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Medicare Today…More Choices, Better Benefits. Instructor’s Name Event Date. 244375 9/06. Topics/Modules. Medicare’s Covered Preventive Care Services Basics of Medicare Prescription Drug Coverage Picking and Switching Medicare Plans How to Get Extra Help with Costs

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Medicare Today…More Choices, Better Benefits

Instructor’s Name



244375 9/06

topics modules
  • Medicare’s Covered Preventive Care Services
  • Basics of Medicare Prescription Drug Coverage
  • Picking and Switching Medicare Plans
  • How to Get Extra Help with Costs
  • What Drugs Do Medicare Plans Cover? All About Formularies
  • What Is the “Donut Hole?”
  • Important Dates for Medicare
medicare has more to offer
Medicare Has More to Offer
  • Preventive services
  • Prescription drug plan coverage
  • New Medicare Health Plan options
  • Extra help for those who need it most
benefits and options
Benefits and Options
  • Increased coverage ofpreventive services in 2005
  • Outpatientprescription drug coverage available January 1, 2006
  • Offered new Medicare Health Plan options in 2006
covered preventive services
Covered Preventive Services
  • Designed to help you stay healthy
  • Began January 2005
    • “Welcome to Medicare” physical exam
    • Cardiovascular screening blood tests
    • Diabetes screening tests
initial preventive physical examination ippe
Initial Preventive Physical Examination (IPPE)
  • “Welcome to Medicare” Physical
  • Who is eligible?
    • All Medicare beneficiaries whose Part B coverage began on or after January 1, 2005
  • When?
    • Once during the first 6 months of Part B coverage
  • Cost to beneficiary?
    • Part B deductible and copayment/coinsurance
cardiovascular disease screening
Cardiovascular Disease Screening
  • Who is eligible?
    • All asymptomatic Medicare beneficiaries
  • When?
    • Every 5 years
  • Cost to beneficiary?
    • No deductible, no co-payment, no coinsurance
elements of cardiovascular screening
Elements of Cardiovascular Screening
  • Total Cholesterol
  • HDL
  • Triglycerides
  • Provides opportunity assess and discuss cardiovascular risk factors, such as
    • Family history - Smoking
    • Diet - Stress
    • Obesity - Diabetes
diabetes screening
Diabetes Screening
  • Who?
    • Beneficiaries diagnosed with pre-diabetes and at-risknon-diabetic beneficiaries
  • When?
    • 2 tests per year for pre-diabetic beneficiaries
    • 1 test per year for undiagnosed, non-diabetic beneficiaries
  • Cost to beneficiary?
    • No deductible, no copay/coinsurance
diabetes self management training dsmt
Diabetes Self-Management Training (DSMT)
  • Who is eligible?
    • Beneficiaries recently diagnosed with diabetes or at risk for complications from diabetes or who were diagnosed with diabetes before becoming Medicare eligible
  • When?
    • A plan of care must be written to include number of sessions, frequency, and duration (up to 10 hours for initial training, up to 2 hours per year thereafter)
  • Cost to beneficiary?
    • Part B deductible, copayment/coinsurance
other covered screening tests
Other Covered Screening Tests
  • Breast cancer
  • Colorectal cancer
  • Prostate cancer
  • Cervical & vaginal cancer
  • Bone Density
  • Glaucoma
covered vaccinations
Covered Vaccinations
  • Influenza
  • Pneumococcal
  • Hepatitis B
smoking cessation counseling
Smoking Cessation Counseling

If diagnosed with a smoking related illness:

  • Inpatient or Outpatient Counseling
    • Up to 8 face-to-face counseling sessions per 12 month period
medicare prescription drug coverage why should you get it
Medicare Prescription Drug Coverage: Why Should You Get It?
  • If you are going to join it’s important to join a plan when you are first eligible
    • Many people with Medicare need or likely will need prescription drugs to stay healthy
    • Medicare prescription drug coverage may help protect against high out-of-pocket costs
    • Enrolling when first eligible may mean that you pay a lower premium
types of medicare prescription drug plans
Types of Medicare Prescription Drug Plans

There are two types of plans available:

  • Prescription Drug Plans (PDPs)
    • Provide prescription drug coverage only
  • Medicare Advantage - Prescription Drug Plans (MA-PDs)
    • Formerly known as Medicare+Choice
    • Provide Medicare Parts A & B medical and hospital care and prescription drug coverage under the same plan
what drugs are covered
What Drugs Are Covered?

