Medicaid beneficiaries eligible for
Medicare
• Social Security Extra help or Supplemental Social
Security
– 2015: Copay no more than $2.65 generic/$6.60
brand
Medicare Part D – Explanation of Benefits (EOB)
• Part D members receive a monthly EOB which
allows members to monitor their benefit
status
• Provides monthly claim details
– total drug spend (TDS)
– total true out-of-pocket (TrOOP)
– negative drug formulary changes
Medicare Part D – B versus D Benefit
• Certain medications may be covered under
Medicare Part B or D depending on the
circumstances (i.e. place of administration,
administration via DME, etc)
• Medications that are covered under Medicare
Part B are not a benefit under Part D plans
• Plans generally use administrative edits (PA) to
stop claims on potential Part B drugs to allow
determination of appropriate payer
Medicare Part D – B versus D Benefit
• In general, Part B covers the following:
– drugs requiring a DME for administration (e.g.
albuterol via nebulizer, insulin via infusion pump)
– immunosuppressive drugs (for a Medicare
covered transplant)
– certain oral drugs for cancer treatment (contain
same active ingredient or pro-drug as injectable
dosage form)
– certain oral anti-emetic drugs (used as full
therapeutic replacement for IV anti-emetic drugs
within 48 hours of chemo)
Medicare Part D – B versus D Benefit
• Part B coverage (continued):
– certain vaccines (e.g. influenza, pneumococcal)
– drugs for ESRD (e.g. erythropoietin)
– drugs furnished “incident to” a physician’s
service: drugs that are administered
predominantly by a physician or under their direct
supervision “incident to” a professional service
Medicare Part D – B versus D Benefit
• A descriptive summary of Part B versus Part D
coverage issues is available at:
https://www.cms.gov/PrescriptionDrugCovGe
nIn/Downloads/PartBandPartDdoc_07.27.05.p
df
• A reference table for frequent B/D coverage
determination scenarios is available at:
https://www.cms.gov/pharmacy/downloads/
partsbdcoverageissues.pdf
Medicare Part D – Drug plan coverage rules
• Prior authorization: Patient and/or prescriber
must contact plan before certain prescriptions
can be filled. Determined by the plans.
• Quantity limits: Limits on how much medication
may be obtained at a time.
• Step therapy: Plans may require patients to try
lower cost, or similar drugs before covering
prescribed drug.
Medicare Part D: coverage
• Commercial vaccines not covered under Part B
when medically necessary to cover illness
• Outpatient/ED settings: Plan may cover certain
drugs not covered under Part B
Medicare Part D – Additional Resources
• www.cms.gov – Centers for Medicaid &
Medicare Services
• www.medicare.gov – official U.S. government
site for Medicare, compare health and drug
plans
Thank you to AMCP member
Bethanie Stein for updating
this presentation for 2015.