Medicare Prescription Drug Coverage. 06/08/20102 Medicare Prescription Drug Coverage Referred to as Medicare Part DReferred to as Medicare Part D Available.

Medicare Prescription Medicare Prescription Drug CoverageDrug Coverage

06/08/2010 2

Medicare Prescription Medicare Prescription Drug CoverageDrug Coverage

• Referred to as Medicare Part DReferred to as Medicare Part D• Available to everyone with Medicare Available to everyone with Medicare • Drug plans approved by Medicare Drug plans approved by Medicare

– Run by private companies Run by private companies • Must be enrolled in a plan to get coverageMust be enrolled in a plan to get coverage• Coverage provided throughCoverage provided through

– Medicare Prescription Drug Plans (PDPs)Medicare Prescription Drug Plans (PDPs)– Medicare Advantage with Prescription Drugs (MA-PDs) Medicare Advantage with Prescription Drugs (MA-PDs)

Understanding Medicare Prescription Drug Coverage

06/08/2010 3

Part D Eligibility RequirementsPart D Eligibility Requirements

• To be eligible to join a Prescription Drug Plan To be eligible to join a Prescription Drug Plan – You must have Medicare Part A You must have Medicare Part A and/orand/or Part B Part B

• To be eligible to join Medicare Advantage plan To be eligible to join Medicare Advantage plan with drug coveragewith drug coverage– You must have Part A You must have Part A andand Part B Part B

– You must live in plan’s service area You must live in plan’s service area – You cannot be incarceratedYou cannot be incarcerated

– You You mustmust be enrolled in a plan be enrolled in a plan


06/01/2010 4

Covered DrugsCovered Drugs

• Prescription brand-name and generic drugsPrescription brand-name and generic drugs• Approved by FDAApproved by FDA• Used and sold in U.S.Used and sold in U.S.• Used for medically-accepted indicationsUsed for medically-accepted indications• Includes drugs, biological products, and Includes drugs, biological products, and

insulininsulin– Supplies associated with injection or inhalationSupplies associated with injection or inhalation

Medicare Drug Coverage Under Part A, Part B and Part D

06/08/2010 5

Required CoverageRequired Coverage

•““All” drugs in 6 categories must be All” drugs in 6 categories must be coveredcovered– Cancer medicationsCancer medications– HIV/AIDS treatmentsHIV/AIDS treatments– AntidepressantsAntidepressants– Antipsychotic medicationsAntipsychotic medications– Anticonvulsive treatments for epilepsy Anticonvulsive treatments for epilepsy

and other conditionsand other conditions– ImmunosuppressantsImmunosuppressants


06/01/2010 6

VaccinesVaccines

•All Part D drug plans must cover:All Part D drug plans must cover:– All commercially available vaccines All commercially available vaccines

• e.g., shingles vaccinee.g., shingles vaccine

Note: Except those covered under Part B Note: Except those covered under Part B • e.g., flu shote.g., flu shot

•Contact drug plan for more Contact drug plan for more informationinformation


06/01/2010 7

Drugs Not Covered by Part DDrugs Not Covered by Part D• Excluded by law from Medicare coverageExcluded by law from Medicare coverage– Anorexia, weight loss or weight gain drugsAnorexia, weight loss or weight gain drugs– Erectile dysfunction drugs Erectile dysfunction drugs – Fertility drugsFertility drugs– Drugs for cosmetic or lifestyle purposes Drugs for cosmetic or lifestyle purposes

– e.g., hair growthe.g., hair growth– Drugs for symptomatic relief of coughs and coldsDrugs for symptomatic relief of coughs and colds– Prescription vitamin and mineral products Prescription vitamin and mineral products

– except prenatal vitamins and fluoride preparationsexcept prenatal vitamins and fluoride preparations– Non-prescription drugsNon-prescription drugs– Barbiturates and benzodiazepinesBarbiturates and benzodiazepines

– To be covered in 2013To be covered in 2013


06/08/2010 8

Drugs Not Covered by Part D Drugs Not Covered by Part D (continued)(continued)

•Medicare Part A or Part B covered Medicare Part A or Part B covered drugs drugs – Unless you don’t meet Part A or B Unless you don’t meet Part A or B

coverage requirementscoverage requirements

•Plan may choose to cover excluded Plan may choose to cover excluded drugs drugs – At their own cost, orAt their own cost, or– Share the cost with membersShare the cost with members


06/08/2010 9

Access to Covered DrugsAccess to Covered Drugs

• Plans must cover at least two drugs in each categoryPlans must cover at least two drugs in each category• Coverage and rules vary by planCoverage and rules vary by plan• Plans can manage access to drug coverage throughPlans can manage access to drug coverage through

