Medicare Part D Prescription Drug Coverage- Part 3

Penalty for Late enrollment Part D

1% of the national average beneficiary premium for each month the beneficiary did not have Part D/ creditable coverage Penalty is in effect as long as the beneficiary has Medicare prescription drug coverage

Lock in for frequently abused drugs

opioids and benzodiaphines

Part D True Out of Pocket costs (TrOOP)

out of pocket costs enrollees incur that count towards the annual out of pocket threshold to move into catastrophic coverage

comprehensive addiction and recovery act (CARA) programs

plans may impose certain limitations to manage utilization for beneficiaries who are at risk of misusing or abusing frequently abused drugs

Creditable Coverage

prescription drug coverage that expects to pay, on average, at least as much as Medicare's standard Part D coverage

Since coverage of Medicare part D benefits is provided only through

private companies, there is no fee-for-serice Part D benefit and medicare pays a share of the program costs

prior authorization

requires the doctor to contact the plan before the plan will cover these prescriptions

Part D plans do not cover all of these drugs because

several similar drugs are availble to treat the same medical condition

Part D plan formularies must include

- >= 2 drugs in each therapeutic category - generic and brand-name drugs

Part D enrollees' optuoins for apying their Part D premium

- automatic electronic monthly mechanism (withdrawal from checking/savings back account/ automatic deduction from credit/debit card - direct monthly billing from plan - automatic deduction form monthly Social Security benefit check must stay with premium payment option for entire year

Standard benefit that the beneficiary is required to pay

- deductible - cost share/ percentage of prescription drug costs between a certain about Part of the costs in Coverage Gap (generic drugs the beneficiary pays more of the share than the name brand drug costs)

What criteria may Part D sponsor measure to adopt for at risk beneficiaries?

# of opioid prescriptions a beneficiary has and the # of prescribers who have written those prescriptinos

Drugs excluded from Part D coverage

- drugs for weight loss/gain, fertility, cosmetic purposes, symptomatic relief of cough + colds - vitamins - medical foods formulated to be consumed. adminstered enterally under th esupervision of a physician that are not regulated as drugs under section 505 of Federal Food, Drug, and Cosmetic Act - erectile dysfunction drugs - non-prescription drugs - some off label use drugs - part covered drugs

Medicare Part D Medication Therapy Management must be designed to

- ensure that covered Part D drugs prescribed to a targeted beneficiaries are appropriately used - to reduce the risk of adverse events, including drug interactions

Some states have assistance programs designed specifically for their residents

- programs are "qualified" state Pharmaceutical Assistance Programs (SPAPs) that count towards TrOOP and some do not count towards TrOOP - becoming familiar with your state's programs may help a beneficiary cost sharing for prescriptions

Medicare Part D eligibility

Beneficiary must live in the plan's service area (PArt D plan coverage is provided through network pharmacies in Part D plan's service area with exception to PFFS plan--> not require to use a pharmacy but may choose to have one)

Who must approve Mid-year formulary changes

CMS

Standard Benefit Plan

Dedcutible: enrollee pays a certain amount Initial coverage: Plan pays 75% and enrollee pays 25% Coverage Gap: Plan pays for 63% for generic, 5% for brand name; Drug manufacturer: 70% for brand name drugs; Enrollee pays 37% for generic/ 25% for brand name Catastrophic coverage: plan pays 95%, enrollee pays greater of 5% or $8.50 brand/$3.40 generic copay

Employer/ Union Coverage of Drugs (EUCD)

Employer/unions will notify their employees of whether their prescription drug coverage is creditable via an annual statement

Bipartisan Budge Act 2018

From 2019 on, the beneficiary cost sharing for brand name drugs after the initial coverage limit is 25%- the same as after the deductible and before the initial coverage limit

What happens if Medicaid beneficiaries do not choose a plan?

Medicare will select one for them; medicaid beneficiaris can change Part D plans throughout the year

Where else is Part D coverage included?

