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Medications For Transplant Patients

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Title: Medications For Transplant Patients


1
Medications For Transplant Patients The Role of
Pharmacy and the TFC
  • Kristin Fox-Smith, BS, MPA
  • University of Utah
  • Pharmacy Administration

2
Topics For Discussion
  • Eligibility and Enrollment for Transplant
  • Medicare Advantage Plans
  • Dual Eligible Enrollment
  • Limited Income Subsidy and Extra Help
  • Medicare Part B vs. Medicare Part D
  • Legality/Compliance Issues for Medicare Part D
  • Medicare Part B vs. D Vaccines
  • Changes for 2009 and Beyond

3
Medicare Overview
Part A Part B Part C Rx Drug Benefit Part D
Benefit Hospital Stays Physician Visits IV Drugs Immunos Managed Care May offer drug coverage Rx Drugs
Eligi- bility Age 65 Disabled Plan A Enrollees Voluntary Part A Part B Benefits Medicare Enrollees Voluntary
of People 41 Million 39 Million 4.6 Million 38 Million
4
Eligibility and Enrollment for Medicare Part D
  • Must be eligible to Medicare Part A and/or
    enrolled in Part B
  • Reside in plans service area
  • Enroll in Medicare drug plan, higher premium for
    delay in enrollment
  • Initial enrollment Nov 15, 2005 May 15, 2006
  • Enrollment 2006 and beyond Nov 15 Dec 31

5
Eligibility for Medicare Covered Transplant
Patients
  • Medicare eligibility for kidney transplant
    patients is automatic for 36 months following
    transplant
  • Medicare eligibility for heart, lung, liver, and
    pancreas transplant patients is NOT automatic.
    Patients must be over age 65 and/or disabled to
    be eligible for Medicare benefits
  • If a patient qualifies for Medicare only because
    they have end-stage renal disease, the Medicare
    coverage will end 36 months after the transplant
    and the patient won't qualify for the extension
    unless they regain eligibility at a later time

6
Coverage Guidelines for Immunosuppressive
Medications
  • Effective for all immunosuppressive drugs
    furnished on or after December 21, 2000, there is
    no longer any time limit for immunosuppressive
    drugs following transplantation previously 36
    months
  • This policy applies to all Medicare beneficiaries
    who meet all of the other program requirements
    for coverage under this benefit
  • Transplant patients with ESRD only will be
    eligible for Medicare, including Part D for 36
    months
  • Transplant patients with Medicare can keep
    Medicare and Part D indefinitely if they have
    Medicare due to age or disability

7
Medicare Coverage Continued
  • Although Part D formularies must only have 2
    drugs per class, they must have all or
    essentially all immunosuppressants
  • Covered under Part B if patient meets criteria
  • Covered under Part D if on formulary and patient
    does not meet Part B criteria

8
Medicare Advantage PlansMedicare Part C
  • Medicare Advantage (MA)
  • Medicare Advantage Part D (MA-PD)
  • Average increase in payment to MA plans is 12,
    can be as high as 50
  • Medicare Advantage enrollment increased by more
    than 40 percent between December 2005 and May
    2007.
  • As of 2008, 23 of all Medicare beneficiaries
    were enrolled in a Medicare Advantage plan
  • Treat Medicare Advantage plans like commercial
    payers, with the exception of Medicare Part B
    covered items, ALL prescriptions must be
    adjudicated at the pharmacy

9
Medicare Advantage
  • Local HMOs and PPOs contract with provider
    networks to deliver Medicare benefits. HMOs
    account for the majority (63) of Medicare
    Advantage enrollment. 8 of all Medicare
    Advantage enrollees are in a local PPO.

10
Medicare Advantage
  • Private Fee For Service Plans (PFFS) are not
    currently required to establish networks, report
    quality measures, or negotiate premiums. Since
    July 2006, PFFS enrollment has nearly tripled
    from 765,000 enrollees to 2.3 million.

11
Medicare Advantage
  • Special Needs Plans (SNPs), mainly HMOs, are
    restricted to beneficiaries who are dually
    eligible for Medicare and Medicaid, live in
    long-term care settings, or have certain chronic
    and disabling conditions.

