state policy changes pharmacy benefit changes impacting state administered programs (medicaid, saga,...
TRANSCRIPT
Medication Access Update
Alicia Woodsby, MSWNational Alliance on Mental
Illness, CT (NAMI-CT)
State Policy Changes
• Pharmacy Benefit Changes Impacting State Administered Programs (Medicaid, SAGA, ConnPACE)
• Pharmacy Benefit Changes Impacting Medicare Part D
Medicaid Fee-for-Service (Adults)
• Provides medical assistance to needy adults who meet “financial” and “categorical” eligibility requirements– Financial: income and assets must be within certain
limits– Categorical: adults must be 65 +, or between 18-65 and
“totally and permanently” disabled or legally blind
• 50% state funded with 50% federal match (Therefore, states must follow federal rules for the program.)
• Also known as “Title XIX “ or “Title 19”
Medicaid vs. Medicare• Medicaid is NOT the same thing as Medicare!– Eligibility for Medicare is based on work
history / work quarters (regardless of income or assets). It is administered by the federal government.– Eligibility for Medicaid is based on income and
assets. It is administered by the state government (DSS)
• People who have both Medicare and Medicaid are called “Dually Eligible”
ConnPACE• About 34 states have State Pharmacy
Assistance Programs (SPAPs)• Connecticut’s SPAP is called “ConnPACE”• ConnPACE is administered by the
Connecticut Department of Social Services (DSS) thru a contractor called “EDS”• 100% state funded (no federal money)
ConnPACE• Helps seniors and people with
disabilities to pay for outpatient prescription drugs, insulin and insulin syringes• Annual registration fee. • Co-pays capped at $16.25 per script• ConnPACE is secondary if member has
Part D
ConnPACE• Age 65, or over 18 and disabled• Must meet Social Security disability criteria
to be considered disabled• Must live in CT at least 6 mo. prior to
application• Cannot have available prescription drug
insurance (other than Part D)• Must have a Part D plan if on Medicare Part
A or B.• Must apply for Part D Low Income Subsidy
(LIS) if income and assets are within LIS limits.
SAGA• State Administered General Assistance
(adults without children)• Individuals who are not eligible for any other
federal or state health care programs and:• Earn an annual income between $6,074 and
$7,327 • Own up to $1,000 in total assets, excluding
home and car• Services are provided through a managed
care program based in the FQHC and hospitals
Summary of Legislative Changes Impacting State Programs
• Mental Health Related Drugs Subjected to the State’s PDL (state has two preferred drug lists – Medicaid and ConnPACE/SAGA)• Previously exempt• Prior Authorization becomes a barrier
for many people in obtaining their medications and can often lead to medication disruptions – main goal person leaves the pharmacy with meds
Mental Health Related Drugs and State Preferred Drug List (PDL)
• 12 month protection intended to prevent disruptions for people who are currently stable on psychotropic medications• May not capture those not in the DSS or
Pharmacy data systems• No protection for new prescriptions (14
day temporary supply – DSS process for notifying prescribers)
Mental Health Related Drugs on State PDL
• Most FDA approved drugs that are not listed are available, with prior authorization by calling EDS toll-free at 1-866-409-8386 or local at (860)269-2030. (EDS = Electronic Data Systems Corporation)• The P&T Committee not expected to
review and finalize list for 4-5 mos. (anticipated start date April 1, 2010)
Medicaid Definition of Medical Necessity
• DSS directed to change the definition of “medically necessary”• DSS will seek the SAGA definition – more
restrictive, eliminates the standard of “maintaining an optimal level of health”• Allows DSS and Medicaid HMOs to deny
services in favor of cheaper ones that are considered “similarly effective” – including medications
Additional Changes to State Pharmacy Policies
• Reduction of Temporary Supply - one time temporary supply reduced from 30 to 14 days• DSS will reportedly implement a process
for notifying prescribers• New policy already in effect• Preserves coverage for over the counter
drugs but subjects them to the state’s PDL and prior authorization
Additional Changes to State Pharmacy Policies
• ConnPACE annual application fee increasing from $30 to $45. Effective 1/1/2010• ConnPACE will have an “open
enrollment” period identical to Part D (11/15 – 12/31). Enrollment will be closed the rest of the year, except to people newly granted Medicare (31 days).