– Formularies (list of covered drugs)Formularies (list of covered drugs)– Prior authorization (doctor requests before service)Prior authorization (doctor requests before service)– Step therapy (type of prior authorization)Step therapy (type of prior authorization)– Quantity limits (limits quantity for period of time)Quantity limits (limits quantity for period of time)


FormularyFormulary• A list of prescription drugs covered by the planA list of prescription drugs covered by the plan• May have “tiers” that cost different amountsMay have “tiers” that cost different amounts

06/08/2010 Understanding Medicare Prescription Drug Coverage 10

Example of Tiers (Plans can form tiers in different ways)Example of Tiers (Plans can form tiers in different ways)

TierTier You PayYou PayPrescription Prescription

Drugs CoveredDrugs Covered

11 Lowest copaymentLowest copayment Most generics Most generics

22 Medium copaymentMedium copayment Preferred, brand-name Preferred, brand-name

33 Highest copaymentHighest copayment Non-preferred, brand-name Non-preferred, brand-name

SpecialtySpecialty Highest copayment Highest copayment or coinsuranceor coinsurance

Unique, very high-cost Unique, very high-cost

06/08/2010 11

Prior AuthorizationPrior Authorization

• Doctor must contact plan for prior Doctor must contact plan for prior authorizationauthorization– Before prescription will be coveredBefore prescription will be covered– Must show medical necessity for that particular Must show medical necessity for that particular

drugdrug

• Ask plan for prior authorization Ask plan for prior authorization requirementsrequirements– Process for requests may vary by planProcess for requests may vary by plan


06/08/2010 12

Step TherapyStep Therapy

• Type of prior authorizationType of prior authorization• Person must try a similar, less-Person must try a similar, less-

expensive drug that has been proven expensive drug that has been proven effectiveeffective

• Doctor can request an exception ifDoctor can request an exception if– Tried similar, less expensive drug and it Tried similar, less expensive drug and it

didn’t work, ordidn’t work, or– Step-therapy drug is medically necessaryStep-therapy drug is medically necessary


06/08/2010 13

Quantity LimitsQuantity Limits

• Plans may limit the quantity of drugs they Plans may limit the quantity of drugs they cover cover – Over a certain period of timeOver a certain period of time– For reasons of safety and/or costFor reasons of safety and/or cost


06/08/2010 14

If Your Prescription ChangesIf Your Prescription Changes

• Get up-to-date information from planGet up-to-date information from plan – By phone or on plan’s websiteBy phone or on plan’s website

• Give doctor copy of plan’s formularyGive doctor copy of plan’s formulary• If the new drug is not on plan’s If the new drug is not on plan’s

formularyformulary– Can request a coverage determination from Can request a coverage determination from

planplan– May have to pay full price if plan still won’t May have to pay full price if plan still won’t

cover drugcover drug


06/08/2010 15

Formulary ChangesFormulary Changes

• Plans may change categories and classes Plans may change categories and classes – Only at beginning of each plan year Only at beginning of each plan year

(Plan year is January through December)(Plan year is January through December)– May make maintenance changes during yearMay make maintenance changes during year

• Plan usually must notify you 60 days before changesPlan usually must notify you 60 days before changes– May be able to use your drug until end of calendar yearMay be able to use your drug until end of calendar year– May ask for exception if other drugs don’t workMay ask for exception if other drugs don’t work

• Plans may remove drugs withdrawn from marketPlans may remove drugs withdrawn from market– By the manufacturer or the Food and Drug Administration, By the manufacturer or the Food and Drug Administration,

without 60 day notificationwithout 60 day notification


06/08/2010 16

Medicare Drug Plan Medicare Drug Plan • Can be flexible in benefit designCan be flexible in benefit design• Must offer at least a standard level of coverageMust offer at least a standard level of coverage• May offer enhanced benefitsMay offer enhanced benefits• Benefits & costs can change from year to yearBenefits & costs can change from year to year

– Monthly premium varies by plan Monthly premium varies by plan • Some plans have no premiumSome plans have no premium

– Possible yearly deductiblePossible yearly deductible• No more than $320 in 2012No more than $320 in 2012

– Copayments or coinsuranceCopayments or coinsurance• May depend on how much spent that yearMay depend on how much spent that year


