bcnepa fph 2006 seminar medicare before and after part d april 26 2006
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BCNEPA/FPH 2006 Seminar Medicare Before and After Part D April 26, 2006

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Randy Grabiak Highmark Senior Products Medicare Part D Product Director. BCNEPA/FPH 2006 Seminar Medicare Before and After Part D April 26, 2006. Agenda. Trends in the Senior Market Part D Benefits & Guidelines Plan Participation Provider Challenges Questions. Trends in the Senior Market.

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bcnepa fph 2006 seminar medicare before and after part d april 26 2006

Randy Grabiak

Highmark Senior Products

Medicare Part D Product Director

BCNEPA/FPH 2006 SeminarMedicare Before and After Part DApril 26, 2006

  • Trends in the Senior Market
  • Part D Benefits & Guidelines
  • Plan Participation
  • Provider Challenges
  • Questions
seniors sources of information

Trends in the Senior Market

Seniors’ Sources of Information

AMONG SENIORS: Percent who say they would be very likely to turn to each of the following for help in deciding whether to enroll in a Medicare drug plan…

Survey March 31 – April 3, 2005

Your doctor

Your pharmacist

A Social Security office, website or phone number

Friends or family members

A Medicare mailing, website or phone number

A health insurance company

A local seniors’ group or community organization

An employer or union











Your doctor

Your pharmacist

Social Security

Friends or family members

A local seniors’ group or community organization


An employer or union

Survey October 13 – 31, 2005








Source: *Kaiser Family Foundation Health Poll Report Survey (conducted Mar. 31-April 3, 2005)

**Kaiser Family Foundation/Harvard School of Public Health (conducted October 13-31, 2005)

health insurance trends prior to part d

Trends in the Senior Market

Health Insurance Trends Prior to Part D
  • To offset the growing out-of-pocket expense, many beneficiaries have turned to various forms of private or public supplemental coverage to help defray the cost of prescription drugs
  • However, more than a third still have no prescription drug coverage
  • Lack of drug coverage can have adverse affects

Sources of Prescription Drug Coverage

health care delivery and expenditure trends

Trends in the Senior Market

Health Care Delivery and Expenditure Trends
  • Seniors are particularly vulnerable to the increased cost of prescription drugs because:
    • Drug usage increases with age
    • Prior to Part D Medicare did not cover most prescription drugs

Source: Ageworks, a division of the Ethel Percy Andrus Gerontology Center, USC

medicare beneficiaries out of pocket prescription drug spending 2000 2013

Trends in the Senior Market

Medicare Beneficiaries’ Out-of-Pocket Prescription Drug Spending, 2000-2013

The Need for Drug Coverage


Average annual out-of-pocket drug

costs among the Medicare population:

* Without Medicare drug benefit.

SOURCE: Actuarial Research Corporation analysis for The Kaiser Family Foundation, June 2003 and November 2004.


Recent Trends in the Senior Market

Part D is Projected to Reduce Average Out-of-Pocket Spending but the Extent of the Reduction is Likely to Vary

All Other Part D Participants(20.3 million)

Part D Participants Who Receive Low-Income Subsidies(8.7 million)

Average Change:- 37%

SOURCE: Actuarial Research Corporation analysis for the Kaiser Family Foundation, November 2004.


Part D Benefits & Guidelines

Decisions forBeneficiaries

Enroll in Part D Plan

Medicare Advantage

Traditional Medicare

HMO (Local)

PPO (Local v. Regional)

Private FFS

Part D Prescription Drug Plan

No Part D coverage

Apply for Low-Income Subsidy

Dual Eligibles

Social Security Office

Medicaid Office

Meet Income and Asset Test?

If yes, qualify for:

Below 150% FPL: Subsidy for premium on sliding scale, $50 deductible, 15% coinsurance to $5,100 in Rx costs, $2/generic Rx, $5/brand name Rx after $5,100

Below 100% FPL:

No premium or deductible, $1/generic Rx, $3/brand name Rx, pay nothing after $5,100 in Rx costs

Below 135% FPL: Subsidy for premium, no deductible, $2/generic Rx, $5/brand name Rx, pay nothing after $5,100 in Rx costs

part d plans

Plan Participation

Part D Plans

To participate in the program, sponsors must offer Medicare Part D benefits to all beneficiaries in one or more of the 34 PDP regions established by CMS

highmark s medicare approved drug plans

Plan Participation

Highmark’s Medicare Approved Drug Plans

To Request Additional Information, please call 1-866-465-4030

highmark s medicare advantage drug plan options
Highmark’s Medicare Advantage Drug Plan Options

* Based on 1-34 Day supply. Copayment for 35-90 day supply (Retail) or 1-90 day supply (Mail Service) is 2.5 times 1-34 day supply.

medicare prescription drug plan cost estimator bluerx basic

Part D Benefits & Guidelines

Medicare Prescription Drug Plan Cost Estimator (BlueRx Basic)

