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The Affordability of the Medicare Drug Benefit Session 1.02 Third Annual National Medicare Congress Susan Sanabria VP Advocacy Programs National Multiple Sclerosis Society. Affordability of Medicare Rx – Four Ways to View. Value of the benefit Cash flow issues

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The Affordability of the Medicare Drug BenefitSession 1.02Third Annual National Medicare CongressSusan SanabriaVP Advocacy ProgramsNational Multiple Sclerosis Society

affordability of medicare rx four ways to view
Affordability of Medicare Rx –Four Ways to View
  • Value of the benefit
  • Cash flow issues
  • Relationship to income and assets
  • Availability of financial assistance
value of the benefit
Value of the Benefit

Value =

(coverage+avoidance of future penalty)



value of the benefit4
Value of the Benefit
  • Coverage against catastrophic need for high-cost drugs
  • % of coverage varies by amount of drug expenses
      • For $1000 of drugs — 21% coverage
      • For $2,250 — 50%
      • For $5,100 — 22%
      • For $16,000 MS drug — 72%
  • % of coverage varies by plan and drugs used
cash flow issues
Cash Flow Issues
  • Largely function of drug costs and how fast one enters donut hole
  • Example of $24,000 for MS therapies
    • Reach donut hole ($2,250) in February
    • Then paying full cost of drugs into March, until drug costs reach $5,100
    • Big outflow of cash ($3,600 in co-pays) early in the year before reaching catastrophic coverage
relationship to income and assets
Relationship to Income and Assets
  • If consider Medicare Rx good value and can afford — easy decision
  • If can’t afford, then must navigate confusing mélange of assistance
availability of financial assistance
Availability of Financial Assistance
  • LIS in program
    • Low income/assets; co-pays difficult for some
    • Two levels
      • Co-pays difficult for some
      • Partial LIS often not enough for those 135-150% FPL
      • Still no help for near poor
    • Cumbersome application process through SSA
      • Requalify each year?
availability of financial assistance8
Availability of Financial Assistance
  • State Presc. Assistance Programs (SPAPS)
    • Not in every state
    • Inconsistent benefit
    • Inconsistent eligibility requirements
    • Not always available for beneficiaries under 65
    • Different application process in each state
availability of financial assistance9
Availability of Financial Assistance
  • Patient Assistance from the Pharmaceutical Companies
    • Usually for higher priced drugs/biologicals
    • Difficult and confusing for beneficiaries
    • Not great for pharmaceuticals either
availability of financial assistance10
Availability of Financial Assistance
  • Patient Assistance from the Pharmaceutical Companies
    • Variable in terms of:
        • Availability — not all companies provide assistance
        • Benefit and eligibility requirements
        • Mechanism: $ from 501(c)(3) or free drug from company
        • Application process
  • Cash Flow Problem
    • Some plans in ’07 will eliminate the donut hole
        • Affordable?
        • Good value?
        • Broad formulary?
    • Allow individual to designate monthly deduction from SS check to even out donut hole payments
    • Lobby all states to provide uniform program
    • Make available to those over and under 65
    • Standard application process, perhaps use LIS application
  • Pharmaceutical Rx Assistance
    • OIG approval for new, centralized mechanism that allows value of free drug provided to beneficiary to count against TROOP
    • Pay or play — if no assistance program, pay into a pool
  • Pharmaceutical Rx Assistance
    • Standard application form, perhaps LIS
    • Still unresolved: assistance for near poor who take moderately priced drugs