Medicare Today…More Choices, Better Benefits

1. Medicare Today…More Choices, Better Benefits Instructor’s Name Event Date 244375 9/06

2. Topics/Modules • Medicare’s Covered Preventive Care Services • Basics of Medicare Prescription Drug Coverage • Picking and Switching Medicare Plans • How to Get Extra Help with Costs • What Drugs Do Medicare Plans Cover? All About Formularies • What Is the “Donut Hole?” • Important Dates for Medicare

3. Medicare’s Covered Preventive Care Services

4. Medicare Has More to Offer • Preventive services • Prescription drug plan coverage • New Medicare Health Plan options • Extra help for those who need it most

5. Benefits and Options • Increased coverage ofpreventive services in 2005 • Outpatientprescription drug coverage available January 1, 2006 • Offered new Medicare Health Plan options in 2006

6. Covered Preventive Services • Designed to help you stay healthy • Began January 2005 • “Welcome to Medicare” physical exam • Cardiovascular screening blood tests • Diabetes screening tests

7. Initial Preventive Physical Examination (IPPE) • “Welcome to Medicare” Physical • Who is eligible? • All Medicare beneficiaries whose Part B coverage began on or after January 1, 2005 • When? • Once during the first 6 months of Part B coverage • Cost to beneficiary? • Part B deductible and copayment/coinsurance

8. Cardiovascular Disease Screening • Who is eligible? • All asymptomatic Medicare beneficiaries • When? • Every 5 years • Cost to beneficiary? • No deductible, no co-payment, no coinsurance

9. Elements of Cardiovascular Screening • Total Cholesterol • HDL • Triglycerides • Provides opportunity assess and discuss cardiovascular risk factors, such as • Family history - Smoking • Diet - Stress • Obesity - Diabetes

10. Diabetes Screening • Who? • Beneficiaries diagnosed with pre-diabetes and at-risknon-diabetic beneficiaries • When? • 2 tests per year for pre-diabetic beneficiaries • 1 test per year for undiagnosed, non-diabetic beneficiaries • Cost to beneficiary? • No deductible, no copay/coinsurance

11. Diabetes Self-Management Training (DSMT) • Who is eligible? • Beneficiaries recently diagnosed with diabetes or at risk for complications from diabetes or who were diagnosed with diabetes before becoming Medicare eligible • When? • A plan of care must be written to include number of sessions, frequency, and duration (up to 10 hours for initial training, up to 2 hours per year thereafter) • Cost to beneficiary? • Part B deductible, copayment/coinsurance

12. Other Covered Screening Tests • Breast cancer • Colorectal cancer • Prostate cancer • Cervical & vaginal cancer • Bone Density • Glaucoma

13. Covered Vaccinations • Influenza • Pneumococcal • Hepatitis B

14. Smoking Cessation Counseling If diagnosed with a smoking related illness: • Inpatient or Outpatient Counseling • Up to 8 face-to-face counseling sessions per 12 month period

15. Basics of Medicare Prescription Drug Coverage

16. Medicare Prescription Drug Coverage: Why Should You Get It? • If you are going to join it’s important to join a plan when you are first eligible • Many people with Medicare need or likely will need prescription drugs to stay healthy • Medicare prescription drug coverage may help protect against high out-of-pocket costs • Enrolling when first eligible may mean that you pay a lower premium

17. Types of Medicare Prescription Drug Plans There are two types of plans available: • Prescription Drug Plans (PDPs) • Provide prescription drug coverage only • Medicare Advantage - Prescription Drug Plans (MA-PDs) • Formerly known as Medicare+Choice • Provide Medicare Parts A & B medical and hospital care and prescription drug coverage under the same plan

18. What Drugs Are Covered? Medicare drug plans will cover most outpatient prescription drugs (and biologics) • The drug (or biologic) must be: • Available by prescription only • Approved by the FDA • Drugs in clinical development will not be covered • Some vaccines, insulin and medical supplies used to inject insulin are also covered • Part B covers diabetes supplies. Part B does not change.