2012 Standard Coverage and Cost2012 Standard Coverage and Cost

Benefit Benefit StageStage

Coverage Coverage RangeRange Plan PaysPlan Pays Beneficiary PaysBeneficiary Pays

Annual Annual DeductibleDeductible

$0-$320$0-$320 0%0% $0$0 100%100% $320$320

Initial Initial CoverageCoverage

$320-$2930$320-$2930(Next $2610)(Next $2610) 75%75% $1957.50$1957.50 25%25% $652.50$652.50

Coverage GapCoverage Gap $2930-6657.50$2930-6657.50(Next $3727.50)(Next $3727.50)

50% - Brand-name50% - Brand-name14% - Generics14% - Generics

50% - Brand-name 50% - Brand-name 86% - Generic 86% - Generic

Catastrophic Catastrophic CoverageCoverage

$6657.50 and up$6657.50 and up 95%95% No No MaximumMaximum 5%5% No No

MaximumMaximum

Monthly PremiumsMonthly Premiums• Starting January 1, 2011 part D monthly Starting January 1, 2011 part D monthly

premiums may be higher based on incomepremiums may be higher based on income– Includes PDP and MA-PD plansIncludes PDP and MA-PD plans

• If income is above If income is above – $85,000 filing individual tax return$85,000 filing individual tax return– $170,000 filing a joint tax return$170,000 filing a joint tax return

Additional monthly adjustments will be charged Additional monthly adjustments will be charged in addition to part D premiumsin addition to part D premiums

• SSA will be contacting those who have to SSA will be contacting those who have to pay higher premiums in Novemberpay higher premiums in November

06/08/2010 19

True Out-of-Pocket Costs (TrOOP)True Out-of-Pocket Costs (TrOOP)

TrOOP is the amount of money (out-of-pocket) that TrOOP is the amount of money (out-of-pocket) that can be used to reach catastrophic coverage can be used to reach catastrophic coverage

• Payment sources that countPayment sources that count– Plan memberPlan member– Family members or other individualsFamily members or other individuals– Illinois Cares Rx paymentsIllinois Cares Rx payments– SSA “Extra Help” (low-income subsidy)SSA “Extra Help” (low-income subsidy)– CharitiesCharities

• Not if established/controlled by current/former employer or Not if established/controlled by current/former employer or unionunion

– Indian Health Services and AIDS Drug Assistance Programs Indian Health Services and AIDS Drug Assistance Programs – Part D Part D manufacturermanufacturer discount for covered Brand-name drugs discount for covered Brand-name drugs

during coverage gapduring coverage gap


06/08/2010 20

Out-of-Pocket Costs that Out-of-Pocket Costs that Do Not CountDo Not Count

• Payment sources that Payment sources that do notdo not count count – Monthly drug premium paymentsMonthly drug premium payments

– Group health plansGroup health plans • Including employer or union retiree coverageIncluding employer or union retiree coverage

– Government-funded programs including Government-funded programs including TRICARE and VATRICARE and VA

– Manufacturer Patient Assistance ProgramsManufacturer Patient Assistance Programs– Other third-party payment arrangementsOther third-party payment arrangements– Part D plan discounts for covered drugs during Part D plan discounts for covered drugs during

coverage gapcoverage gapUnderstanding Medicare Prescription Drug Coverage

Coverage Gap DiscountCoverage Gap Discount

• If you reach the coverage gap in 2012 you If you reach the coverage gap in 2012 you may receive discounts on both brand-name may receive discounts on both brand-name and generic drugsand generic drugs– 50% discount on brand-name prescription drugs 50% discount on brand-name prescription drugs

in 2012in 2012– 14% discount on generic drugs in 201214% discount on generic drugs in 2012

• Additional savings in coverage gap each Additional savings in coverage gap each yearyear– Gap to be closed in 2020 Gap to be closed in 2020

06/08/2010 21Understanding Medicare Prescription Drug Coverage

Cost Sharing for Brand-name Drugs in the Cost Sharing for Brand-name Drugs in the Medicare Part D Coverage Gap, 2010-2020Medicare Part D Coverage Gap, 2010-2020

Cost Sharing for Generic Drugs in the Medicare Cost Sharing for Generic Drugs in the Medicare Part D Coverage Gap, 2010-2020Part D Coverage Gap, 2010-2020


When you can Join or SwitchWhen you can Join or SwitchMedicare Prescription Drug PlansMedicare Prescription Drug Plans

Initial Coverage Initial Coverage Election Period Election Period (IEP)(IEP)

•7 month period7 month period•Starts 3 months before Starts 3 months before

month of eligibilitymonth of eligibility

Annual Open Annual Open Enrollment Enrollment Period (AOEP)Period (AOEP)

• October 15 – December 7October 15 – December 7


When You Can Join or SwitchWhen You Can Join or SwitchMedicare Prescription Drug Plans Medicare Prescription Drug Plans (continued)(continued)

Medicare Medicare Advantage Advantage Disenrollment Disenrollment Period (MADP)Period (MADP)

January 1–February 14, you can January 1–February 14, you can leave an MA plan and switch to leave an MA plan and switch to Original Medicare. Original Medicare.

