MEDICARE D UPDATES

As is apparent from media coverage and the questions we are all receiving, Medicare D is proving complex and difficult for Medicare recipients to understand. According to a Boston Globe editorial “there's a reason it is so complicated: The Republican leaders of Congress who crafted the plan are unsympathetic to social programs, and they loaded it up with special exceptions and limitations to further the goals in their political agenda” (November 22, 2005). To help you and your patients sort it all out, we are adding a special Medicare D section to the department’s website - coming soon!

In the meantime, some new clarifications are highlighted here.

Formulary Inclusion Required for Certain Drugs- Medicare is requiring “all or substantially all” of the drugs in the following drug categories to be on plan formularies: antidepressant, antipsychotic, anticonvulsant, anticancer, immunosuppressant, and HIV/AIDS.

-From http://mass.gov/Eeohhs2/docs/masshealth/pres_drugcov/frequently_asked_questions.pdf

Interactions with Other Programs

(See fact-sheets attached. Excerpts below.)

PRESCRIPTION ADVANTAGE (PA)

• Prescription Advantage is expected to provide continued primary coverage for those ineligible for Medicare and secondary coverage for those with Medicare (who will be required to enroll in Medicare D to continue to receive help from PA).
• Prescription Advantage will pay for benzodiazepines (a category of drugs which is excluded from Medicare coverage) for Prescription Advantage members. Prescription Advantage will not cover other drugs excluded from Medicare coverage, such as barbiturates and over-the-counter drugs.

FREE CARE/UNCOMPENSATED CARE

Since Medicare/Free Care patients may prefer to continue using Free Care for their medications, providers must educate patients about the important reasons to sign up for Medicare Prescription Drug Coverage (Part D):

• If patients are eligible for a Low Income Subsidy (<150% FPL), they will have minimal cost sharing, if any.
• Patients can use their Medicare prescription drug coverage at retail pharmacies.
• Free Care is likely to change in the next year and may not be an option to them any longer.
• If patients postpone enrollment in Medicare prescription drug coverage, they will face a financial penalty when they do enroll (higher monthly premiums).

Part D and Free Care fact sheet

Unintended Consequences:

• Employers Reap Windfall at Taxpayer Expense. The Boston Globe reports that “Raytheon Co. will save $170 million by using a new Medicare plan (Medicare D) to shift some expenses for retirees' prescriptions to taxpayers.” In a larger context, “(t)o help prevent companies from dropping drug benefits, the federal law includes $71 billion over eight years in subsidies to employers…. Mark Hamelburg, director of the employer policy and operations group at the centers (Centers for Medicare and Medicaid Services), said that while it is too early to say how most companies have responded, surveys indicate that many will use the government subsidies (to retain coverage). But the law also permits them to move the bulk of their drug coverage to Medicare, he said.” (November 28, 2005)
• Drug Companies Limit Patient Assistance Programs. As reported in The Boston Globe “Under federal rules effective Jan. 1, low-income and elderly patients who enroll in the program, known as Medicare Part D, will lose the ability to get free medications through the drugmakers' tax- deductible charities, known as patient- assistance programs. Some companies, going further, said …(recently) that they would drop patients who were merely eligible for Part D, whether or not they actually enrolled in it, as allowed under longstanding rules…. News of the cutoff followed a ruling last week by the Inspector General of the Department of Health and Human Services barring companies from giving free drugs to Part D enrollees, hoping to prevent fraud.” The article indicates that AstraZeneca PLC will take a strict interpretation of this ruling, while Pfizer Inc., Bristol-Myers Squibb Co., and Merck & Co. Inc., have said they will continue to offer their Patient Assistance Programs to those who are eligible, but do not enroll in Medicare D. The position of GlaxoSmithKline PLC was unclear.

- From “ Medicare plan to cut off free drugs for the needy: Enrollees to lose medicine given by firms via charities”, By Thomas Ginsberg, Knight Ridder, November 19, 2005 in The Boston Globe .

11/2005