Medicare Prescription Drug Improvement and Moderation Act of 2003
-created 4 programs
Medicare Part A
Provides hospitalization insurance
Medicare Part B
provided medical insurance for physician services
Medicare Part C
medicare managed care
Medicare Part D
prescription drug program
CMS
Centers for Medicare and Medicaid Services
MA
Medicare Advantage
MA-PD
Medicare Advantage Prescription Drug Plan
MTM
Medication therapy management
PDP
prescription drug plan
TrOOP
true out of pocket expense
Medicare part D
-since January 2006 medicare beneficiaries
-cost depends on income
-if not low income they will pay a monthly premium, annual
deductible, and co-pays
-everyone must have their own plans
-deductibles may be reduced or waived but may charge higher premiums
-co-payments based on 4 tiers: 1:least expensive generic drug, 2:
preferred brand name drug; 3: non-preferred brand name drug; 4: rarer,
high cost drugs
-cant be changed between January 1 and December 31
-beneficiary may change plans only once a year unless he/she moves
out of the area, into a nursing home, or plan stops service in area
-coverage gap is coined as medicare donut hole
Medicare Part D
in 2008 medicare part D began to cover the cost of vaccines and their
administration, formerly covered by Part B
Provisions of medicare programs
1. all rx benefits must accept participation from any pharmacy that
agrees to the terms and conditions of their drug plan
2. the sponsors cannot require beneficiaries to obtain meds through
mail order
3. Large quantities including 90 day supplies may be obtained from
local pharmacies
4. if a brand name product is dispensed the patients must be
informed of lower cost generics
5. pharmacist are eligible for mtm payment
6. each drug plan sponsor must establish mtm programs for each
patient with high drug costs
7. importation of drugs from Canada is okay if the HHS certifies
that there is no risk to public health
8. blocking the use of medicare's purchasing power to negotiate
prices with pharmaceutical manufacturers
9. awp will be phased out to asp
10. can't file multiple 30 month stays
11.
formulary requirements
-must include drugs within all the therapeutic categories
-6 drug categories that require most drugs to be covered:
anticonvulsants, antidepressants, antineoplastics, antipsychotics,
antiretrovirals, and immunosuppressants
-plans may alter their therapeutic categories and classes only at
the beginning of each year unless a change is needed to accommodate
newly approved drugs
-replacing a brand with a generic can happen at any time
-the following drugs usually aren't covered: barbiturates,
benzodiazepines, weight loss, hair growth, fertility drugs,
prescription vitamins, outpatient drugs
-changes have to have CMS approval, a 60 day notice must be given
too CMS, state prescription plans, pharmacies, and plan enrollees. the
exception is black box warning drugs.
Medicare enrollment
-people can enroll 3 months before and 3 months after there birthday
month/basically 7 months
-pay months or get it deducted from monthly social security checks
-if enrolled in medicare stop contributing to HSA
Medigap
#NAME?
MTM program
-centers for medicare and medicaid services has stated that MTM
programs must evolve and become a cornerstone of the medicare
prescription drug benefit
-part D sponsors must automatically enroll qualified beneficiaries
unless they opt-out
-beneficiaries must be targeted for enrollment at least quarterly:
those who have multiple chronic disease states usually 2-3 and are
taking 2-8 drugs and are expected to incur a predetermined annual cost
-sponsors cannot require more than 3 chronic illnesses and must
target at least 4 of the following seven: hypertension, heart failure,
diabetes, dyslipidemia, respiratory disease, bone disease, and mental health