If you make this change, you may If you make this change, you may also join a Medicare Prescription also join a Medicare Prescription Drug Plan to add drug coverage. Drug Plan to add drug coverage. Coverage Coverage begins the first of the begins the first of the month after the plan gets month after the plan gets enrollment formenrollment form. .

When you can Join or SwitchWhen you can Join or SwitchMedicare Prescription Drug Plans Medicare Prescription Drug Plans

(continued)(continued)

5-star 5-star Special Special Enrollment Enrollment Period Period (5-star SEP)(5-star SEP)

December 8, 2011 – December 31, 2012December 8, 2011 – December 31, 2012

Beneficiaries will have a Beneficiaries will have a one-timeone-time enrollment into any 5-star plan. This will enrollment into any 5-star plan. This will include both the Stand-alone prescription include both the Stand-alone prescription drug plan (PDP) or Medicare Advantage drug plan (PDP) or Medicare Advantage with drug coverage (MA-PD). with drug coverage (MA-PD).


When you can Join or SwitchWhen you can Join or SwitchMedicare Prescription Drug Plans Medicare Prescription Drug Plans

(continued)(continued)

Special Special Enrollment Enrollment Periods (SEP)Periods (SEP)

• You permanently move out of your You permanently move out of your plan’s service areaplan’s service area

• You lose other creditable Rx coverageYou lose other creditable Rx coverage• You weren’t adequately informed your You weren’t adequately informed your

other coverage was not creditable/was other coverage was not creditable/was reduced and no longer creditablereduced and no longer creditable

• You enter, live in or leave a long-term You enter, live in or leave a long-term care facilitycare facility

• You have a continuous SEP if you You have a continuous SEP if you qualify for Extra Helpqualify for Extra Help

• Or in exceptional circumstancesOr in exceptional circumstances

06/08/2010 28

Creditable Drug CoverageCreditable Drug Coverage

• If you have other drug coverage If you have other drug coverage – It may or may not be creditableIt may or may not be creditable– If creditable, it meets or exceeds Medicare’s If creditable, it meets or exceeds Medicare’s

minimum standardsminimum standards

• With creditable coverageWith creditable coverage– Will not have to pay a late-enrollment penaltyWill not have to pay a late-enrollment penalty

• Plans inform yearly about whether Plans inform yearly about whether creditablecreditable– e.g.; employer group plans, retiree plans, VA, e.g.; employer group plans, retiree plans, VA,

TRICARE and FEHBTRICARE and FEHB


06/08/2010 29

Penalty Calculation Penalty Calculation Late EnrollmentLate Enrollment

• National base beneficiary premium National base beneficiary premium – $30.23 in 2012$30.23 in 2012– Can change each yearCan change each year

•Pay 1% (of $30.23 in 2012) for every Pay 1% (of $30.23 in 2012) for every month eligible but not enrolledmonth eligible but not enrolled– Unless person has creditable coverageUnless person has creditable coverage– Penalty added to premium paymentPenalty added to premium payment


06/08/2010 30

Extra Help with Drug CostExtra Help with Drug Cost

• Sometimes called the Low-Income Subsidy (LIS)Sometimes called the Low-Income Subsidy (LIS)• For people with lowest income and resourcesFor people with lowest income and resources

– Pay no premiums or deductibles & small or no copaymentsPay no premiums or deductibles & small or no copayments

• Those with slightly higher income and resourcesThose with slightly higher income and resources– Pay reduced deductible and a little more out of pocketPay reduced deductible and a little more out of pocket

• No coverage gap for people who qualify for LISNo coverage gap for people who qualify for LIS


06/08/2010 31

Qualifying for Extra HelpQualifying for Extra Help

Some will automatically qualify if they Some will automatically qualify if they have Medicare and;have Medicare and;– Get full Medicaid benefitsGet full Medicaid benefits– Supplemental Security Income (SSI) Supplemental Security Income (SSI) – Medicare Savings ProgramMedicare Savings Program