12
Medicare Advantage Cons
  • Network restriction
  • Once you enroll in a Medicare Advantage plan, you
    no longer have health coverage through Medicare
  • Medicare pays the insurance company a
    pre-negotiated monthly rate as long as
    beneficiary is enrolled
  • Leaves many gaps in coverage doctor visits,
    hospital visits, skilled nursing care, emergency
    services
  • Physicians are restricted by plan with the level
    of care they can provide, are forced to abide by
    plans network and level of treatment

13
Medicare Advantage and ESRD
  • If you develop ESRD while enrolled in an MA plan
    you
  • can continue your coverage in that MA plan.
    However,
  • if you have ESRD and you are not already enrolled
    in a
  • Medicare Advantage plan, you can not enroll in
    one,
  • and insurance companies do NOT have to sell you a
  • Medigap policy when you go on Medicare

14
Special Enrollment Period
  • Permanent move out of the plan service area
  • Individual entering, residing in, or leaving a
    long-term care facility - 0 co-pays for patients
    accessing this benefit
  • Involuntary loss, reduction, or non-notification
    of coverage as good or better than Medicare
  • Other exceptional circumstances
  • Dual eligibles continued enrollment, all year
    long!

15
Medicare
  • All individuals newly entitled to Medicare are
    given a 7 month initial enrollment period for
    Part D
  • 3 months before month of eligibility Coverage
    begins on date eligible
  • Month of eligibility Coverage begins the first
    of the following month
  • 3 months after month of eligibility Coverage
    begins first of the month after month of
    application

16
Eligibility for Extra Help
  • Income
  • Below 150 Federal poverty level
  • 16,245 annual (1354 per month for an
    individual) or
  • 21,855 annual (1821 per month for a married
    couple)
  • Based on family size
  • Resources
  • Up to 12,510 (individual)
  • Up to 25,010 (married couple living together)
  • Includes 1,500/person funeral or burial expenses
  • Counts savings and stocks
  • Does not count home the person lives in
  • Higher amounts for Alaska and Hawaii
  • -Not available in
    the U.S. territories

17
Extra Help
Group 1 100 FPL Group 2 gt 100 lt135 FPL Group 3 135 lt150 FPL
Premium 32/month 0 0 Sliding scale based on income
Deductible 310/year 0 0 50
Coinsurance up to 4,550 out of pocket 1.10/3.30 copay 2.50/6.30 copay 15 coinsurance
Catastrophic 5 0 0 2.50/6.30 copay
18
What Limited Income Subsidy Really Means
  • Individuals eligible for Limited Income Subsidy
    (LIS) are approved by Social Security, but must
    be enrolled by Center for Medicare and Medicaid
    Services (CMS)
  • LIS verification MUST be provided to the Part D
    plan that the patient is signed up with, pharmacy
    can NOT make these changes, and has no power to
    override them!

19
Dual Eligibles
  • Individuals who are dually eligible for Medicare
    and Medicaid are entitled to the broad range of
    benefits provided by both programs
  • This population, many of whom have significant
    and complex health needs and generally have a
    lower level of health literacy, rely heavily upon
    the overlapping coverage of the two programs
  • Enrollment into Medicare Advantage plans for
    these individuals can create problems not
    encountered for dual eligibles who enroll in
    Original Medicare and state Medicaid

20
Dual Eligibles
  • Problems faced by dual eligibles in MA plans
  • Many dual eligibles do not understand or are not
    informed that an MA Plan curtails how they use
    their Medicare coverage. All benefits must be
    received through an MA plan in order to be
    covered, and patients can not go outside the MA
    plan
  • Dual eligibles commonly experience a lack of
    information regarding the benefits they are
    entitled to as MA enrollees. MA plans are only
    required to offer coverage for Medicare services,
    but are NOT required to offer Medicaid covered
    services or assist enrollees in accessing
    services outside the MA plan

21
Dual Eligibles
  • Many dual eligible enrollees are unclear about
    the Medicare and Medicaid rules and benefits
  • Enrollees have experienced interruptions in
    treatment resulting in a negative impact on their
    health, due to coverage and benefit issues
  • Dual eligible beneficiaries MUST see providers
    who accept BOTH Medicare and Medicaid in order to
    receive the full scope of services covered under
    both programs and to ensure continuity of care
  • Medicare rules do not protect duals from paying a
    premium for the portion of the MA plan coverage
    that is not for Part D prescription drugs

