Medicare Part D Q and A: 10 Most Asked Questions About the Medicare Prescription Drug Program

These are the top 10 most asked questions that I have encountered with regard to the new Medicare prescription drug program by both beneficiaries and providers. They typically fall into three main categories: enrollment, accessing medications, and additional resources. The answers to these should provide the basis for addressing many of your own questions.

ENROLLMENT

1. Where should I direct patients/families who have questions about the new plans?
Ideally someone in your office staff should be trained to answer patients’ questions regarding which prescription drug plan (PDP) provides the greatest level of access to medications on an individual basis. This training is available directly through Medicare or through some of the pharmaceutical companies. The second option would be a pharmacist that you have a relationship with who can work collaboratively with you. A third source would be community-based organizations, such as the Area Agency on Aging or similar nongovernmental group, as well as Medicare directly through either 1-800-MEDICARE or www.Medicare.gov.

2. Can patients continue to get their meds without signing up for the Part D benefit? Can they continue to receive coverage through Medigap prescription coverage or employee retiree plans after January 1, 2006?
Of course, patients can and will continue to get medications outside of the Medicare Part D benefit, but they will in most cases save money by enrolling in this voluntary benefit. As a result, patients, especially those eligible for the low-income subsidy, should definitely apply for this extra help. Those individuals currently covered through another program should first find out if those programs provide coverage that is just as good as Medicare Part D, also referred to as creditable coverage—if that is the case as is most common with employee retiree plans, they should stay in those programs rather than switching.

3. If someone delays enrollment are they subject to a penalty?
There is a late enrollment penalty for those that delay enrollment into a Medicare prescription drug plan. For every month that a beneficiary is eligible but fails to enroll in a prescription drug plan or be covered by a creditable plan (such as an employee retiree program, VA benefit), that individual will be paying a premium of 1% for each uncovered month once he/she does enroll in Medicare Part D. For younger seniors age 65 who delay enrollment until age 70 and are not covered by any creditable coverage during that time, their premium under Medicare Part D will be 60% higher as a result of delaying their enrollment.

4. What happens if my patient enters a nursing home or an assisted living facility? Will his/her plan change?
Long-term care (LTC) facilities provide residents four unique characteristics: (1) access to a special enrollment period; (2) special packaging through institutional pharmacy providers; (3) no-cost sharing for the dually eligible; and (4) greater access to nonformulary medications. Unfortunately, LTC facilities encompass only skilled nursing facilities (SNFs) and intermediate-care facilities for the mentally retarded (ICF/MRs), but not assisted living facilities (ALFs). As a result, there is a financial and clinical disincentive to living outside the LTC setting. Some states, such as New Jersey, recognize this and are covering all cost sharing for the dually eligible so that their residents utilizing home and community-based waivers to live outside of SNFs are not penalized.

ACCESSING MEDICATIONS

5. How will I know which meds are covered by which plans?
The best method to determine which meds are covered by each plan is to evaluate them at the Centers for Medicare & Medicaid Services’ Medicare website, where there is a tool for comparing formularies. Go to www.Medicare.gov or call 1-800-633-4227 to learn more about the Medicare prescription drug program or any Medicare topic.

6. What is meant by “tiered” coverage of meds? Will all meds currently used by my patients be “covered” by the new plans? Which common meds will be excluded from coverage?
Each prescription drug plan will have a list of medications they will cover, also known as the formulary. Despite a medication being on this formulary, there still may be additional barriers such as prior authorization, tiering, step-therapy requirements, and quantity limits. Tiering is the placement of medications at different copayment levels to encourage the use of generic medications and preferred brand products. Keep in mind that the dually eligible (those with both Medicare and Medicaid) are not subject to tiering. Instead, they pay between $1 and $2 per generic prescription and between $3 and $5 for any formulary branded prescription; if they are in a LTC facility, they pay nothing for formulary medications.

Medicare Part D medications that are not on the formulary can be accessed through the Exceptions and Appeals process (see below). But not all medications are Medicare Part D medications; there are specific medications that by law are excluded from coverage. The Medicare Modernization Act excludes from Medicare Part D coverage certain medications based on their class and use. These medications include:

Specific excluded classes
Over-the-counter (OTC)
Barbiturates
Benzodiazepines
Vitamins (except prenatal)

Specific excluded uses
Weight-related (except when used to treat obesity)
Fertility
Cosmetic
Symptomatic relief of cough or colds

These medications cannot be covered by Medicare Part D funds, but prescription drug plans can choose to provide them at no cost using other sources of funding. Some prescription plans have chosen to do that, especially for nonsedative antihistamines and OTC proton pump inhibitors (PPIs), as they believe this will be less expensive for them than paying a percentage of a prescription equivalent medication.