• Medicaid help with some Medicare cost Medicaid help with some Medicare cost

• All others must apply with Social SecurityAll others must apply with Social Security– Online at Online at www.socialsecurity.gov, or , or – Call Call 1-800-772-1213 1-800-772-1213 (TTY 1-800-325-0778)(TTY 1-800-325-0778)

• Ask for “Application for Help with Medicare Prescription Ask for “Application for Help with Medicare Prescription Drug Plan Costs”Drug Plan Costs” (SSA-1020)(SSA-1020)


http://www.socialsecurity.gov/

06/08/2010 32

Income and Resource LimitsIncome and Resource Limits IncomeIncome

– Below 150% Federal poverty levelBelow 150% Federal poverty level• $16,335 per year for a single person* or$16,335 per year for a single person* or• $22,065 per year for a married couple*$22,065 per year for a married couple*• Based on family sizeBased on family size

ResourcesResources– Up to $12,640 (individual)Up to $12,640 (individual)– Up to $25,260 (married couple)Up to $25,260 (married couple)

• Includes $1,500/person funeral or burial expensesIncludes $1,500/person funeral or burial expenses• Counts savings and stocksCounts savings and stocks• Does not count home you live inDoes not count home you live in

2011 2011 amountsamounts

2011 2011 amountsamounts

*Higher amounts for Alaska and Hawaii*Higher amounts for Alaska and Hawaii


06/08/2010 33

Auto- and Facilitated EnrollmentAuto- and Facilitated Enrollment

• CMS identifies and enrolls people each monthCMS identifies and enrolls people each month– Randomly assigned to plansRandomly assigned to plans

• Premiums at or below regional low-income premium Premiums at or below regional low-income premium subsidy amountsubsidy amount

• May join MA plan meeting special needsMay join MA plan meeting special needs

• If you are already enrolled in an MA planIf you are already enrolled in an MA plan– You’ll be enrolled in the same plan with Rx coverage You’ll be enrolled in the same plan with Rx coverage

(MA-PD)(MA-PD)– If offered by your current planIf offered by your current plan


06/08/2010 34

Medicare and Full MedicaidMedicare and Full Medicaid

• You are auto-enrolled in a plan unlessYou are auto-enrolled in a plan unless– You are already in a Part D planYou are already in a Part D plan– You choose and join a plan on your ownYou choose and join a plan on your own– You call the plan or 1-800-MEDICARE to opt outYou call the plan or 1-800-MEDICARE to opt out

• You are covered 1st month you are covered byYou are covered 1st month you are covered by– Medicaid and are entitled to MedicareMedicaid and are entitled to Medicare

• Will get auto-enrollment letter on yellow paperWill get auto-enrollment letter on yellow paper

• You have a continuous Special Enrollment PeriodYou have a continuous Special Enrollment Period


06/08/2010 35

Others Qualified for Extra HelpOthers Qualified for Extra Help

• Facilitated into a plan unlessFacilitated into a plan unless– You already are in a Part D planYou already are in a Part D plan– You choose and join own plan You choose and join own plan – You’re enrolled in employer/union plan receiving subsidyYou’re enrolled in employer/union plan receiving subsidy– You call the plan or 1-800-MEDICARE to opt outYou call the plan or 1-800-MEDICARE to opt out

• Coverage is effective 2 months after CMS notifiesCoverage is effective 2 months after CMS notifies

• Will get facilitated enrollment letter on green paperWill get facilitated enrollment letter on green paper

• Have continuous Special Enrollment PeriodHave continuous Special Enrollment Period


06/08/2010 36

People New to Extra HelpPeople New to Extra Help

• You can apply for Extra Help any timeYou can apply for Extra Help any time– If denied, can reapply if circumstances changeIf denied, can reapply if circumstances change

• If in a Medicare drug plan and later qualifyIf in a Medicare drug plan and later qualify– Plan is notified you qualify for Extra HelpPlan is notified you qualify for Extra Help– Plan refunds costs back to effective date of Extra Plan refunds costs back to effective date of Extra

HelpHelp• Deductibles/PremiumsDeductibles/Premiums• Cost-sharing assistanceCost-sharing assistance


06/08/2010 37

Enrollment NoticesEnrollment Notices

• CMS notifies people of enrollment in a PDP CMS notifies people of enrollment in a PDP – Auto-enrollment letter on yellow paperAuto-enrollment letter on yellow paper– Facilitated enrollment letter on green paperFacilitated enrollment letter on green paper

• Denotes either full or partial subsidyDenotes either full or partial subsidy• Includes list of area plans at/below regional low-Includes list of area plans at/below regional low-

income premium subsidy amount income premium subsidy amount

• MA plan sends notice if enrollment in MA-MA plan sends notice if enrollment in MA-PDPD


