Understanding Medicare Part D
As health care professionals, we are constantly faced with new advances and challenges. This year, we are facing probably the largest change, and challenge, in health care – understanding Medicare Part D! As of January 1st, Medicare has instituted prescription drug coverage for people who receive or are eligible to receive Medicare. While this is a federal program, the prescription drug plans are being administered by a number of private drug plans (PDPs). While some of these are national plans, many are only regional. Medicare has set rules by which these PDPs must operate, however, the costs and coverage offered by each may vary. Differences exist on the cost of premiums, co-pays, and deductibles, and whether limits are put on the amount of a drug that can be dispensed per month. Some PDPs may require prior authorizations on certain drugs, while others use a tiered process of co-pays, or require a step approach for the treatment of certain conditions.
Medicare Part D is supposed to be an insurance plan for prescription medications. When you do the math, it ends up in many cases to be more of a drug discount plan. However, for people who require multiple medications and do not have any coverage now, this may prove to be quite helpful. Here are the bullet points, and estimates, of how it works:
There is a monthly premium – average of $32 per month, but they can range much higher or lower.
- Yearly deductible - Individual pays the first $250
- Co-pays – individual pays about 25% of the next $2,000 and the plan pays 75%
- “Doughnut hole” – individual pays all of their drug costs for the next $2,850 (estimated amount)
- Catastrophic – individual pays only 5% of the cost of their drugs, once their out-of-pocket drug costs exceed $3,600
So how does this affect people with epilepsy?
We aren’t sure of everything yet, but here are a few important points – both good and bad:
- Epilepsy is one of six ‘protected conditions – which means that PDPs must cover all or substantially all of the treatments for epilepsy. Thus, most epilepsy drugs should be covered, but the manner in which they are covered may vary. Some may be preferred drugs; others require prior authorization or special exceptions for coverage. The bad news – this classification as a ‘protected condition’ is only good for this year. The Epilepsy Foundation and other advocates are actively working with the Centers for Medicare and Medicaid on what will happen next year!
- Medicare Part D plans do not cover barbiturates or benzodiazepines. Since a number of these drugs are used for epilepsy care, both chronic and acute treatment of seizures, this may pose dilemmas for many people. If a person also has Medicaid, the state Medicaid plan is supposed to cover the cost of these drugs, but individuals are strongly encouraged to check with their state Medicaid to verify this. If a person does not have Medicaid and needs one of these drugs, patients and providers will need to request coverage of the drug as medically necessary for the individual patient. However, keep in mind that if a generic version of the drug is available, some plans may cover it. Have patients check with their drug plan and pharmacy early so you have time to appeal the decision if needed!
- Financial help is available for people with low incomes. Patients who have both Medicaid and Medicare (called ‘dual eligibles’) are supposed to qualify for the low income subsidy. Depending on their income and assets, they may get help on costs of premiums, deductibles, and co-pays for their medications. Patients who are not on Medicaid, but who have limited income and assets should still apply for this extra help.
- Each PDP has its own drug formulary. Providers must become familiar with the formularies of plans in their area – these can be obtained from the plans online in most cases.
- Each plan has its own appeals process and its own forms for prior approval. Providers are encouraged to know the rules and keep copies of the forms for prior approval.
- Plans may change their formularies, providing that they give beneficiaries about 60 days notice. Thus, patients may find that drug X that they are taking was covered last month, but won’t be covered two months from now!
- Patients may not be able to continue using their usual pharmacy, or have trouble getting medications while traveling or out-of-state. Getting medications by mail-order may help this.
- There are many different types of PDPs. Some plans provide coverage just for medications. Others, called Medicare Advantage Plans, provide coverage for medications only if they also receive their health care services through their plan’s HMO or PPO network. This may affect from whom or where patients can get their care.
- Encourage patients to do their homework before choosing a plan. Refer them to a social worker, community agency, or Medicare counselor who can work with them to find the best plan to meet their needs. Epilepsy.com has information for the public, including important dates and contact information at www.epilepsy.com. Patients should also look at the Medicare website at www.medicare.gov where they can find more details about the plans, compare plans or enroll online.
I hope this information is helpful as you negotiate your way through the new maze of prescription drug coverage. I would encourage people to let their elected officials know what they like or don’t like about the plan. Since this is a work in progress, there may be more changes in the future. Epilepsy.com will be updating information regularly. Also, the Epilepsy Foundation has been working with the Centers for Medicare and Medicaid to advocate on behalf of people with epilepsy. Visit their website at www.epilepsyfoundation.org for legislative updates and changes on Medicare Part D.
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