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
