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Medicare Part D: A friend with
conditions
by
Heather Woolwine
Public
Relations
Navigating and understanding the federal government’s new prescription
drug plan, Medicare Part D, is like getting the latest and greatest
computer on the market; the benefit is there, but you almost must
become an expert to find and use it.
Depending on who you talk to, Medicare Part D encompasses many things.
It embodies a true benefit to the nation’s elderly who must take
expensive medications. To some, it’s legislation written to not only
provide a benefit, but also to help fill the pockets of pharmaceutical
companies. Others believe it to be more complicated and convoluted than
need be in providing a prescription drug benefit. Still more worry
about the plan’s affect on insurance rates, reimbursement for services
and medications, and the fate of the independent pharmacist.
With so many issues swirling, even those in the know find themselves
baffled from time to time. The following article is an attempt to
describe the plan without government verbiage, the issues that surround
it, and most importantly, explain resources available for help with
Medicare Part D.
The
Essentials
Medicare Part D is part of a large, mandated government act by Congress
that enables private insurance companies to provide a prescription drug
benefit to anyone 65 or older.
These people may already have other health insurance, but are still
encouraged to sign up for the program, and thus an individual
prescription drug plan (prior to May of this year, or face penalties
for signing up later on).
Medicare prescription drug coverage is insurance that covers both
brand-name and generic prescription drugs at participating pharmacies.
It provides protection for people who have high drug costs. Everyone
with Medicare is eligible for this coverage, regardless of income and
resources, health status, or current prescription expenses.
To get Medicare coverage for your prescription drugs, patients must
choose and join a Medicare drug plan. Some key factors of these various
plans may differ, like cost, coverage, convenience, and peace of mind
now and later.
When determining cost, consider how much you want to pay in a monthly
premium, as they vary by plan (South Carolina’s range from $16.57 to
$68.74 per month). The same goes for a deductible. This is the amount
someone pays for prescriptions before the plan begins to share in the
cost of those medications. These also vary by plan, but no plan can
have more than a $250 deductible for the year 2006. Enrollees must also
consider co-pays for each prescription after the deductible is paid out.
Coverage is possibly the most important aspect to consider, as there’s
little reason to go with a plan that won’t cover most of an
individual’s medications. A list of drugs that a Medicare drug plan
covers is called a formulary.
Formularies include generic drugs and brand-name drugs. Some plans may
require a prior authorization, meaning that before the plan will cover
these prescriptions, a physician must first contact the plan and show
there is a medically necessary reason why a patient must use that
particular drug for it to be covered.
It’s important that drug plans contract with pharmacies in the area.
Check with the plan to make sure a pharmacy in the plan is convenient.
The government advised that even if an individual doesn’t take a lot of
prescription drugs now, he or she still should consider joining a drug
plan in 2006. It’s no secret, the older we get, the more medicine we
need. By joining now, patients will pay a lower monthly premium in the
future, and if they don’t sign up now, they may pay a penalty if they
choose to join later. It’s not a one time penalty either; it lasts as
long as an individual has a Medicare drug plan. Medicare created a
great website to help understand the process at http://www.medicare.gov/pdphome.asp
and for additional information concerning what plans are available in
South Carolina, visit http://www.medicare.gov/medicarereform/map.asp#SC.
There is also a resident expert on programs that help people from
impoverished or low-income backgrounds to receive their medications.
John Petit, Rutledge Tower Pharmacy, generated more than two million
dollars last year alone in free medication for MUSC patients. To speak
with him about the Extra Help program, the GAPS program (used in
conjunction with the Medicare program), and more, e-mail
petitj@musc.edu.
