prescription drug improvement and modernization act
DESCRIPTION
Prescription Drug Improvement and Modernization Act. Dorothy Della Sherwood, M.D. Presbyterian Hospital of Dallas 2/22/2006. MMA. - PowerPoint PPT PresentationTRANSCRIPT
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Prescription Drug Improvement and Modernization Act
Dorothy Della Sherwood, M.D.Presbyterian Hospital of Dallas
2/22/2006
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MMA
• This year, Medicare introduced the prescription drug benefit-the most significant change in Medicare coverage since the program’s inception…which will help patients and doctors work together to alleviate symptoms and reduce the rate of complications from serious illness.
» Mark B. McClellan, M.D., PhD., NEJM 12/05
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MMA
• America’s older citizens have been barraged with educational and marketing initiatives for various drug plans….an October poll indicated that 61% did not understand the program and 54% did not intend to sign up.
» Richard L. Kravitz, M.D. NEJM 12/05 UC Davis
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MMA
CMS Goal for the Drug Benefit1. Ensure all beneficiaries have access to high-quality, affordable drug coverage2. Provide continuous access to drugs needed by the chronically ill3. Create a competitive, transparent marketplace
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MMA
• Competitive/Transparent– Medicare Prescription Drug Plans ( MPDP)
negotiate with drug companies to purchase drugs at a discounted price which they pass on to the beneficiary.
– CMS is counting on this competition to hold down prescription prices
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MMA
• When choosing a PDP, one should compare– Deductible – Monthly Premium– Co-pay for Rx – Formulary – Gap Coverage – Mail-in or local pharmacy
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MMA
• The minimum prescription-drug benefit required by Medicare– No more than $250.00 deductible– A monthly premium ( average of $37.00/mo)– Pay 25% of the next $2000.00 in costs ($500.00)– Pay 100% of the next $2,850.00 – the gap– Total out of pocket costs could reach $3,600.00/yr– Catastrophic coverage begins and beneficiary pays
only 5%
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MMA
• Competition has resulted in better coverage than those that have been mandated.
• WWW.CMS.GOV
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MMA
• Help for People with Limited Incomes– People with lowest income and resources
• Pay no premiums or deductibles• Have small or no co-payments
– Eligibility• <$1,197 per month for an individual with <$11,500
in assets (excluding house)• <$1,604 per month for a couple with <$23,000 in
assets (excluding house)
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MMA
• How to apply for extra help.– SSA mailed applications to those who may be
eligible– www.ssa.gov
• All dual eligible ( Medicare and Medicaid) are automatically enrolled
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MMA
• What about Medigap?– Information was sent to people with Medigap
giving them the following choices:• Keep Medigap• Join Medicare Prescription Drug Plan and delete
drug coverage from Medigap• Drop Medigap and join Medicare Advantage
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MMA
• What about Employer/Union Coverage?– Choices include
• Keep coverage offered by employer/union• Join MPDP• Join Medicare Advantage Plan
– Advise to contact Employers/Union• There is a tax free subsidy provided by Medicare to
the Employers who offer coverage• Employers may contract with a MPDP to provide
coverage
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MMA
• Specific Drug Coverage mandated by MMA– Cancer medications– HIV/AIDS treatments– Antidepresssants– Antipsychotics– Anticonvulsants– Immunosuppressants
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MMA
• Excluded Drugs– Weight Loss Drugs– Fertility Drugs– Cosmetic hair growth products– Cough suppressants– Benzodiazepines– Barbituates– Vitamins– Non-prescription drugs
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• Formularies– Most MPDP have formularies– All formularies must include at least 2 drugs
from every category of drug– The formulary must be approved by CMS– Tier 1 drugs have the lowest cost sharing– There must be an exception procedure for
tiered formularies – to obtain a drug at a more favorable cost or obtain a drug not on formulary
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PDP Formulary Available at
www.epocrates.com
http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp
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MMA
• Perils– Exception Request:
• Patient is unable to take a statin due to myopathy and therefore requires Zetia
• PDP considers Zetia a ‘Step Drug’ after maximizing statin
• The enrollee can request an exception to the plan’s step-therapy requirement
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MMA
• Process: – PDP pharmacy initiates with fax entitled
“Request for Prescription Information or Change”
– Physician initiates request to the PDP with a “Request for Prescription Exception”
– Exceptions should be reviewed in 24 hours if the need is immediate
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• Plan Contacts for appeal:– www.cms.hhs.gov/PrescriptionDrugCovGenIn
• There are 5 levels of appeal and it may indeed end up in the Federal Courts!– Redetermination by plan– Reconsideration by a Medicare drug coverage QIC– Administrative Law judge– Medicare Appeals Council– Federal District Court
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MMA
• Why should the Medicare beneficiary enroll now?– Late enrollment results in a 1% increase in
premium per month for every month the person was eligible but did not join.
– This penalty will be paid forever!– This penalty does not apply to individuals with
prescription drug coverage that equals the Medicare coverage
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• Individual Choice• Last date for enrollment is May 15th, 2006 • All Medicaid beneficiaries were
automatically enrolled by Jan 1st if they had not chosen a plan.
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MMA
• So what will this cost? BILLIONS over the next 8 years. – Payments to MPDP : 448 to 479 – Low Income Subsides: 192 to 239
• 35% of the Medicare Population – Spending on health care is expected to
increase from 1.8 trillion dollars in 2003 to 3.6 trillion dollars in 2014
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MMA
• Web sites for your patients– www.medicare.gov– www.cms.hhs.gov– www.ssa.gov
• Phone – 1-800-MEDICARE (800-633-4227)– SS – 1-800-772-1213