Medicare drug plans will cover most outpatient prescription drugs (and biologics)

  • The drug (or biologic) must be:
    • Available by prescription only
    • Approved by the FDA
      • Drugs in clinical development will not be covered
  • Some vaccines, insulin and medical supplies used to inject insulin are also covered
  • Part B covers diabetes supplies. Part B does not change.
pharmacies under part d
Pharmacies Under Part D
  • Part D plans must provide pharmacy options:
    • Network of retail pharmacies
    • Long-term care pharmacies
    • Home infusion providers
  • Mail order pharmacies are permitted
    • 90-day supplies are available through retail and mail options
how to sign up for a medicare prescription drug plan
How to Sign Up for a Medicare Prescription Drug Plan

There are several ways to enroll:

  • Call the plan directly
  • Visit the plan’s website
  • Call 1-800-Medicare
  • Visit
enrollment for those who need help paying for a plan
Enrollment for Those Who Need Help Paying for a Plan
  • People who have both Medicare and Medicaid coverage (dual eligibles) are automatically enrolled into a Medicare drug plan by CMS
    • They are notified of their enrollment
    • They can switch plans monthly if they are not satisfied or cannot get the medicines they need
  • Others with limited resources must apply for extra help to determine eligibility
decide what kind of plan you want
Decide What Kind of Plan You Want
  • Medicare Advantage with Prescription Drugs (MA-PD):
    • New name for Medicare+Choice plans
    • Medicare Managed Care Plans covering medical and hospital care and prescription drugs
    • Includes Medicare HMOs, Preferred Provider Organization Plans (PPOs)
  • Prescription Drug Plan (PDP):
    • Only covers drugs
    • Can be coupled with traditional Medicare Program
if you join a medicare advantage plan
If you join a Medicare Advantage Plan …
  • You are still in the Medicare program
  • You have all your Medicare rights and protections
  • You will get all the basic Medicare coverage
  • You may get more benefits
pointers for picking a medicare prescription drug plan
Pointers for Picking a Medicare Prescription Drug Plan
  • Most people will want to pick a plan with low yearly costs considering all associated costs:
    • Monthly Premiums + Copays/Coinsurance + Deductible
  • Other things to consider:
    • Use of a preferred pharmacy or mail order
    • Getting prescriptions during travel (e.g., snowbirds)
    • Limits such as prior authorization, step therapy requirements, and quantity limits on the patient’s medications
    • Reputation of the plan
steps for picking a plan
Steps for Picking a Plan
  • Go to and click on “Find and Compare Plans.” Follow the instructions to use the Prescription Drug Plan Finder ;


Call 1-800-MEDICARE and ask the representative to enter your information in the Prescription Drug Plan Finder

steps for picking a plan continued
Steps for Picking a Plan (continued)
  • Choose if you want to do a “Personalized…” or a “General Plan Search”. You will also need to pick the type of plan you want:
    • Prescription Drug Plan only (PDP)
    • Medicare Advantage Plan (MA-PD)

(List your medications and strengths when prompted)

steps for picking a plan continued1
Steps for Picking a Plan (continued)
  • The Prescription Drug Plan Finder will list all the plans in your area. You can check up to three plans at one time to compare plan information

4. Select 3 or 4 possible plans from the Prescription Drug Plan Finder

steps for picking a plan continued2
Steps for Picking a Plan – (continued)

5. Contact each plan to get more information:

  • How is the plan’s Customer Service? Are they quick to answer your call? Helpful in answering your questions? Courteous?
  • Are there restrictions on your medications, such as prior authorization requirements?
  • Can you get your drugs if you travel part of the year?
  • Is mail order available if you want it?
steps for picking a plan continued3
Steps for Picking a Plan – (continued)
  • Decide on the right plan you want and sign up using the options below:
    • Call the plan directly
    • Call 1-800-MEDICARE
    • Visit the web site of the plan sponsor
    • Visit
    • Submit a paper form provided by the plan sponsor
comparing plans
Comparing Plans
  • Why do some plans cost more than others?
    • Every plan is different and has different benefits that may increase its costs compared to other plans
      • For example, depending on the medications you take, some plans may be more expensive because your medicines are not on their preferred drug lists
      • Other plans may offer additional services
  • Paying more doesn’t mean it’s a better plan!
    • You should find the plan that best fits your needs
evaluating your current plan
Evaluating Your Current Plan

Open enrollment is a time to do a satisfaction check of your current plan

  • Ask yourself the following questions:
    • Are the medicines my doctor prescribed on the plan’s formulary (drug list)?
    • If I hit the coverage gap (donut hole), am I still able to afford my medicines, or should I look for a plan with better coverage options during the gap?
    • Would enrolling in a Medicare Advantage plan be a better option than a stand-alone Prescription Drug Plan where I can get both medical and pharmaceutical coverage?
pros and cons of switching to a different plan

You may:

Save money if you pick a lower cost plan

Be more satisfied if you pick a plan that covers all your medications


It may require research and time to pick a new plan

You may have concerns about the new plan that are unknown at the time of enrollment

Pros and Cons of Switching to a Different Plan
help for those who need it most
Help for Those Who Need it Most
  • Those with the lowest incomes pay no premiums or deductibles and have small or no copayments
  • Those with slightly higher incomes pay a little more
  • You may qualify if your annual income is less than 150% of the Federal Poverty Level and you are
    • Single and annual income less than $14,700
    • Married and annual income less than $19,800
  • Some people will automatically qualify
applying for extra help
Applying for Extra Help
  • Apply for Low Income Subsidy (LIS) through the Social Security Administration (SSA)
    • Online at
    • Look up the local SSA in your phone book for the local telephone number
  • Apply through your State Medical Assistance Office
other sources of help paying for prescription drugs
Other Sources of Help Paying for Prescription Drugs
  • State Pharmaceutical Assistance Programs
    • Certain states have programs for people who meet age and income requirements
    • Examples: EPIC (New York), PAAD (New Jersey), PACE (Pennsylvania)
  • Pharmaceutical Manufacturer Programs
    • Check with the company that makes your medication to see if you qualify for their assistance program or online at
  • Charitable Organizations
plan formulary
Plan Formulary