Weathering
the Storm
By law, those senior citizens previously enrolled in the state drug
prescription benefit plan through Medicaid are now part of the Medicare
system. What this means is that those covered by the state before are
now part of the federal government’s coverage. In the past, Medicare
did not have a drug program. Individuals that were enrolled in or
qualified for both programs, Medicare and Medicaid, are considered
dual-eligible and were switched automatically into a Medicare drug
program. Some of these people picked out their own plan, others just
went into the proverbial pot and came out with a plan that may or may
not cover their medication. Of course this oversight created much
confusion for many senior citizens who were told on the first day in
January 2006 when coverage was supposed to begin that their plan did
not cover their medications.
Joe Newton, R.Phar., Rutledge Tower Pharmacy recounted that first day.
“In addition to dealing with the folks who didn’t have any idea what
plan they were enrolled and so on, we had only about 40 percent of all
our Medicare participants who received their cards from CMS (in charge
of handling the program for the federal government) by January 1,” he
said. “Those cards have a six-digit number telling us what plan they’re
enrolled in and thus what medications are covered or not covered. South
Carolina alone has 18 different plans, so you can imagine the time and
energy that went into figuring out the details for our patients. We
were lucky to have developed a computer program with the help of some
friends at Medicaid and QS/ 1 to identify the drug plan and company for
those recipients without cards. We could get an almost instant answer
on which plans our patients were enrolled in for about 90 percent of
those who came to us. I’d say that despite the confusion, we were able
to accommodate 98 percent of the people that came to see us those first
few days.” The 2 percent not accommodated by a plan were given a three
day supply of medication until their eligibility and plan could
be established.
To alleviate some of that initial confusion throughout the country, the
federal government mandated that all pharmacists fill whatever
prescriptions a Medicare patient needed for 30 days, until all the
kinks were worked out. The timeline was then expanded to 90 days, or
the end of March. But with phone lines constantly jammed those first
few days, medications requiring prior authorizations, and the inability
to get through for those authorizations, many pharmacies, like Rutledge
Tower, had to simply give away the medications in hopes that the
insurance companies and/or federal government would reimburse them
somehow. “We just had to take the chance, these people need their
medications, especially our transplant patients,” Newton said.
“Overall, despite all the challenges, I think we handled it well. We
expected complete and total disaster and it was ok.”
Loops and
a Doughnut Hole
Wayne Weart, Pharm.D., College of Pharmacy and Family Medicine
professor, elaborated on some of the problems related to the new
prescription drug plan. “Those first 30 days, pharmacies had to cover
all those medications, whether they were covered under individual plans
or not. Then because of the large number of complications, they
extended that period, but they’ve done this with no plan in place to
reimburse the pharmacies. There is currently no plan to pay for these
medications. Quite possibly, many pharmacies will end up eating the
cost, despite not being able to afford it.”
Weart was quick however, not to dismiss the program or its handling
entirely. “The goal of the program is to get the medications you need
at the lowest cost possible,” he said. “You can get most medications
covered on most plans.” For example, his mother-in-law will now pay
$850 for medications this year instead of the $3,000 she paid last
year. Using her example, it’s obvious that the program will help many
people throughout the country, but its complex nature has people
frustrated. In addition, its loopholes and gaps seem designed to
benefit the companies who create the plans and the pharmaceutical
companies who lobbied for increased involvement in designing the
legislation. “Pharmacists seem to be the only people who really know
the ins and outs of this plan, not patients or physicians,” he said.
“And even a pharmacist can’t tell you which plan to choose. We can
assist you in selecting the best options, but ultimately, the patient
has to decide. The good thing is that there is an open enrollment
period from November through December of each year and dual-eligibles
can change plans on a monthly basis to keep up with companies who
change their formularies.”
Companies participating in the Medicare plan have the option to change
their formularies and are required to give their patients 60 days
notification. Dual eligibles can then change plans, but others must
wait until open enrollment. “There are two appeals processes in place
to try to off-set any inconveniences caused by this part of the
program,” Weart said.
But no amount of appealing can help patients with the doughnut hole.