7. What will be my role if a patient’s meds cannot be provided by the plan? Will I be requested to appeal noncoverage decisions on behalf of my patients?
The exception process, which ensures that beneficiaries have access to prescription drugs they need, is unique to the drug benefit. It provides a straightforward process for an enrollee to obtain a covered Part D drug at a more favorable cost-sharing level, or to obtain a Part D drug that is not on the plan’s formulary. Physicians may be asked to provide input to an enrollee’s request for an exception and/or appeal under the following circumstances:

• The enrollee is using a drug covered on a plan’s formulary that has been removed during the plan year for reasons other than safety;
• The enrollee’s physician prescribed a nonformulary drug for the enrollee that the physician believes is medically necessary;
• The enrollee is using a drug that has been moved during the plan year from the preferred to the nonpreferred cost-sharing tier; or
• The enrollee’s physician prescribed a drug for the enrollee that is included in a plan’s more expensive cost-sharing tier because the prescribing physician believes the drug that is included in the less expensive cost-sharing tier is medically inappropriate for the enrollee.

Generally, plans must grant exceptions when they determine that it is medically appropriate to do so. If the exceptions request involves a plan’s tiered cost-sharing issue, the Part D drug being prescribed may be covered if the prescribing physician determines that the preferred drug for treatment of the same condition would not be as effective as the prescribed drug, or would have an adverse effect for the enrollee, or both. If the enrollee is requesting coverage of a nonformulary drug, the drug may be covered if the prescribing physician determines that none of the drugs on the formulary would be as effective as the prescribed drug, or would have adverse effects for the enrollee, or both. In both cases, the plan would have to agree with the physician’s determination.

Once a plan makes an unfavorable coverage determination such as denying an exception request, the enrollee, or his or her appointed representative, may appeal the plan’s decision. The Part D appeals process is modeled after the Medicare Advantage appeals process that is currently being used successfully.

8. What will I need to do if my patients transition to one of the PDPs?
Transition is the right word. CMS has set up a transition process whereby Medicare beneficiaries would continue to have access to their nonformulary medications as they move from one plan to another, such as from Medicaid to Medicare prescription drug plan for those currently with both insurances (Medicare and Medicaid). The transition period also applies as one moves across the levels of care from the hospital to the subacute; in those settings, medications are covered under Medicare Part A and therefore may not match up to the outpatient community-based formulary. For LTC residents, the transition period is 90-180 days; for those in the community, it is a one-time fill, the quantity of which is at the plan’s discretion.

Many Medicare beneficiaries will need to change from their medications covered by their current prescription drug plan to those covered under their new Medicare Part D plan. This may result in transitioning from one medication to another within the same class. Part D plans must establish an appropriate transition process for new enrollees, which CMS will review as part of its benefit package review process. Failure to appropriately transition certain beneficiaries could result in aggravation of certain medical conditions.

At a minimum, CMS expects that a transition process will address procedures for medical review of nonformulary drug requests and, when appropriate, a process for switching new Part D plan enrollees to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination. The transition process will also address situations where an individual first presents at a participating pharmacy with a prescription for a drug that is not on the formulary, unaware of what is covered by the plan or what is included in the plan’s exception process to provide access to Part D drugs that are not covered. This will be particularly true for full-benefit dual eligible beneficiaries who are auto-enrolled in a plan and who did not make an affirmative choice based on review of a plan’s benefit relative to their existing medication needs. CMS expects that plan sponsors would consider processes such as the filling of a temporary one-time transition supply in order to accommodate the immediate need of the beneficiary, and to allow the plan and/or the enrollee time to work out with the prescriber an appropriate switch to another medication or the completion of an exception request to maintain coverage of an existing drug based on reasons of medical necessity. Such practices exist in the industry today and may represent the most efficient method of triaging requests for filling initial prescriptions of nonformulary drugs for large numbers of new enrollees who, despite education efforts to make beneficiaries aware of the plan’s benefit, may not be aware of all the drugs listed on the plan’s formulary. Plan sponsors have discretion in deciding the appropriate time frame for a one-time transition supply.

9. What if patients change plans? Will I need to provide new prescriptions?
Changing of plans falls into the transition period, where the previous medications will be covered for a period of time. This time period is recommended by CMS to be a one-time fill for those in the community and between 90-180 days for those in LTC. So as Medicare beneficiaries, for example, change from Medicaid to a Medicare prescription drug plan, they will have a transition period to either argue through the Exceptions and Appeals process or to allow weaning off of the nonformulary medication.

ADDITIONAL RESOURCES

10. Where can I turn for additional information about Medicare Part D?
www.Medicare.gov
This link provides access to a comparison of all the prescription plans that are available to beneficiaries living in a specific zip code, and ranks the plans from the least to the most expensive, based on up to 25 medications as a basis for comparison.

www.ssa.gov
Social Security office and the state Supplemental Health Insurance Program (SHIP) are also available to answer questions and enroll residents in the different programs available. 

www.medicarerexeducation.org
A Key Dates Calendar is posted by the nonprofit MedicareRx Education Network, which includes on its site a printable chart of important dates regarding implementation of the new Medicare drug benefit.

www.americangeriatrics.org
The American Geriatrics Society has information and resources of particular importance to healthcare providers focusing on seniors.

www.kff.org
The Kaiser Family Foundation makes available a significant amount of material suitable for professionals about the Part D benefit as well as the issues surrounding it.