Medicare Part D Update: How to Help Your Patients Choose the “Right” Prescription Drug Plan

May 15, the end of the initial open enrollment period for Medicare Part D, is quickly approaching and, despite all the talk about the dangers of not making a decision, some 20 million Medicare beneficiaries have yet to enroll in a prescription plan. But how do people evaluate, select, and enroll in a prescription plan? The fact is that it is a complex process, but in most cases well worth it because the costs involved in not making a decision are high, and the benefits of joining are much greater. Those costs include a late enrollment penalty, being locked out until January 1, 2007 from any coverage, and the lost opportunity for significantly reduced out-of-pocket expenditures, especially for those eligible for the low-income subsidy. But how exactly should individuals go through this process, and what can busy practices do to assist them?

ASSESSING THE OPTIONS

To start the enrollment assessing process, people need to first ask themselves if they have creditable coverage. Creditable coverage is prescription drug coverage that is just as good as Medicare Part D. This coverage can come from current or previous employers, the federal government through a military benefit such as the Veterans Administration, or certain State Pharmacy Assistance Programs. These providers are supposed to provide a letter stating whether their coverage is creditable, and if that is the case, to also inform the Centers for Medicare & Medicaid Services (CMS). This notification is to assure that if these individuals switched from this creditable coverage to a Medicare Part D prescription plan they would not be subject to a late enrollment penalty. If individuals are not covered by a creditable plan, in almost all cases they should enroll in a Medicare Part D prescription plan.

Others who should definitely enroll in a Medicare Part D prescription plan are those who are eligible for the “extra help.” Some 9 million Americans qualify for this extra help through the low-income subsidy; the enrollment for this program is managed by the Social Security Administration and state Medicaid program. Unfortunately, less than 1 million Medicare beneficiaries have taken advantage of this significant benefit. If you have patients who are having a difficult time paying for their medications because of limited income and assets, they should be encouraged to apply for the low-income subsidy, and then enroll in a prescription plan.

Now to the question of what type of plan. There are basically two types of prescription plans: those covering just prescription drugs known as prescription drug plans (PDPs), and those from Medicare Advantage Prescription Drug (MA-PD) plans that cover not only the prescription drugs but also benefits offered under Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). The benefit of one over the other must take into account personal preference with regard to access and conveniences. While the MA-PDs are able to offer greater benefits, they do so within a network of providers.

Within the options for MA-PDs are traditional health maintenance organizations (HMOs), preferred provider organizations (PPOs), and a new entity called special needs plans (SNPs). The SNPs become possible as a result of a provision within the Medicare Modernization Act; these plans can choose to treat one of three unique groups: institutionalized Medicare beneficiaries, those suffering from chronic illnesses, or the dually eligible (those having both Medicare and Medicaid). Those individuals who fit into one of these three groups should look into the availability of a SNP in their area, and decide whether this specialized program that covers all of their Medicare services would be most beneficial for them.

Once it has been decided whether to enroll in a PDP or a MA-PD, the process moves to assessing the different companies and their plan offerings. With 10 national PDPs offering multiple different plan designs, Medicare beneficiaries have well over 40 prescription plans from which to choose. To sort out which prescription plan is most appropriate, the current best approach utilizes the Medicare website—specifically the Compare Medicare Prescription Drug Plans section. This tool can be accessed directly online at www.medicare.gov, or by calling 1-800-MEDICARE, it can even be accessed indirectly. Many pharmacies also are providing free education and assistance with this tool for Medicare beneficiaries.

When utilizing the Compare Medicare Prescription Drug Plans tool it is important that people realize that they need to look beyond the monthly cost for their specific medications within that plan. After entering in their medication profile, they will be given a list of all the plans providing coverage for those medications—from the low-cost plan to the high-cost plan. They will also be given the details on how each medication is treated within that prescription plans’ formulary. This will detail the utilization tools that may be in place with regard to that medication. These utilization tools can include prior authorization, quantity limits, and step therapy, tools that we are familiar with and are frequently used in pharmacy benefit management. It is important that individuals realize that it may be well worth paying slightly more per month for a plan to be assured freer access to their needed medications rather than going through any or all of these utilization restrictions.

PRACTICE ASSESSMENT

Physician practices can also utilize this same Medicare assessment tool to determine for their patients, in general, which plan provides the greatest access to the medications that are important to that practice. By going to www.medicare.gov, and utilizing the Compare Medicare Prescription Drug Plans, a practice can start by entering its zip code, because prescription plans are specific for locale. From there, the practice can enter up to 25 of the most commonly utilized medications within that practice. This will obviously vary somewhat from practice to practice. From this information, CMS will provide a list of plans that range from the low-cost to the high-cost again, also noting the utilization tools employed by each plan for those specific medications. This exercise will help practices identify prescription plans that are likely to allow for the greatest access to those medications felt to be important for that practice.

Once this has been established, practices can help educate their patients, provided they continue to do so in the best interest of their patients. The CMS has stated that to the extent that a provider can assist a beneficiary in an objective assessment of the beneficiary’s needs and potential plan options that may meet those needs, providers are encouraged to do so. Obviously, CMS does not want pharmacies or health care professionals steering beneficiaries into plans based upon the financial self-interest of the pharmacy or of the provider, since this would not be in the best interest of the beneficiary or the Medicare program. But CMS does understand the findings of the Kaiser Family Foundation and others that showed that physicians, other health care professionals, and pharmacists are the first persons Medicare beneficiaries would turn to for help—help that they definitely need in order to join the “right” plan.

JUST DOING IT

Hopefully by now physicians and patients are realizing the danger of doing nothing, and through the tools provided here will feel a little more comfortable to evaluate the different options they have. Once this evaluation has taken place, Medicare beneficiaries should then feel more comfortable in joining the prescription plan that will provide them with the prescription drug insurance that will increase their access to those medications that their physician orders because of medical necessity. In the end, this process will take some learning and a good deal of our help, but we need to be prepared to do it.