Additional Changes to State Pharmacy Policies
• Medicare Savings Programs (MSP) - MSP income limits increased effective 10/1/09 (income limits raised to ConnPACE levels)• Asset limits eliminated for all MSP
programs effective 10/1/09• MSP estate recovery eliminated
effective 1/1/2010
Summary of Legislative Changes Impacting Part D
• No coverage of non-formulary drugs at all effective 1/1/2010• Dually eligible and ConnPACE members
enrolled in non-benchmark plans must pay excess premium over benchmark threshold. Effective 1/1/2010• Dually eligible will have to pay the first
$15.00 in pharmacy co-pays each month. Effective date not announced.
Summary of Legislative Changes Impacting Part D
• Part D Co-pays for those on LIS (Low-Income Subsidy) will be $2.40/$6. in 2009 and $2.50/$6.30 in 2010.• ConnPACE and Medicaid will still cover
most drugs that are “excluded” from Part D coverage, e.g., barbiturates (e.g., Lorazepam) and benzodiazepines (e.g., Xanax and Valium).
Summary of Legislative Changes Impacting Part D
• Everyone on MSP is automatically eligible for the Part D Low Income “LIS” Subsidy
• LIS pays or contributes to Part D premium payment
• With LIS:– generic co-pays = $2.40 (2009) / $2.50 (2010)–brand name co-pays = $6. (2009) / $6.30 (2010)–No Part D deductible –No Part D “donut hole” (gap in coverage)
Part D Transition Process• Part D transition process - requires plans to
provide a one-time temporary 30-day fill of a non-formulary drug within the person’s first 90 days in their new plan
• Plans may apply PA and step-therapy limits during the transition process, BUT only if they are resolved at point of sale. The beneficiary always should leave the pharmacy with a sufficient quantity to last the allowable days supply (30 days or less if the script is for fewer days).
Part D Transition Process• If the plan approves the drug for
transition purposes only, but not permanently, the plan must notify the beneficiary (to begin exception/appeal process if necessary). • The notice must be sent via first class
mail within 3 days of the temporary fill.
Potential Responses to Non-formulary Drug Issues
• Change to a formulary drug• Request an Exception• Appeals • Switch Plans – option for those on
Low –Income Subsidy (LIS)
Exception Requests• Exceptions – ask your drug plan for an
exception if you/your prescriber believe: • you need a drug not on your plan’s
formulary• that a PA or Step Therapy should be
waived• You should pay less for a higher tiered
drug b/c you can’t take the lower tiered drug for the same condition
Exception Requests• Exceptions – you/prescriber must
contact your plan to ask for a coverage determination/exception• If pharmacy can’t fill the script as
written – must provide you a notice explaining how to contact your plan to make your request
More on Exception Requests• Exceptions – Your prescriber must
provide a statement explaining the medical reason why similar drugs covered by your plan wont work and may be harmful (form available)
• Plan must make coverage determination/exception request decisions within 72 hrs from the time they receive the supporting info from your doctor
And more…• Doctor can request “expedited
consideration” stating that waiting 72 hrs will endanger your life/health/jeopardize ability to regain maximum function• Plan must grant request and make
decision in 24 hrs or less
Part D Appeals• Appeals – you have 60 days to
appeal a denial – can consult with the Center for Medicare Advocacy (CMA) to help you decide this (860-456-7790)• Independent Review Entity
(Maximus)
Appeals Continued
• Administrative Law Judge Hearing
•Medicare Appeals Council Review
• Federal Court Review
Center for Medicare Advocacy, Inc. (860) 456-7790, (800) 262-4414 or
www.medicareadvocacy.org
Formulary Finder – http://formularyfinder.medicare.gov
Medicare and You 2009 Online Manualhttp://www.medicare.gov/Publications/Pubs/pdf/10050.pdf
