Pharmacy Outreach ProgramThe University of Rhode IslandThe University of Rhode Island

College of Pharmacy

Updated October 2012

MEDICARE Medicare provides health insurance for…

A d 65 ld Aged 65 years or older Aged 65 years or less with certain disabilities

All l ith E d St R l Di (ESRD) All people with End-Stage Renal Disease (ESRD) All people with Lou Gehrig’s Disease (ALS)

THE PARTS OF MEDICARE Part A

Hospital insurance Hospital insurance Part B

Medical insurance Medical insurance Medicare Advantage Plans

Part D Prescription drug coverage

Medicare Part A Covers:

Inpatient hospital care Skilled nursing facilities (Under

certain conditions)certain conditions)

Typically doesn’t require a monthly payment (Premium)

Does require out-of-pocket deductible for hospital stays (in 2012): $1,156 of 1-60 days

$289 d f d 61 90 $289 per day co-pay for days 61-90 $578 per day co-pay for days 91-150 All costs beyond 150 days

For skilled nursing facilities:For skilled nursing facilities: $144.50 per day for days 21 through

100 for each benefit period

Medicare Part B Helps cover: p

Physician services Durable medical equipment Physical therapists

Also covers other services and Also covers other services and supplies: Glucose monitors Test strips Lancets Lancets

There is a monthly premium to enroll The standard Part B premium for 2013 is

$120.20 per month (income based) In general, automatically deducted from

social security checks Once deductible is paid enrollee generally

pays a 20% co-payment for each servicepays a 20% co payment for each service

Medicare Advantage (Part C) Health insurance

coverage, including preventative care PLUSpreventative care PLUS prescription drug coverage in a single plan

In exchange, typically must use a certain

t k f d tnetwork of doctors, hospitals, and pharmacies (HMO, PPO)

Medicare Advantage 6 plans available in Rhode Island

If you already have a Medicare Advantage plan and you want to add drug coverage you MUSTadd drug coverage you MUSTobtain it through your Medicare Advantage provider. If you obtain an independent standalone

drug plan instead, your health coverage under the Medicare Advantage plan will stop.

Medicare Advantage Annual Enrollment Period in 2012

October 15‐December 7, 2012

Can choose to leave current Medicare Advantage plan to switch to an Original Medicare planswitch to an Original Medicare plan Can add prescription coverage ‐ Part D

MEDICARE PART DMEDICARE PART D Stand-alone prescription drug coverage

Open to all people eligible for Medicare

Open enrollment begins October 15, 2012Open enrollment begins October 15, 2012 Enrollment for coverage of the year 2013

ends on December 7, 2012, Coverage Begins on January 1st, 2013

M di P t D i VOLUNTARY!!Medicare Part D is VOLUNTARY!!

Wh C I E llWhen Can I Enroll                    in a Part D Plan?

Re-enrollment begins October 15th, 2012!

in a Part D Plan?

Your new plan will take effect January 1st, 2013

If you are happy with your current part D plan, youIf you are happy with your current part D plan, you don’t need to do anything during the re-enrollment period! Your Med D plan will automatically re-enroll you But be aware::::: your premiums, co-pays,

formulary or deductible may be changed forformulary, or deductible may be changed for the new year!

Enrollment Info NEW Open enrollment is from

Oct 15 – Dec 7th 2012 of each year Dates just changed Dates just changed

Coverage begins on January 1, 2013

If you become eligible for Medicare Part D after the enrollment period, you have a 7 month period toyou have a 7 month period to enroll without incurring a penalty

3 months before, the month of and 3 months after the month of your 65th birthday

Who Should Apply? People who are enrolled in a Med D plan right now,

but thinking about switching to another plan next year

You didn’t sign up for a plan when eligible last time around but you’re thinking of enrolling now

Penalt for e er month itho t co erage Penalty for every month without coverage

Enrolled in a Medicare Advantage Plan or Medigap g g pSupplemental Insurance Plan but you want to add or change your drug coverage

People who have major changes in the medicationsthey take on a daily basis

Who Doesn’t Need To Apply If you have CREDITABLE Coverage:

This means that you already are enrolled in a plan that provides a prescription drug benefit that is EQUIVALENT or better than thatprescription drug benefit that is EQUIVALENT or better than that being offered through Medicare Part D

You would have already been made aware of this by your insurance provider by mail

KEEP THIS LETTER IN A SAFE PLACE** KEEP THIS LETTER IN A SAFE PLACE**

**If you are unsure if your coverage isIf you are unsure if your coverage is creditable or not, ask your employer or union for it!**

Penalty Info If you did not enroll but were eligible to do so,

when you enroll now for coverage beginning on J 1 2013 ill i lt f 1%Jan.1, 2013 – you will incur a penalty of 1% per month of average premium

Will have to wait until 2013 enrollment period to join a Medicare drug plan if don’t do so now!