06/08/2010 38

Re-establishing Eligibility for People Re-establishing Eligibility for People Who Automatically QualifyWho Automatically Qualify

• CMS re-establishes eligibility in the Fall CMS re-establishes eligibility in the Fall – For next calendar yearFor next calendar year– If you no longer automatically qualifyIf you no longer automatically qualify

• CMS sends letter in September on gray paperCMS sends letter in September on gray paper– Includes SSA applicationIncludes SSA application

– If you automatically qualify & your copayment If you automatically qualify & your copayment changedchanged

• CMS sends letter In early October on orange CMS sends letter In early October on orange paperpaper


06/08/2010 39

Extra Help – What You PayExtra Help – What You Pay

Group 1Group 1

100% FPL100% FPLGroup 2Group 2

100-135% FPL100-135% FPLGroup 3Group 3

135-150% FPL135-150% FPL

PremiumPremium $0*$0* $0$0Sliding scale Sliding scale

based on incomebased on income

Yearly Yearly deductible deductible $310/year$310/year

$0*$0* $0$0 $60$60

Coinsurance up Coinsurance up to $4,700 out of to $4,700 out of

pocketpocket

$1.10/$3.30 $1.10/$3.30 copaycopay

$2.60/$6.50 $2.60/$6.50 copaycopay

Up to 15% Up to 15% coinsurancecoinsurance

Catastrophic Catastrophic coveragecoverage $0$0 $0$0

$2.60/$6.50 $2.60/$6.50 copaycopay


*If you join a basic plan with a premium at or below the regional low-income premium subsidy amount.*If you join a basic plan with a premium at or below the regional low-income premium subsidy amount.

LI-NETLI-NET

• Limited Income Newly Eligible Transition Program Limited Income Newly Eligible Transition Program (LI-NET)(LI-NET)– Combined auto-enrollment and Point-of-Sale Facilitated Combined auto-enrollment and Point-of-Sale Facilitated

EnrollmentEnrollment• For full duals and SSI-only beneficiariesFor full duals and SSI-only beneficiaries

• Provides Part D coverage for all uncoveredProvides Part D coverage for all uncovered– Full duals and SSI-only beneficiaries retroactivelyFull duals and SSI-only beneficiaries retroactively– LIS eligible beneficiaries on a current basisLIS eligible beneficiaries on a current basis


LI-NET Coverage and EnrollmentLI-NET Coverage and Enrollment

• CoverageCoverage– Full Dual/SSI-only up to 36 monthsFull Dual/SSI-only up to 36 months– Partial Dual/LIS Applicants up to 30 daysPartial Dual/LIS Applicants up to 30 days– Unconfirmed up to 7 daysUnconfirmed up to 7 days

• Enrolled in LI NET for temporary coverage Enrolled in LI NET for temporary coverage – In Standard PDP for future coverageIn Standard PDP for future coverage

• Open Formulary, No Prior Authorization, No Open Formulary, No Prior Authorization, No Pharmacy RestrictionsPharmacy Restrictions

• Standard PDP Rights for Enrollees, Eligibility Standard PDP Rights for Enrollees, Eligibility Reviews for Non-EnrolleesReviews for Non-Enrollees


Access to LI-NetAccess to LI-Net

• Three ways to access the LI-NET Three ways to access the LI-NET programprogram– Auto: Enrollment by CMSAuto: Enrollment by CMS– Point of Service (POS)Point of Service (POS)– Submitting a receipt for drugs already Submitting a receipt for drugs already

paid out-of-pocketpaid out-of-pocket• During eligible periodsDuring eligible periods

State Pharmacy Assistant State Pharmacy Assistant Program (SPAP)Program (SPAP)

• In Illinois, SPAP is Illinois Cares RxIn Illinois, SPAP is Illinois Cares Rx• Two types of coverageTwo types of coverage

– Illinois Cares Rx Basic Illinois Cares Rx Basic • formerly Pharmaceutical Assistance Programformerly Pharmaceutical Assistance Program

– Illinois Cares Rx Plus Illinois Cares Rx Plus • formerly SeniorCareformerly SeniorCare

• Can also assist individuals not on MedicareCan also assist individuals not on Medicare

