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Medciare Part D was established as part of the...
Medicare Prescription Drug Improvement and Modernization Act (MMA) which established voluntary outpatient prescription drug coverage for Medicare beneficiaries.
How do Beneficiaries Receive Coverage?
- Stand-alone prescription drug plans (PDPs)
- Medicare Advantage prescription drug plans (MA-PDs)
Stand-alone prescription drug plans (PDPs)
- receive hc through Medicare Part A&B
- free standing prescription drug plans (separately serviced)
- traditional FFS insurance
Medicare Advantage Prescription Drug Plans (MA-PDs)
- HC received through Medicare Part C and prescription drug coverage
- managed health care plans (HMO, PPO)
- prescription plan ins bundled (administered) in their program --> under one umbrella
Why is Medicare trying to control drug costs?
Increase the number of prescription plans
Who pays the most for Medicare Part D? Who pays the least?
- Federal government pays the most for Medicare Part D
- State pays the least
Standard Benefit of Part D
everyone typically gets --> it has co-insurance
- some plans offer enhanced benefits (alternative benefit designs), but must be comparable in coverage to the standard benefit
- differences in (partial) deductibles, (higher) premium payments, coverage in the doughnut hole
Part D has formularies and cost saving tools such as:
- step therapy - encourages use of similar, lower cost drugs
- prior authorization - use drugs not on formulary
- quantity limits such as 30 days supply
- tiered formularies - different copay for brand and generic drugs, and tiers for high cost specialty drugs
Part D appeals can be sought for:
- non-formulary drugs
- step therapy requirements
- prior authorization requirements
- quantity limits
- tiered cost sharing issues
- beneficiaries have a 60 days to appeal if Part D plan doesn't grant a formulary exception
Important Information for Enrollees
- Voluntary program
- Medicare Part D is NOT ran by the government or Medicare; run by independent insurance companies who have been approved by Medicare.
- Part D plans vary from company to company
- Make sure pharmacy is in the preferred network
- Look at drug formulary before purchasing drugs
- Enrollees can only change plans once a year (Oct 15-Dec 7)
Initial Enrollment Period
- Total of 7 months:
- 3 months before 65 + the month you become 65 + 3 months after you're eligible
- penalty for late enrollment
When marketing Part D, pharmacists CAN provide
- names of plans they accept
- help applying for income subsidy
- distribute marketing materials and compare plans
- distribute application forms
- provide objective information on plan formularies, covered benefits, copayments, etc
When marketing Part D, pharmacists CANNOT provide
- direct, urge, persuade any patient to enroll in a particular plan based on financial interest of pharmacy
- offer incentives/gifts to enroll in a specific plan
- health screenings combined with plan marketing is prohibited
- receive compensation from the plan (direct/indirect)
- created your own material comparing plans
- directly recommend a "best choice" for the patient
What would you like to do?
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