Medicare Drug Plans

  • Do not cover every drug
  • Generally have a list of drugs they cover, called a formulary
  • Must cover prescription drugs in all defined categories and classes
    • Must include more than one drug in each class
    • Includes brand and generic drugs
  • Certain drugs are excluded by law
    • For example,Medicare cannot pay for benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for relief of colds.
plan formulary1
Plan Formulary
  • Using drugs on a plan’s list will save money
    • You will pay lower prices for drugs that are “preferred” by the plan
  • Choosing a covered generic drug instead of a brand-name medication may also save money
    • You should always check with your doctor before agreeing to have your medicines changed or to have your prescription filled with a generic
plan formulary2
Plan Formulary
  • Plans manage drug use with the following:
    • Prior authorization – requiring plan approval before a Rx can be filled
    • Step therapy – encouraging the use of generic or less expensive drugs first
    • Quantity limits
  • Processes are available to you that can help you get the medicines your doctor feels you need through
    • Transition supply
    • Exceptions process
    • Appeals process
plan formulary3
Plan Formulary
  • Plans must fill prescriptions that are not on the plan’s list
    • For new enrollees
    • For residents of Long-term Care (LTC) facilities
  • This will allow time for you and your doctor
    • To find another acceptable formulary drug
    • To request an exception so the plan will cover your drug, even if it is not on their formulary
plan formulary4
Plan Formulary
  • Exception requests may be warranted if a:
    • Patient has tried covered drugs and they don’t work, or
    • Physician believes the patient requires a specific non-covered drug
  • If a request is approved, the plan will cover the drug
exception requests
Exception Requests
  • Anyone can request an exception
  • Contact the drug plan and they will advise
    • How to submit a request
    • What information needs to be submitted
  • Physician must submit supporting documentation
    • Must demonstrate that requested drug is “medically necessary”
  • Plan must notify patient of its decision within
    • 72 hours for standard processing (after receiving physicians statement), or
    • 24 hours for expedited processing
appeals process
Appeals Process
  • A person can appeal a Medicare drug plan’s unfavorable exception decision
  • First level appeal is to the plan
  • Expedited appeals take only a few days
  • An appointed representative may appeal
  • Generally, appeals must be made in writing
  • You should get information about the appeals process upon enrollment
  • You may have as many as 5 levels of appeal/review
what is the coverage gap or doughnut hole1
What is the Coverage Gap or Doughnut Hole?
  • The coverage gap is that time when beneficiaries must pay 100% of their drug costs
  • Medicare is set up as a cost sharing benefit. In 2007, beneficiaries willpay
    • A deductible (if applicable)
    • A monthly premium
    • A co-pay for each prescription drug
    • 25% of the first $2,400 of total drug spend
    • 100% of the next $3,051 of total drug spend
    • 5% of any additional drug spend beyond $5,451
2007 drug plan cost sharing
2007 Drug Plan Cost Sharing

Out-of-pocket spending

Medicare Part D benefit

Catastrophic coverage



“Medicare Part D benefit”






$3,051 Gap

“Donut hole”

Actuarial Equivalence



Partial coverage up to limit



“Medicare Part D benefit”





Percent of Rx spend

Source: Kaiser Family Foundation

what can you do about costs in the coverage gap
What Can You Do About Costs in the Coverage Gap?
  • Apply for Medicare’s Low Income Subsidy (LIS) if you have not already done so
  • If your State has a Pharmaceutical Assistance Program (SPAP), apply for it
  • Check with the pharmaceutical companies that make your medications about whether they have a Patient Assistance Program to help you with costs
  • Talk with your pharmacist or doctor about applying to charitable organizations for medication assistance
  • Continue to use your Medicare Plan’s card when you pay for prescriptions - your payments will be counted toward the amount you must spend before “catastrophic” coverage begins
important dates
Important Dates

New preventive services began…

January 1


important dates1
Important Dates

Watch your mail for the Medicare & You handbook, which will have information about the plans in your area

October/ November


important dates2
Important Dates

You can begin to compare Medicare prescription drug plans…

  • 1-800-MEDICARE
  • Local SHIP office
  • Local community groups

October 2006

important dates3
Important Dates

You can enroll in a Medicare prescription drug plan, or change plans!

November 15 through

December 31

each year

important dates4
Important Dates

Medicare prescription drug coverage begins for those who are enrolled…

January 1

for more information
For More Information
  • Medicare & You 2007 handbook
  • 1-800-MEDICARE (1-800-633-4227)
    • TTY users call 1-877-486-2048
  • (Spanish)
  • State Health Insurance Program (SHIP)
  • Community groups (Local Agency on Aging)