Average premium 2013 = $31 17 Average premium 2013 = $31.17 1% of $31.17 = $0.31 12 months penalty= $3.74 Therefore, $3.74 will be added on to your

monthly premium every month forever!

Penalty Info

You will not have this l   f dpenalty enforced:

If you were not previously                 y p yeligible for Medicare Part D

If you previously had                      y p ycreditable coverage

Affordable Care Act Changes Lower costs during donut hole:

Patients pay 47.5% of brand name drugs Discount of generic drugs will raise from 21% this year Discount of generic drugs will raise from 21% this year

Better Quality care: Bonus payments from the government will give p y g gincentives to Medicare Advantage plans with better quality care

HOW PART D WORKS Remember::: this is just an explanation of the

template used as a general basis for the plans there are options!--there are options!

STANDARD PLAN (2013) $31 17 per month premium ($374 04) $31.17 per month premium ($374.04) $325 deductible 75% coverage from $320 to $2,970g New limited coverage from $2,970 to $6,733.75 Patient pays 50% of Brand Drugs and up to 86% of

generic drugsgeneric drugs This is called the coverage gap or “Donut Hole”

95% coverage beyond $6 733 7595% coverage beyond $6,733.75

HOW PART D WORKSC t t hi C

HOW PART D WORKSCatastrophic Coverage> $6733.75 Medicare Pays

95%

Donut hole - $2970 –$6733.75

5%

47.5%-79%

Co-Insurance : $325-2970

$

75% 25%

0 - $325 is your Deductible You Pay 100%

New Change for Donut hole, will only spend 47.5% out of pocket for brand name and 79% maximum for generic drugs!!!

Think of it as Steps! Step #1 – The Deductible

You pay 100% and plan pays 0%Y i $325 h

Medicare Pays You receive $325 worth

of medications

St #2 C i5%

ed ca e ays95%

Step #2 – Co-insurance You pay 25% and plan

pays 75% Yo recei e $2645 orth

47.5%-79%

You receive $2645 worth of medications

(Total: Step 1 + Step 2 = $2970)

75% 25%

$2970)You Pay 100%

Think of it as Steps!o t as Steps! Step #3 – The Donut Hole

N h l t New changes let you pay 47.5% of brand drugs Max of 79% generics

You receive $3 763 75 Medicare Pays You receive $3,763.75 worth of medications

Total: Step 1 + Step 2 + Step 3 = $6733.75 5%

Medicare Pays95%

47.5%-79%

p $ New discounts!

Step #4 – Catastrophic Coverageg You pay 5% and plan

pays 95% You receive unlimited

75% 25%

drugs for the remainder of calendar year You Pay 100%

Remember! Even though you were

enrolled in a program last year, p g y ,you start from the Step #1 all over again on January 1, 2013

You will continue to pay the premium every month regardless of what stepevery month regardless of what step that you are on Even when in the “donut hole” a

person still pays the monthly premium!

Besides Standard Plan… Must offer basic/standard drug benefit

May offer enhanced benefit

Some have no deductible

Some have help during “donut hole” (coverage gap) Some have help during donut hole (coverage gap)

The Premium depends on the enhancements

Mail order options may save costs on maintenance medications (90 days)

Explaination of Benefits A statement sent by your insurance company telling you which medical services were paid for by them.I l d Includes: The service: date/place service provided Doctors fee and what was paid by them Doctors fee and what was paid by them Remainder that the patient is responsible for

To show you what portion the insurance is paying for and which portion you are.p y

How Do I Choose The Right Plan?CRx Enrollment Check-Up:

CostWill i d t h i 2013? Will your premium and costs change in 2013?

CoverageWill you need more comprehensive coverage?Will your current meds be covered by your plan?No that don t hole is partiall co ered is s itching aNow that donut hole is partially covered, is switching a

better option?

Customer ServiceCustomer Service Are you satisfied with your service from your current plan?

Side Note:  If you decide that your

current Med D plan willcurrent Med D plan will meet your needs in 2013 then you do not needthen you do not need to re-enroll

Coverage will continue through 2013 starting from Step 1

Plans AvailablePlans Available in RI for 2012in RI for 2012 

Total of 30 prescription plans offered

14 l il bl ith NO d d tibl ! 14 plans available with NO deductible!