22
Dual Eligibles
  • The least suitable option for a dual eligible is
    a PFFS plan, as they are not currently required
    to establish a network or contractual
    relationship with health care providers PRIOR to
    a beneficiaries receipt of services
  • Some of the worst and most widespread marketing
    violations have involved dual eligibles who are
    sold PFFS plans
  • Duals are often enticed by extra benefits that
    agents and plans say will save them money (Ex
    20 worth of OTC medications, extra hearing,
    vision, and dental coverage)

23
Medicare Prescription Drug Coverage
  • Prescription drugs, biologicals, insulin
  • Medical supplies associated with injection of
    insulin
  • When a drug is not FDA approved for an indication
    but it has clinical literature to support its use
  • Vaccines not covered by Part B
  • A drug plan may not cover all drugs
  • Brand name and generic drugs will
    be in each formulary

24
Formulary Review
  • Plan formulary must be developed by a Pharmacy
    and Therapeutics Committee
  • Formulary must include at least 2 drugs in each
    therapeutic category and class of covered drugs
    and in certain categories, must contain all or
    substantially all the medications
  • Antiretrovirals
  • Antineoplastics
  • Immunosuppressants
  • Antidepressants
  • Antipsychotics
  • Anticonvulsants

25
Excluded Drugs
  • Drugs for
  • Anorexia, weight loss, or weight gain
  • Fertility
  • Cosmetic purposes or hair growth
  • Symptomatic relief of cough and colds
  • Prescription vitamins and mineral products
  • Except prenatal vitamins and fluoride
    preparations
  • Non-prescription drugs
  • Barbiturates
  • Benzodiazepines

26
Medicare Part B Versus Medicare
PrescriptionDrug Coverage
  • There WILL still be Part A and Part B drugs
  • Part A drugs
  • Drugs bundled together with hospital payment
  • Part B drugs
  • 1. Drugs delivered in MD office
  • 2. Drugs delivered in by medical equipment
  • 3. Few outpatient chemo and immunosupps
  • 4. Hospital outpatient drugs billed separately
  • 5. ESRD drugs (i.e. EPO)

27
Medicare Part D
  • 12 national stand-alone prescription drug plans
  • Aetna
  • CIGNA
  • Coventry Health Care Inc. First Health
  • CVS Caremark Corporation Silverscript,
    RXAmerica
  • Health Net, Inc.

28
Medicare Part D
  • HealthSpring, Inc.
  • Humana Inc.
  • Medco Health Solutions, Inc.
  • Torchmark Corporation First United American
    Life Insurance, United American
  • UnitedHealth Group, Inc. UnitedHealthcare
  • Universal American Corporation Universal
    American
  • Wellpoint, Inc. Blue MedicareRX, UniCare

29
Medicare Part D Statistics
  • Average number of part D plans per state 49
  • Percent of 0 deductible plans 55
  • Percent of plans with any gap coverage 25
  • Percent of people with a premium increase 88

30
Medicare Parts B and D Coverage Issues
  • In retail, home infusion, and long-term care
    settings, access to Medicare benefit remains the
    same
  • Medicare Part B covers medications for patients
    who received Medicare covered transplants
  • Medicare Part D covers medications for patients
    who did not receive a Medicare covered
    transplant, and for patients who are outside
    their 36 month coverage window

31
Solutions to Medicare Part B vs. D Problems
  • Implementation of mandatory note on all
    immunosuppressive prescriptions Medicare Part B
    covered drug
  • This will force the pharmacy to look at the
    prescription and verify if they are a Medicare
    Part B supplier
  • If prescription is filled by NON Medicare Part B
    supplier, responsibility falls back on pharmacy,
    not patient, in event of audit or retraction

32
Medicare Part D Donut Hole
  • The standard statutory Part D drug benefit
    provides for drug coverage for formulary drugs up
    to an initial coverage limit of 2,700
  • Upon reaching this coverage limit, beneficiaries
    fall into the Donut Hole, and become responsible
    for the full cost of their formulary medications
  • Beneficiaries do not get out of this coverage gap
    until they incur 4,550 in out-of-pocket costs
    for drugs on their Part D formulary (4,550
    310 deductible 630 (25 of 2520) 3610
    (donut hole))
  • Also responsible for the full costs of
    non-formulary and non-covered drugs
  • The deductible, initial coverage limit, and
    out-of-pocket threshold has increased yearly
    since Medicare Part D inception