The doughnut hole is a gap in coverage through the plans in the
Medicare program for those whose yearly medication spending falls
between $2,250 and $5,100 (in South Carolina). By increasing plan
premium costs, the doughnut hole can go away, but it’s difficult to
imagine having to spend thousands a year on medications and then
expecting thousands more in premiums to cover the gap. Some insurance
companies will pick coverage back up once reaching the $3,600 mark, and
others won’t. Some plans might offer coverage during the gap. But, even
if a plan requires that a patient pay 100 percent of covered drug costs
after a certain limit, the patient still pays less than he or she would
without the Medicare drug coverage.
And the
Rich get Richer?
Weart also briefly discussed the pharmaceutical company lobbying that
took place during the writing of the legislation involving Medicare
Part D. There is some suspicion that the pharmaceutical lobby in
Washington was given too much influence when writing the bill. The way
the legislation reads now, pharmaceutical companies never have to
negotiate the price of pharmaceuticals, meaning that the cost of
medications won’t go down on the companies’ accord. Raising the
public’s taxes to reimburse pharmacies would only skim the surface, so
how are pharmacies going to get paid?
Weart also prophesized a time when the private insurance companies
begin to ask for the same pay rate as the federal government, further
decreasing reimbursement for pharmacies. “You can’t make up with volume
what you lose on the cost of the prescription, it just doesn’t work,”
he said.
And what about all of these pressures on the independent pharmacist,
already competing with large pharmacy chains, mail-order medications,
and the like? Well, Weart sees a future where they could become a
nostalgic part of our past. He told the story of an independent
pharmacist who supplied more than $250,000 in medications the first
month of the new Medicare Part D program, and frankly may be looking at
losing his practice. “In addition to all of this, the insurance
companies and the government are talking about continuing to reduce
reimbursement, while we’re being asked as a profession to do more. It’s
really kind of outrageous how much and how hard we work in pharmacy to
make things easier and better for our patients and this is how we are
treated for that effort.
“They already have to delve into other things to stay afloat now, like
compounding and carrying medical equipment,” he said. “It could be that
this is the final blow to put many independent pharmacists out of
business for good.”
What is Medicare prescription
drug coverage?
Medicare prescription drug coverage is insurance that covers both
brand-name and generic prescription drugs at participating pharmacies
in your area. Medicare prescription drug coverage provides protection
for people who have very high drug costs.
Who can get Medicare
prescription drug coverage?
Everyone with Medicare is eligible for this coverage, regardless of
income and resources, health status, or current prescription expenses.
How does Medicare prescription
drug coverage work?
Your decision about Medicare prescription drug coverage depends on the
kind of health care coverage you have now. There are two ways to get
Medicare prescription drug coverage. You can join a Medicare
prescription drug plan or you can join a Medicare Advantage Plan or
other Medicare Health Plans that offer drug coverage.
Like other insurance, if you join, you will pay a monthly premium,
which varies by plan, and a yearly deductible (no more than $250 in
2006). You will also pay a part of the cost of your prescriptions,
including a co-payment or coinsurance. Costs will vary depending on
which drug plan you choose. Some plans may offer more coverage and
additional drugs for a higher monthly premium. You can apply or get
more information about the extra help by calling Social Security at
1-800-772-1213 (TTY 1-800-325-0778) or visiting http://www.socialsecurity.gov.
What if I have a limited income
and resources?
There is extra help for people with limited income and resources.
Almost 1 in 3 people with Medicare will qualify for extra help and
Medicare will pay for almost all of their prescription drug costs. You
can apply or get information about the extra help by calling Social
Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting http://www.socialsecurity.gov.
Source: http://www.medicare.gov
Friday, March 3, 2006
Catalyst Online is published weekly,
updated
as needed and improved from time to time by the MUSC Office of Public
Relations
for the faculty, employees and students of the Medical University of
South
Carolina. Catalyst Online editor, Kim Draughn, can be reached at
792-4107
or by email, catalyst@musc.edu. Editorial copy can be submitted to
Catalyst
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