Illinois Cares Rx for those on Medicare Illinois Cares Rx for those on Medicare

• Will assist with some cost sharing with a Will assist with some cost sharing with a coordinating plan coordinating plan – Deductible up to $320 of total drug costDeductible up to $320 of total drug cost– Initial coverage up to $2,930 of total drug costInitial coverage up to $2,930 of total drug cost– Coverage gap from $2,930- $6,657.50 of total Coverage gap from $2,930- $6,657.50 of total

drug costdrug cost– Catastrophic coverage begins at $6,657.50 – Catastrophic coverage begins at $6,657.50 –

provides NO wrap coverageprovides NO wrap coverage

NOTENOTE: Applicants must apply for LIS through Social Security at least once and follow : Applicants must apply for LIS through Social Security at least once and follow instructions from SSA if qualify for any portion of assistanceinstructions from SSA if qualify for any portion of assistance

State Pharmacy Assistance Program State Pharmacy Assistance Program

Medicare and Illinois Cares Rx Medicare and Illinois Cares Rx – Provides wrap-around coverage Provides wrap-around coverage – Must be enrolled in a coordinating PDP or MA-PD plan in Must be enrolled in a coordinating PDP or MA-PD plan in

order to get the wraporder to get the wrap– Pays the premium for a coordinating Part D plan, orPays the premium for a coordinating Part D plan, or– Expands greatly the population served by the state of Expands greatly the population served by the state of

IllinoisIllinois

• Costs incurred by IL Cares Rx can count toward out-Costs incurred by IL Cares Rx can count toward out-of-pocket limitof-pocket limit

• Applications can be filed on line at www.cbrx.il.gov/Applications can be filed on line at www.cbrx.il.gov/

Medicare and Illinois Cares RxMedicare and Illinois Cares Rx

• Must meet annual income requirement ofMust meet annual income requirement of– $21,780* for a household of 1$21,780* for a household of 1– $29,420* for a household of 2$29,420* for a household of 2– $37,060* for a household of 3$37,060* for a household of 3

• Must follow Part D plan rules for coverageMust follow Part D plan rules for coverage• Must Apply for SSA “Extra Help”Must Apply for SSA “Extra Help”

– At least once, even if you do not meet At least once, even if you do not meet requirementsrequirements

* Income amounts are based on an application filed in 2010 using 2009 income * Income amounts are based on an application filed in 2010 using 2009 income

Illinois Cares RxIllinois Cares Rx

• For individuals who need drug For individuals who need drug assistance but are not on Medicare assistance but are not on Medicare will have towill have to– Meet income requirementsMeet income requirements

• For Plus or Basic coverageFor Plus or Basic coverage

– Be 65yrs or older; orBe 65yrs or older; or– Persons with disabilityPersons with disability– Follow Illinois Cares Rx formulary listFollow Illinois Cares Rx formulary list

Illinois Cares Rx BasicIllinois Cares Rx Basic• Must be without Medicare coverage and either Must be without Medicare coverage and either

– Age 65 or older, or Age 65 or older, or – A person with disabilities A person with disabilities

• Annual income of no more than Annual income of no more than – $21,780* for a household of 1$21,780* for a household of 1– $29,420* for a household of 2$29,420* for a household of 2– $37,060* for a household of 3$37,060* for a household of 3

IL Cares Rx Basic Drug Coverage for 11 Disease CategoriesIL Cares Rx Basic Drug Coverage for 11 Disease CategoriesAlzheimer’s DiseaseAlzheimer’s Disease ArthritisArthritis

CancerCancer DiabetesDiabetes

GlaucomaGlaucoma Heart and blood pressure problemsHeart and blood pressure problems

HIV/AIDS (if not eligible for Medicare)HIV/AIDS (if not eligible for Medicare) Multiple SclerosisMultiple Sclerosis

OsteoporosisOsteoporosis Parkinson’s DiseaseParkinson’s Disease

Lung Disease and smoking related illnessesLung Disease and smoking related illnesses

* Income amounts are based on an application filed in 2010 using 2009 income * Income amounts are based on an application filed in 2010 using 2009 income

Illinois Cares Rx PlusIllinois Cares Rx Plus

• Illinois Cares Rx PlusIllinois Cares Rx Plus provides coverage provides coverage for almost all prescription drugsfor almost all prescription drugs

• Must be a citizen or qualified non-citizen Must be a citizen or qualified non-citizen 65 or older without Medicare65 or older without Medicare

• Annual income of no more than $21,780* Annual income of no more than $21,780* (single) or $29,420* (married couple)(single) or $29,420* (married couple)

* Income amounts are based on an application filed in 2010 using 2009 income* Income amounts are based on an application filed in 2010 using 2009 income

06/08/2010 50

Things to Consider Before Joining a PlanThings to Consider Before Joining a Plan

Important questions to askImportant questions to ask– Do you have other current health insurance coverage?Do you have other current health insurance coverage?– What about current prescription drug coverage?What about current prescription drug coverage?– Is any prescription drug coverage you might have as Is any prescription drug coverage you might have as

good as Medicare drug coverage?good as Medicare drug coverage? – How does your current coverage work with Medicare?How does your current coverage work with Medicare?– Could joining a plan affect your current coverage?Could joining a plan affect your current coverage?– Could joining a plan affect a family member’s Could joining a plan affect a family member’s

coverage?coverage?