19. Pharmacies Under Part D • Part D plans must provide pharmacy options: • Network of retail pharmacies • Long-term care pharmacies • Home infusion providers • Mail order pharmacies are permitted • 90-day supplies are available through retail and mail options

20. How to Sign Up for a Medicare Prescription Drug Plan There are several ways to enroll: • Call the plan directly • Visit the plan’s website • Call 1-800-Medicare • Visit www.medicare.gov

21. Enrollment for Those Who Need Help Paying for a Plan • People who have both Medicare and Medicaid coverage (dual eligibles) are automatically enrolled into a Medicare drug plan by CMS • They are notified of their enrollment • They can switch plans monthly if they are not satisfied or cannot get the medicines they need • Others with limited resources must apply for extra help to determine eligibility

22. Picking or Switching Medicare Prescription Drug Plans

23. Decide What Kind of Plan You Want • Medicare Advantage with Prescription Drugs (MA-PD): • New name for Medicare+Choice plans • Medicare Managed Care Plans covering medical and hospital care and prescription drugs • Includes Medicare HMOs, Preferred Provider Organization Plans (PPOs) • Prescription Drug Plan (PDP): • Only covers drugs • Can be coupled with traditional Medicare Program

24. If you join a Medicare Advantage Plan … • You are still in the Medicare program • You have all your Medicare rights and protections • You will get all the basic Medicare coverage • You may get more benefits

25. Pointers for Picking a Medicare Prescription Drug Plan • Most people will want to pick a plan with low yearly costs considering all associated costs: • Monthly Premiums + Copays/Coinsurance + Deductible • Other things to consider: • Use of a preferred pharmacy or mail order • Getting prescriptions during travel (e.g., snowbirds) • Limits such as prior authorization, step therapy requirements, and quantity limits on the patient’s medications • Reputation of the plan

26. Steps for Picking a Plan • Go to www.medicare.gov and click on “Find and Compare Plans.” Follow the instructions to use the Prescription Drug Plan Finder ; OR Call 1-800-MEDICARE and ask the representative to enter your information in the Prescription Drug Plan Finder

27. Steps for Picking a Plan (continued) • Choose if you want to do a “Personalized…” or a “General Plan Search”. You will also need to pick the type of plan you want: • Prescription Drug Plan only (PDP) • Medicare Advantage Plan (MA-PD) (List your medications and strengths when prompted)

28. Steps for Picking a Plan (continued) • The Prescription Drug Plan Finder will list all the plans in your area. You can check up to three plans at one time to compare plan information 4. Select 3 or 4 possible plans from the Prescription Drug Plan Finder

29. Steps for Picking a Plan – (continued) 5. Contact each plan to get more information: • How is the plan’s Customer Service? Are they quick to answer your call? Helpful in answering your questions? Courteous? • Are there restrictions on your medications, such as prior authorization requirements? • Can you get your drugs if you travel part of the year? • Is mail order available if you want it?

30. Steps for Picking a Plan – (continued) • Decide on the right plan you want and sign up using the options below: • Call the plan directly • Call 1-800-MEDICARE • Visit the web site of the plan sponsor • Visit www.medicare.gov • Submit a paper form provided by the plan sponsor

31. Comparing Plans • Why do some plans cost more than others? • Every plan is different and has different benefits that may increase its costs compared to other plans • For example, depending on the medications you take, some plans may be more expensive because your medicines are not on their preferred drug lists • Other plans may offer additional services • Paying more doesn’t mean it’s a better plan! • You should find the plan that best fits your needs

32. Evaluating Your Current Plan Open enrollment is a time to do a satisfaction check of your current plan • Ask yourself the following questions: • Are the medicines my doctor prescribed on the plan’s formulary (drug list)? • If I hit the coverage gap (donut hole), am I still able to afford my medicines, or should I look for a plan with better coverage options during the gap? • Would enrolling in a Medicare Advantage plan be a better option than a stand-alone Prescription Drug Plan where I can get both medical and pharmaceutical coverage?

33. Pros: You may: Save money if you pick a lower cost plan Be more satisfied if you pick a plan that covers all your medications Cons: It may require research and time to pick a new plan You may have concerns about the new plan that are unknown at the time of enrollment Pros and Cons of Switching to a Different Plan

34. How to Get Extra Help with Medicare Part D Costs

35. Help for Those Who Need it Most • Those with the lowest incomes pay no premiums or deductibles and have small or no copayments • Those with slightly higher incomes pay a little more • You may qualify if your annual income is less than 150% of the Federal Poverty Level and you are • Single and annual income less than $14,700 • Married and annual income less than $19,800 • Some people will automatically qualify