33
Donut Hole
  • In 2007, 13 states offer no Part D plans
    providing coverage during the donut hole
  • The number of seniors without access to donut
    hole coverage was 375,000 in 2006, jumped to 6.6
    million by July 2007
  • Sierra Rx Plus, offering brand name coverage
    during coverage gap in 2007 (only plan available
    in the West for brand coverage) reported a 3
    million loss in January
  • By February, Sierra announced that brand coverage
    would not be offered for 2008 (all three plans)
  • Humana was only plan to offer this unlimited
    coverage in 2006, did not offer for 2007

34
Medicare Covered Vaccinations
  • Medicare Part D pays for all vaccines not covered
    under Part B
  • Vaccines that require clinical review to
    determine whether Part B or Part D coverage
    Anthrax, Hepatitis A, Hepatitis B, Rabies, and
    Tetanus
  • ALL other vaccines should be covered under
    Medicare Part D
  • All patients receiving Zostavax must have
    coverage checked
  • If Part D vaccines are not billed through Part D,
    there is no reimbursement. This is true even if
    the vaccine is given in clinic

35
Vaccines Continued
  • Pneumococcal and Influenza vaccines are ALWAYS
    covered by Medicare Part B
  • Medicare Part B only covers Hepatitis B for
    medium-to-high risk patients please review
    handouts for the details
  • Tetanus Toxoid is only covered by Medicare Part B
    if given for therapeutic reasons
  • Rabies is only covered by Medicare Part B if
    given for therapeutic reasons

36
Options During the Coverage Gap
  • 4 generic prescription initiative started with
    WalMart in 2006, 331 generics included, this
    model now adopted at hundreds of retail
    pharmacies (Target, Kmart)
  • Of the 10 most prescribed drugs in the United
    States, only Amoxicillin is available on the 4
    plan
  • 4 of the top 20 prescribed medications are
    included in this 4 plan
  • Multiple strengths of drugs on plan are also 4

37
Coverage Gap Options
  • Most manufacturers do NOT disclose income
    guidelines for patient assistance, but average
    income for household of 1 is 32,000 and
    household of 2 is 45,000
  • Must prove patients inability to pay
    out-of-pocket expenses
  • Coverage IS available for patients with
    commercial or Medicare Part D coverage!

38
Options During the Coverage Gap
  • Important that patient continue to use Medicare
    Part D card!
  • Plans negotiated prices are generally lower than
    retail, result in patient savings
  • Money spent on covered drugs counts towards True
    Out-Of-Pocket (TrOOP)
  • Part D plan will track spending, and monitor when
    coverage gap ends, reinstating pharmacy benefits

39
Changes on the Horizon
  • CMS will NOT be looking at changing Medicare Part
    B and Medicare Part D covered drugs until 2011 at
    the earliest
  • Patients will continue to have two deductibles
    and two co-insurance and co-pay structures
  • Deductibles and co-pays must not be waived, this
    is an illegal practice and CMS can revoke a
    pharmacies ability to dispense medications for
    Medicare programs

40
Successes at the University of Utah
  • Patients are given detailed information about
    Medicare Part B coverage and the importance of
    using a Medicare Part B supplier
  • University of Utah contacts patients each month,
    one week before refills are due, reminding them
    to refill their medications
  • Mail-order system in place, all medications are
    sent by 2nd day Federal Express at no charge to
    patients

41
Successes at the University of Utah
  • Discharge process in place all patients are
    counseled regarding their individualized pharmacy
    benefit prior to discharge
  • Discharge medications are provided by the
    University of Utah
  • Medicare application assistance is provided by
    social work, financial counselors, and pharmacy
    department

42
Successes at the University of Utah
  • 87 of all patients receiving a transplant at the
    University of Utah continue to use our pharmacy
    services
  • Compliance and customer service satisfaction are
    high, as patients are assisted through the maze
    of Medicare and commercial drug coverage by
    knowledgeable pharmacy staff
  • Patients transplanted at other institutions and
    outside the state have found their way to the
    University pharmacy system as a result of
    seamless process for patients

43
Successes at the University of Utah
  • All primary and secondary billing handled by the
    pharmacy, patients are removed from this process
  • Medicare coverage is tracked by patient from time
    of discharge, and patients are notified prior to
    Medicare ending
  • If sufficient coverage is not in place, patient
    assistance and financial hardship paperwork is
    started PRIOR to Medicare ending

44

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Contact Information
  • Kristin Fox-Smith Pharmacy Billing Manager,
    University of Utah
  • Kristin.fox_at_hsc.utah.edu
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