06/08/2010 51

Annual Notice of ChangeAnnual Notice of Change

All Part D plans send to all members by All Part D plans send to all members by September 30September 30– May arrive with Evidence of CoverageMay arrive with Evidence of Coverage

Will include information for upcoming yearWill include information for upcoming year– Summary of BenefitsSummary of Benefits– FormularyFormulary– ChangesChanges

• New premiumNew premium• Cost sharing – copayments and coinsuranceCost sharing – copayments and coinsurance• OtherOther


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Residents of Long-Term Care Residents of Long-Term Care FacilitiesFacilities

Get drugs from pharmacy chosen by Get drugs from pharmacy chosen by facilityfacility

Will have convenient accessWill have convenient access Can change plans at any timeCan change plans at any time With Medicare and full Medicaid benefitsWith Medicare and full Medicaid benefits

– Have no deductible and no copaymentsHave no deductible and no copayments


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Coverage DeterminationCoverage Determination

Initial decision by planInitial decision by plan– Benefits a member is entitled to receiveBenefits a member is entitled to receive– Amount member is required to pay for a Amount member is required to pay for a

benefitbenefit May be standardMay be standard May be expeditedMay be expedited

– Life or health seriously jeopardizedLife or health seriously jeopardized


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Part D Exception RequestsPart D Exception Requests Two types of exceptionsTwo types of exceptions

– Tiers Tiers • e.g., getting Tier 2 drug at Tier 1 coste.g., getting Tier 2 drug at Tier 1 cost

– Formulary Formulary • Drug not on plan’s formulary or Drug not on plan’s formulary or • Access requirementsAccess requirements

Requests can be made only by you, your Requests can be made only by you, your appointed representative, or the prescriberappointed representative, or the prescriber

Requires supporting statement from physicianRequires supporting statement from physician


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Approved ExceptionsApproved Exceptions

Exception valid for refills for remainder Exception valid for refills for remainder of year if of year if – Person remains enrolled in the plan andPerson remains enrolled in the plan and– Physician continues to prescribe drug, andPhysician continues to prescribe drug, and– Drug stays safe to treat person’s conditionDrug stays safe to treat person’s condition

Plan may extend coverage into new Plan may extend coverage into new plan yearplan year– If not, must send written notice If not, must send written notice

– At least 60 days before plan year endsAt least 60 days before plan year ends


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Coverage Determination TimeframCoverage Determination Timeframe

Plan must notify of coverage determinationPlan must notify of coverage determination– Standard request within 72 hoursStandard request within 72 hours– Expedited request within 24 hoursExpedited request within 24 hours– Exception involvedException involved

– Time clock starts when plan receives physician statementTime clock starts when plan receives physician statement

– Missed timeframeMissed timeframe– Goes to independent review entity (IRE)Goes to independent review entity (IRE)

– MAXIMUS – MAXIMUS – www.medicarepartdappeals.com

– Skip 1Skip 1stst level of appeal level of appeal


http://www.medicarepartdappeals.com/

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Requesting AppealsRequesting Appeals

In general, appeal requests must be In general, appeal requests must be writtenwritten– Plans must accept expedited requests orallyPlans must accept expedited requests orally

An appeal can be requested byAn appeal can be requested by– Plan member Plan member – Appointed representativeAppointed representative

5 levels of appeals5 levels of appeals


ResourcesResources• Illinois Senior Health Insurance ProgramIllinois Senior Health Insurance Program

– www.insurance.illinois.govwww.insurance.illinois.gov– (800) 548-9034(800) 548-9034

• MedicareMedicare– www.medicare.gov www.medicare.gov – (800) 633-4227(800) 633-4227– Medicare and You 2012 Medicare and You 2012 handbookhandbook

• Social Security AdministrationSocial Security Administration– www.socialsecurity.govwww.socialsecurity.gov

Medicare Prescription Drug Coverage. 06/08/20102 Medicare Prescription Drug Coverage Referred to as Medicare Part DReferred to as Medicare Part D Available.

Documents

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