Estimated Savings Report:

Cost Breakdown:

*BlueRx Basic Plan

** Assumption: 4 generic prescriptions/month

low income subsidy

Part D Benefits & Guidelines

Low-Income Subsidy
  • Medicare will provide premium and cost-sharing subsidies to assist low-income beneficiaries
  • Dual eligibles will be automatically assigned to a PDP and auto-enrolled if they do not choose another plan
  • Benefit: Reduction of premium, deductible & cost-sharing
  • Process: Requires completion of SSA form
  • Eligibility:

*Excludes primary residence and automobiles

late enrollment penalty

Part D Benefits & Guidelines

Late Enrollment Penalty
  • Medicare Part D is an entitlement but enrollment is voluntary
  • Low-income subsidy provides additional cost savings
  • Waiting to enroll until after May 15, 2006 may come at a penalty

Nov 15, 2005

May 15, 2006

January 2008

January 2007

Sign up & pay = $34.78/Month**

Sign up & pay = $32.20/Month*

Sign up & pay = $38.95/Month**

*Amount based on $32.20 national average monthly beneficiary premium (CMS, August 2005).

**Assumes national average premium does not increase annually

national part d enrollment not meeting hhs projections
National Part D Enrollment not meeting HHS Projections
  • 39.1 million beneficiaries would enroll in 2006 of which 10 million would have creditable
  • coverage under a qualified plan such as an employer or union sponsored plan.
  • 29.3 million would be enrolled in a Part D plan.
  • Additional 11.4 million will need to sign up for a stand alone or MAPD plan in order to reach the
  • 29.3 million member target.

*Projected Part D Enrollment = 29.3M


*Includes MAPD & Stand Alone PDP

17.9 million


15.8 million

14.3 million

11.6 million

6.4 mil

4.9 mil

3.6 mil

Enrolled in Stand Alone PDPs

1 mil


4.7 mil

5.1 mil

4.5 mil

4.4 mil

Enrolled in MA-PD

6.4 mil

6.2 mil

6.2 mil

6.2 mil

Dual Eligible Auto Assigned from CMS


Dec 2005

Jan 2006

Feb 2006

Mar 2006

Actual Part D Enrollment

Source: Projected: HHS, Medicare Drug Benefit Final Rule 1/28/05. Actual: HHS 12/22/05, 1/17/06 , 2/22/06, & 3/23/06


Provider Challenges


Covered Drugs

Statutory Exclusions

  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Antiretrovirals
  • Immunosuppressants
  • Antineoplastics.
  • Over the counter medications
  • Weight gain and loss drugs
  • Fertility and cosmetic/hair growth drugs
  • Drugs to relieve cold symptoms
  • Some vitamins and minerals
  • Barbiturates, and benzodiazepines

Prescription Drug Plans Must:

Assure a broad access to drugs

Require two drugs per Categories & Classes

Must comply with USP model guidelines


Provider Challenges


Drug coverage can differ based on how the drug is prescribed dispensed or administered to the patient

  • Inhalation DME supply drugs – solution for inhalation via nebulizer only
  • Oral Anti-cancer agents
  • Diabetic test strips & lancets
  • Influenza, pneumococcal, Hepatitis B vaccines
exceptions appeals process

Provider Challenges

Exceptions & Appeals Process
  • Plans must have a drug transition process in place to assure a seamless transition for patients
    • A 90 day period may be needed for patients taking non formulary drugs
    • For rapid transitions, beneficiaries may need to use a plan’s exceptions & appeals process
    • Establish an adequate exceptions process to help LTC residents who need non formulary drugs
    • Provide a one time temporary or emergency supply to ensure that there is no coverage gap during the exceptions process
medication therapy management

Provider Challenges

Medication Therapy Management

MTM programs must be designed to assure that covered medications will be used appropriately by targeted beneficiaries. A plan’s MTM services must be developed in cooperation with licensed and practicing pharmacists and physicians.

  • Optimize therapeutic outcomes
  • Improve medication use
  • Reduce risk of adverse events & interactions
  • Increase patient’s adherence & compliance with regimens
key date
Key Date
  • May 15, 2006 – The last day that current Medicare eligible beneficiaries can join a drug plan without paying a penalty.
message points for providers
Message Points for Providers
  • Patients will ask you for advice
  • One plan does not fit all Medicare beneficiaries
  • Evaluate Drug Benefit Cost Sharing
  • Encourage patients to look into low income subsidies
  • Premium Penalty for delay in signing up
  • Advise to compare formularies and pharmacy networks
  • Know where to tell patients to turn for more information
where to turn for more information
Where to Turn for More information:
  • Highmark
    • 1-866-465-4030
  • Medicare
    • 1-800-MEDICARE
    • &
  • Social Security Administration
    • 1-800-772-1213