36. Applying for Extra Help • Apply for Low Income Subsidy (LIS) through the Social Security Administration (SSA) • Online at www.socialsecurity.gov • Look up the local SSA in your phone book for the local telephone number • Apply through your State Medical Assistance Office

37. Other Sources of Help Paying for Prescription Drugs • State Pharmaceutical Assistance Programs • Certain states have programs for people who meet age and income requirements • Examples: EPIC (New York), PAAD (New Jersey), PACE (Pennsylvania) • Pharmaceutical Manufacturer Programs • Check with the company that makes your medication to see if you qualify for their assistance program or online at www.pparx.com • Charitable Organizations

38. What Drugs Do Medicare Plans Cover? Information About Formularies

39. Plan Formulary Medicare Drug Plans • Do not cover every drug • Generally have a list of drugs they cover, called a formulary • Must cover prescription drugs in all defined categories and classes • Must include more than one drug in each class • Includes brand and generic drugs • Certain drugs are excluded by law • For example,Medicare cannot pay for benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for relief of colds.

40. Plan Formulary • Using drugs on a plan’s list will save money • You will pay lower prices for drugs that are “preferred” by the plan • Choosing a covered generic drug instead of a brand-name medication may also save money • You should always check with your doctor before agreeing to have your medicines changed or to have your prescription filled with a generic

41. Plan Formulary • Plans manage drug use with the following: • Prior authorization – requiring plan approval before a Rx can be filled • Step therapy – encouraging the use of generic or less expensive drugs first • Quantity limits • Processes are available to you that can help you get the medicines your doctor feels you need through • Transition supply • Exceptions process • Appeals process

42. Plan Formulary • Plans must fill prescriptions that are not on the plan’s list • For new enrollees • For residents of Long-term Care (LTC) facilities • This will allow time for you and your doctor • To find another acceptable formulary drug • To request an exception so the plan will cover your drug, even if it is not on their formulary

43. Plan Formulary • Exception requests may be warranted if a: • Patient has tried covered drugs and they don’t work, or • Physician believes the patient requires a specific non-covered drug • If a request is approved, the plan will cover the drug

44. Exception Requests • Anyone can request an exception • Contact the drug plan and they will advise • How to submit a request • What information needs to be submitted • Physician must submit supporting documentation • Must demonstrate that requested drug is “medically necessary” • Plan must notify patient of its decision within • 72 hours for standard processing (after receiving physicians statement), or • 24 hours for expedited processing

45. Appeals Process • A person can appeal a Medicare drug plan’s unfavorable exception decision • First level appeal is to the plan • Expedited appeals take only a few days • An appointed representative may appeal • Generally, appeals must be made in writing • You should get information about the appeals process upon enrollment • You may have as many as 5 levels of appeal/review

46. What Is the Coverage Gap or “Doughnut Hole?”

47. What is the Coverage Gap or Doughnut Hole? • The coverage gap is that time when beneficiaries must pay 100% of their drug costs • Medicare is set up as a cost sharing benefit. In 2007, beneficiaries willpay • A deductible (if applicable) • A monthly premium • A co-pay for each prescription drug • 25% of the first $2,400 of total drug spend • 100% of the next $3,051 of total drug spend • 5% of any additional drug spend beyond $5,451

48. 2007 Drug Plan Cost Sharing Out-of-pocket spending Medicare Part D benefit Catastrophic coverage 95% 5% “Medicare Part D benefit” $5,451 100% Beneficiary Responsibility “Out-of-pocket” $3,051 Gap “Donut hole” Actuarial Equivalence “Out-of-pocket” $2,400 Partial coverage up to limit 25% 75% “Medicare Part D benefit” “Out-of-pocket” $265 Deductible “Out-of-pocket” Percent of Rx spend Source: Kaiser Family Foundation

49. What Can You Do About Costs in the Coverage Gap? • Apply for Medicare’s Low Income Subsidy (LIS) if you have not already done so • If your State has a Pharmaceutical Assistance Program (SPAP), apply for it • Check with the pharmaceutical companies that make your medications about whether they have a Patient Assistance Program to help you with costs • Talk with your pharmacist or doctor about applying to charitable organizations for medication assistance • Continue to use your Medicare Plan’s card when you pay for prescriptions - your payments will be counted toward the amount you must spend before “catastrophic” coverage begins

50. Important Dates for Medicare Services