Medicare-Medicaid Plans PACE plans other Medicare health plan demonstrations

What beneficiaries can enroll in a stadalone PDP to receive Part D benefits

Original Medicare MA-MSA PFFS Cost plan

During the transition period

Part D plan does not apply authorization/ step therapy riles the enrollee and his/her physician can request an exception to the part D plan's formulary to continue coverage of the non-formulary drug/ can transition --> a formulary drug

Covered Part D Drugs law

Part D plans are permitted to cover any prescription drugs and biologic that must be covered by states that provide Medicaid prescription drug benefits

PArt D Plan Benefits Standard

Part D plans must cover at least the Part D standard benefit or its actuarial equivalent

substitution

Part D sponsors may substitute generic drugs for brand name drugs if teh generic drugs have the same/ lower cost sharing and certain conditions are met

Types of Part D plans

Stand-alone Prescription Drug plans (PDP) Medicare Advantage Prescription Drug plan (MA-PD)--> MA health plans that also cover Part D pd Cost-PD plans --> medicare cost plans that cover Part D pd as optional supplemental benefit

Medicaid Drug Coverage

When Medicaid beneficiary becomes eligible for Medicare then Medicare covers teh Part D drugs once the beneficiary is enrolled in a Part D plan

Beneficiaries enrolled in a MA MA MSA may obtain Part D benefits through

a standalone PDP

Enrollee payments for Part D prescription drugs

annual deductible cost sharing above the deductible--> up to the inital coverage limit above the inital coverage limit up to annual out of pocket threshold

Some pharmaceutical manufacturers operate programs that

assist low income individuals in obtaining drugs at reduced/ no costs

Step therapy

one or more similar lower cost drugs must be tried before other more costly drugs are tried;

Why should the beneficiary check with the employer/ union benefits administrator before making any change?

because if the beneficiary drops employer/union prescription drug coverage, s/he may not be able to get it back and also may lose health coverage

Who are not subjected to late enrollment for Part D penalty?

beneficiaries who qualify for the low-income subsidy

Low income subsidy (LIS) qualifications

beneficiary income may not exceed 150% of the Federal Poverty Level

Medicare Part D Medication Therapy Management eligibilty

beneficiary must - have multiple chronic diseases (diabetes, hypertension, asthma) - be taking multiple Part D drugs - be likely to incur costs of a specified amount

EUCD noncreditable coverage

beneficiary will need to enroll in Medicare Part D during his/her initial eligibility period to avoid the late enrollment penalty

MTM program elements

comprehensive reviews of medications used on an annual basis quarterly medication reviews identification of medication related problems prescriber and beneficiary interventions to promote coordinated care standardized action plans and summaries

Included entities

costs do count towards TrOOP - qualified State Pharmaceutical Assistance Programs (SPAPs); - most charities - non-government and Indian Health Service funded tribal coverage - AIDS drug Assistance Programs - health savings accounts - flexible spending accounts - medical savings

Excluded entities

costs do not count towards TrOOP - Medicaid - State Children's Health Insurance Program (CHIP) - Federally Qualified Health Centers - Rural Health Clinics - Patient Assistance Programs (PAPs) outside the Part D benefit - TRICARE Federal Employees Health Benefits Program (FEHBP) - Black Lung Funds - health reimbursement arrangements

What are some costs that do not count toward the Part D TrOOP cost total?

costs for - drugs not on PArt D formulary (unless its an exemption) - over the counter and other non-Part D drugs - covered PArt D drugs obtained out of network (unless plan's policy applies_ - paid for/ reimbursed to an enrollee by insurance, group health plan, most govt funded health programs or other 3rd part - costs for drugs purchased outside US

After the initial coverage period, a drug manufacturer's discount for brand name drugs

counts toward the true out of pocket costs

When can Part D plans not make any formulary changes

during the first 60 days of the contract year (unless it is in response to a drug's removal from market);

Part D Pharmacy Networks

enrollees may fill prescriptions for covered drugs at network pharmacies that contract with plans

Part D Drug management tools

formulary cost sharing tiers Step therapy prior authorization substitution comprehensive addiction and recovery act (CARA)

