Access denied the medicare part d benzodiazepine challenge and maine s coverage solution
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Access Denied? The Medicare Part D Benzodiazepine Challenge and Maine’s Coverage Solution. PowerPoint PPT Presentation


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Access Denied? The Medicare Part D Benzodiazepine Challenge and Maine’s Coverage Solution. Stacie Sparkman Medicare Prescription Drug Specialist Eastern Agency on Aging. Medicare Prescription Drug, Improvement and Modernization Act of 2003. Signed into law December 8, 2003.

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Access Denied? The Medicare Part D Benzodiazepine Challenge and Maine’s Coverage Solution.

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Access denied the medicare part d benzodiazepine challenge and maine s coverage solution

Access Denied?The Medicare Part D Benzodiazepine Challenge and Maine’s Coverage Solution.

Stacie Sparkman

Medicare Prescription Drug Specialist

Eastern Agency on Aging


Medicare prescription drug improvement and modernization act of 2003

Medicare Prescription Drug, Improvement and Modernization Act of 2003

  • Signed into law December 8, 2003.

  • Implemented outpatient prescription drug coverage for seniors and the disabled population.

  • Is a voluntary program. If a person has state Medicaid and wants to continue to receive prescription assistance, they must be enrolled into a Part D plan.


Medication coverage

Medication Coverage

  • Prescription Drug Plan (PDP) formularies must include drugs within each therapeutic category and class of covered Part D drugs, though not necessarily all the drugs in each category or class.

  • The legislation excludes from coverage the following drugs or classes of drugs, or their medical uses:


Excluded medications

Excluded Medications

  • Agents when used for anorexia, weight loss, or weight gain

  • Agents when used to promote fertility

  • Agents used for cosmetic purposes or hair growth

  • Agents when used for the symptomatic relief of cough and colds

  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

  • Non-prescription drugs

  • Outpatient drugs for which the manufacturer seeks to require associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale

  • Barbiturates

  • Benzodiazepines


Access denied the medicare part d benzodiazepine challenge and maine s coverage solution

All of the classes of excluded medications have the potential to impact medical care in the elderly or disabled population. Continuity of care issues could include the use of:

  • Benzodiazepines, widely used for management of acute anxiety, panic attacks, seizure disorders, and muscle spasms in those with cerebral palsy or other disorders like Ativan, Xanax and Valium.

  • Over-the-counter medications, including agents for pain, constipation, and other common conditions.

  • Medications used to treat weight loss, such as in those persons who lose weight due to cancer or AIDS.

  • Barbiturates like Phenobarbital, which is widely used in the elderly for treatment of seizures.


Maine s coverage solution

Maine’s Coverage Solution

  • The Centers for Medicare and Medicaid Services authorized states to provide coverage of –and receive federal matching funds for-medications the Medicare Modernization Act excludes.1

  • Before Medicare Part D started on 1/1/06, the State of Maine made the decision to continue coverage of excluded medications already on the state’s preferred drug list. This coverage included members who received prescription assistance under state Medicaid and the Low Cost Drug Program.

    1 Policy Guidance Regarding Medicaid Coverage of Prescription Drugs Excluded from the New Medicare Prescription Drug Benefit, http://www.cms.hhs.gov/letters/smd060305.pdf


Low income subsidy

Low Income Subsidy

  • The Medicare Modernization Act gave three groups automatic Low Income Subsidy.

  • Individuals with State Medicaid.

  • Individuals with Supplemental Security Income.

  • Individuals with their state’s Medicare Savings Program.


Medicare savings program

Medicare Savings Program

  • Pays for the Medicare Part B Premium-$93.50 in 2007 and $96.40 in 2008

  • Enrollment into the MSP will deem a person eligible for full Low Income Subsidies for Part D which includes:

  • Payment of the part D premium for approved plans

  • Payment of the deductible

  • Small co-pays of between $1 and $5.35

  • No Coverage Gap

  • Catastrophic Coverage


Medicare savings program1

Medicare Savings Program

  • Each state sets the income and asset levels for the MSP.

  • The state of Maine did away with the asset test on 1/1/06 and raised the income limit to 185% of the federal poverty limit on 4/1/07.

  • The Department of Health and Human Services determines eligibility and countable income. There are some instances where individuals or couples may be eligible for the MSP even if their income is higher than 185% of the federal poverty limit.

  • Maine also provides a wrap benefit through the state’s Low Cost Drug program. This program continues to provide coverage for excluded medications listed on the state’s preferred drug list. This benefit helps those transitioning, from the Low Cost Drug Program and Mainecare into Medicare and Medicare Part D, continue to receive their medications without interruption.


Direct savings

Direct Savings

  • Since Medicare Part D started in 2006 Maine has covered benzodiazepine and barbiturate prescriptions.

  • The estimated total savings for the consumer is

  • We will never know the total cost of savings related to hospitalizations and mass confusion, but we know it is priceless.


Resources

Resources

  • Legal Services for the Elderly, Inc. Part D Appeals Unit 1-877-774-7772

  • Maine Area Agencies on Aging/State Health Insurance Assistance Program (SHIP)

    1-877-353-3771

  • Maine Department of Health and Human Services Regional Offices

  • Maine Office of Elder Services 1-800-262-2232

    TTY 1-800-606-0215

  • Maine Pharmacy Helpdesk 1-866-796-2463

  • Medicare 1-800-Medicare or 1-800-633-4227

    TTY 1-877-486-2048

  • Social Security Office 1-800-772-1213

    TTY 1-800-325-0778


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