Medicare Modernization Act, Part D Prescription Drug Benefit

1. Medicare Modernization Act, Part DPrescription Drug Benefit Presentation for County Program Administrators September 1, 2005

3. Timeline: When It All Happens

4. Timeline: When It All Happens

5. II. Impacts • On Client • On County Clinicians • On County Psychiatrists • On County Budgets

6. Client Impacts • Client Awareness. Many of county mental health clients are isolated and do not have the benefit of family members to help them understand and navigate this process. • Coverage of PDP and/or MA-PD plans. • Formularies. CMS guidance indicates that PDPs and MA/PDs must cover “all or substantially all” medications in six pharmaceutical classes. • Step Therapy. PDPs and/or MA-PDs may require the use of step therapy prior to authorizing the payment of other medications. • Pharmacies May Not Contract with All PDPs or MA/PDs.

7. Client Impacts • Client Co-pays and Deductibles. • Extra Help Low Income Subsidy May Not Cover All the Costs. • For Medi-Medi clients, the transition period is insufficient. • Co-payments create an undue hardship • Cost control mechanisms may deny access to current medications (e.g. step therapy) • “Bait and switch” - plans offer generous, inclusive coverage initially and reduce access through subsequent plan amendments. • Coverage that Follows Client with Transitions to Other Levels of Care. • Transitional Levels of Care. There may be unintended consequences for transfers to other levels of care such as PHFs, IMDs, Jail, Juvenile Hall, etc.

8. Impact on Clinician Increased case management. • Educating clients • Cross-referencing plan coverage with psychotropic medication needs/prescriptions. • If client is not full benefit dual eligible, but is Medicare eligible, the clinician will need to help these individuals complete the “Extra Help” Low Income Subsidy. • Continuity of Care. Ensuring plan coverage takes place during transitions to other levels of care.

9. Impact on County Psychiatrists Formularies: Tier 1 is lowest cost sharing • Subsequent tiers have higher cost sharing in ascending order • CMS will review to identify drug categories that may discourage enrollment of certain people with Medicare by placing drugs in non-preferred tiers. • Plan must have exceptions procedures for tiered formularies. Psychiatrists will need to know what the exceptions procedures are. And, each plan may have different exceptions procedures.

10. Impact on County Psychiatrists • TAR Process.Knowledge and understanding of TAR process and which drugs will fall under the TAR. • Medication Coverage • Six classes (including antidepressants and antipsychotics). CMS guidance indicates PDPs and MA-PDs are required to cover “all or substantially all” medications. • Other health conditions may actually define consumer choice of PDPs or MA-PDs. • Knowledge of plan benefits and drug coverage.

11. Impact on County Mental Health • Increase in staff time for case management, both at the front end (enrollment) and through the Appeals Process. • Increase in staff time for administrative functions and problem resolution, including fiscal administration, navigating CMS system, and complaint/resolution process. • Increase in ER visits due to loss of eligibility and/or difficulty in navigating. • Depending upon county decisions, resources, and feasibility, counties could potentially be in the position of having to pick up a share or shares of cost.

12. III. Coordination with Inter-county agencies • County Welfare • “Extra Help” Low Income Subsidy. What directives do county welfare agencies want county mental health to follow in terms of enrolling clients in the LIS?

13. III. Coordination with Inter-county agencies • County Health Care • Who should be the “lead” in ensuring the client’s PDP/MA-PD plan covers all health medication needs and all mental health needs? • What kind of protocol makes sense? • What happens when a PCP changes a client’s health care medication and realizes that the medication is not covered under the client’s current PDP or MA-PD and advocates a change in plan for client? How will county mental health know about this change and how will it impact psychotropic script?

14. County Inter-agency • County Pharmacies • What role will county pharmacies play?