Plan D Late Enrollment Penalty

have to pay premium penalty if - they do not have creditable coverage and do not enroll when first eligible for part D - a period of at least 63 continuous days following a beneficiary's initial enrollment period for Part D during which the beneficiary did not have either Part D/ creditable coverage

If a beneficiary has creditable drug coverage through TriCare, VA, FEHBP

he/she can compare that coverage with available Part D plans to decide whether to enroll in Part D

EUCD creditable coverage

he/she will not incur a premium penalty if he.she later loses/ drops the employer coverage and joins a Part D plan

Part D premiums

higher premium means lower out-of-pocket costs for the plan

PArt D plans must enroll any eligible beneficiary who applies regardless of health status except

in limited circumstances in the case of MA-PD plans under MA program rules

Full Low Income Subsidy

income less than 135% of the FDL and resources below the applicable threshold have $0 deductible and cost sharing of - maximum cost sharing up to the OFP threshold - $3.40- generic drugs - $8.50- drugs drugs - cost sharing after the out of pocket threshold

Partial Low Income Subsidy

income less than 150% of the FDL and resources below the applicable threshold have $0 deductible and cost sharing of - 15% up to the - maximum cost sharing up to the OFP threshold - $3.40- generic drugs - $8.50- drugs drugs - cost sharing after the out of pocket threshold

What individuals are eligible to enroll in Part D plans?

individuals entitled to Part A and/or enrolled under Part B

formulary

list of drugs covered by the plan

tools that CARA plans may use to manage risk include

locking the beneficiary into one - pharmacy prescriber

Biologics

made from a variety of natural sources; not chemically synthesized; composed of sugars, proteins, or NA or complex combos of these substances or maybe living entities such as cells and tissues

When can Plan D plans make limited mid-year formulary?

march 1st

What must plan sponsors provide in order for enrollees to quickly request determination/ appeal a decision

must provide access via a secure website/ email on the website must also require network pharmacies to provide enrollees with a printed notice with the plan's toll-free # and website for requesting a coverage determination

Enrollees have the right to request a formulary exception for either coverage of

non-formulary drugs/ formulary drugs at a less costly formulary tier

How are TrOOP calculated?

on an annual basis which includes enrollee payments for Part D prescription drugs

NOminal costs under catastrophic coverage

once beneficiary expenditures reach a certain total amount, the beneficiary is through the coverage gap and reaches coverage; future prescriptions the beneficiary will pay a co pay of a few dollars for generic drugs or several dollars for brand name drugs/ coinsurance of 5%, whichever is greater

enrollees initially enrolling in Part D, those switching plans, and current enrollees affected by formulary changes must receive coverage of a ___ fill of their non-formulary drugs during the 1st __ days after their enrollment, the plan switch, or the formulary change

single one month; 90

Part D plans include

the drugs they will cover on formularies that are developed by pharmacists, doctors, and other experts

What can a doctor/ enrollee do if the doctor thinks an enrollee needs a drug that is not on the formulary?

the enrollee/ doctor can apply for a formulary exception

Beneficiaries enrolled in a Cost Plan or MA PFFS plan may obtain Part D benefits through

their plan (if offered) or through a standalone PDP

Beneficiaries enrolled in a MA HMO/PPO may obtain Part D benefits through

their plan; although employer group plan enrollees may have additional choices

What happens if the beneficiary retires/ otherwise loses employer/union creditable coverage and joins a Medicare Part D plan/ otherwise obtains creditable drug coverage within 63 days?

there will not be a late enrollment penalty

Beneficiaries enrolled in a Medicare-Medicaid or PACE plan may obtain Part D benefits through

through that plan

cost sharing tiers

tier 1: generic drugs tier 2: preferred brand name drugs tier 3: non-preferred brand name drugs tier 4: high cost drugs

examples of biologics

vaccines allergenic extracts gene therapies cellular therapies

Medicare Part D Medication Therapy Management

what Medicare Part D sponsors are required to have