20 Plans without gap coverage Monthly premiums start at $15 AARP MedicareRx Saver Plus Monthly premiums start at $15 AARP MedicareRx Saver Plus

10 Plans with gap coverage Monthly premiums with gap coverage start at $39 and go up to y p g p g $ g p

$114 Lowest premiums have only generic coverage

All Medicare patients are eligible for a Medicare advantage plan

What is a                            F l ?Formulary?

Formulary system Formulary system Each plan selects certain drugs

from each drug class that they will coverfrom each drug class that they will cover May have a tier system

May have up to 5 tiersy p Generic drugs = cheapest (ex: $5) Preferred brand names = more expensive (ex: $28) Non-preferred brand names = most expensive (ex: $40) Non preferred brand names most expensive (ex: $40) Certain injectable and specialty drugs= highest tiers

(ex: $58)

Drugs Not Covered Under Most Part D FormulariesPart D Formularies

Benzodiazepines Drugs for cosmetic BarbituratesWeight loss

purposes or hair growthWeight loss

Erectile dysfunctionCough & cold relief

Fertility drugsPrescription Cough & cold relief

Non prescription drugs

pvitamins, minerals Except prenatal vitamins

and fl oride preparationsdrugs and fluoride preparations

Definitions:  Generics: will be required to be covered by ALL plans

Chemically identical to brand‐name drugs and meet the same rigorous  standards put forth by the FDA (US Food and Drug Administration) for: Safety, Purity, Effectiveness

Generic drugs can be legally produced in the US if a patent has expired, or for drugs which have never been patented 

Prior authorization: may be needed for some medications Appeal process mandated by insurance company which includes paperwork

involving the MD

Step Therapy: may be required before certain medications will be covered Step Therapy: may be required before certain medications will be covered ex: Prilosec before Nexium, or Motrin before Celebrex

Quantity limits: may be enforced 30 day quantities retail vs. 90 day mail-order

Some plans DO allow 90 day quantities of maintenance medicines at community pharmacies.

Frequently Asked Questions

Who pays for my vaccines? Now Medicare part D must

cover all vaccines not covered by part Bcovered by part B Ex: Zostavax (Shingles vaccine)

Vaccines covered by part B Pneumococcal InfluenzaInfluenza Hepatitis B Vaccines necessary to treat a

disease or prevent one after directdisease or prevent one after direct exposure Ex: tetanus

WHAT ABOUT MY RIPAE? You SHOULD keep your RIPAE!

It will provide coverage throughout the deductible & coverage gapthe deductible & coverage gap

BUT, it is not creditable coverage You need a Medicare Part D Plan too RIPAE is only available for those enrolled in a Medicare

part D plan Must send in copy of enrollment letter or card

See your SHIP counselor or call The Point for RIPAE yinformation

RIPAE…

Provides extra benefit for those who don’t lif f t h l f M diqualify for extra help from Medicare

Applicable to all expenses that i 100% ibl fperson is 100% responsible for:

Deductible Coverage gap (“Donut Hole”) Coverage gap ( Donut Hole ) Drugs not covered under your Part D Plan

Only certain ones!y

RIPAE… Eligible: Eligible:

Single, income less than $45,991 per year Married, income less than $52,561 per year, $ , p y The lower the financial category,

the higher percentage RIPAE will pay

More information:401-462-4444 The Point

Wrong phone number on Medicare & You 2008 Booklet!Booklet!

Talk to SHIP counselor

What About My Tricare,                                                 VA, Pension Benefits?,

They are creditable coverage, l tt h b t i il!letters have been sent in mail!

H ld t th l tt ! Hold on to these letters!

Contact your pension benefits Contact your pension benefits manager or union if you have any questionsy q

Dual Eligibles (Medicare/Medicaid)g ( / ) Will automatically be eligible for:

No premiumN d d tibl No deductible

No donut hole Minimum co-payments ($1.10 generic & $3.30 brand)

Have been automatically enrolled in a plan & will be automatically re-enrolled in a plan Part D plan for 2013 won’t necessarily

b th l 2012be the same plan as 2012

Reassignment notices are being sent out Enrollment confirmations will followEnrollment confirmations will follow If you are “dually eligible,” you can change your

plan at any time during the year! Once per month!

What is Extra Help? (Low Income Subsidy)(Low Income Subsidy) Federal poverty limits determined

by government each year Best to apply and be formally denied

Many deductions, so apply! In order to be eligible a person’s resourcesIn order to be eligible, a person s resources

must be no greater than the limits established

Single* Married*Yearly Income <$16,335 <$22,260

Resources <$12 640 <$25 260Resources <$12,640 <$25,260

*Includes $1,500 per person burial expenses

“Deemed” Population Defined as those who had Low Income Subsidy

(LIS) for 2012 & are not automatically eligible for 20132013

Notifications being sent out with applications to re-enroll

Does not mean that you are not eligible Reapply!!!

Check with your SHIP counselor or The Point Check with your SHIP counselor or The Point

Ways to Lower Your Drug CostsWays to Lower Your Drug Costs During the Coverage Gap

Ask your doctor about generic and less expensive brand name drugs (therapeutic substitutions) Cheaper in the gap Less likely to hit the gap if avoid brand

name medications from the beginning!

Ask your doctor for samples Pharmaceutical Assistance Programs

A il bl f th h ti l f t Available from the pharmaceutical manufacturers Contact the Partnership for Prescription Assistance

1-888-477-2669

Ways to Lower Your Drug CostsWays to Lower Your Drug Costs During the Coverage Gap

State Pharmaceutical Assistance Programs RIPAERIPAE

Based on your income, RIPAE will pay 15%, 30%, or 60% of drug cost during coverage gap

Apply for Extra Help If you have limited income and y

resources, you may qualify for extra help

For more information go to www.socialsecurity.gov or call1-800-772-1213

New Medicare Changes Changes in amount covered during

the Coverage Gap!47 5% f b d i ti (↓ f 47.5% for brand name prescriptions (↓ from 50%)

79% for generic prescriptions (↓ from 86%)

G t C f ti Greater Coverage for preventive medical services Depression Cardiovascular Disease Alcohol Abuse Obesity

What if I Like A Plan & OneWhat if I Like A Plan & One                    of My Drugs is Not Covered?

Options: Ask your pharmacist about

therapeutic substitutiontherapeutic substitution Compare prescription vs. over-the-

counter (OTC) optionsN i $158 00 Nexium $158.00

Prilosec OTC $21.99 Omeprazole Rx- lowest cost or co-pay

Always consult with your doctor regarding changes to yourregarding changes to your medications

D th t N t C d bDrugs that are Not Covered by ANY Part D Plan

Can still get these drugs but must pay the retail price (“cash”) and it does not count towards outprice (“cash”) and it does not count towards out of pocket expenses or total drug costs

Examples:Examples: Benzodiazepines

alprazolam, lorazepam, diazepamp , p , p Drugs for weight loss, hair loss, and fertility Drugs covered under Medicare parts A and B

Example: Drugs received while in the hospital, diabetic testing supplies

Medicare Fraud

The vast majority of your health care providers are itt d t idi ith hi h litcommitted to providing you with high quality care…

However, there are some individuals who cheat the t t f illi f d ll hi h lt isystem out of millions of dollars, which results in

higher premiums for its members. Be very cautious when dealing with your Medicare information, &

h it ith di l f i l lnever share it with a medical professional unless you are absolutely certain that they need it.

Never share your Medicare information over the phone with someone else!someone else!

Using the Internet Get a complete list of your medications

Include all prescriptions-eye drops, creams, inhalers, patches, etc.

Go to www.Medicare.gov and click on “Formulary Finder” Follow the prompts and enter your medicationsFollow the prompts and enter your medications

Can also call 1-800-MEDICARE (1-800-633-4227) Can enroll on line—have your Medicare card ready CVS and Walgreens both have websites to condense your

search of possible plans Rite Aid has plan finding software, just call your Rite Aid e d as p a d g so a e, jus ca you e d

pharmacist and schedule a time to choose a plan

Important DatesImportant Dates                               to Rememberto Remember

October 1- Compare and PrepareOctober 1 Compare and PrepareOctober 15- Open Enrollment BeginsDecember 7- Open Enrollment EndspJanuary 1, 2013- Coverage Begins

In summary…. No single plan is best for everyone

You must pick the plan that’s right for YOU!

Yes, it is confusing! Don’t be afraid to ask for help: The Point!!! (401) 462-4444 SHIP counselors at your local Senior Center SHIP counselors at your local Senior Center Dept. of Elderly affairs (401) 462-4000 Ask a relative or friend to help you navigate the Web Social Security Administration 1 800 772 1213 Social Security Administration 1-800-772-1213 Pharmacy Outreach Program 1-800-215-9001

www.uri.edu/pharmacy/outreach

THANK YOU!