Title: Medications For Transplant Patients
1Medications For Transplant Patients The Role of
Pharmacy and the TFC
- Kristin Fox-Smith, BS, MPA
- University of Utah
- Pharmacy Administration
2Topics 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
3Medicare 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
4Eligibility 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
5Eligibility 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
6Coverage 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
7Medicare 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
8Medicare 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
9Medicare 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.
10Medicare 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.
11Medicare 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.
12Medicare 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
13Medicare 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
14Special 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
16Eligibility 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 -
-
17Extra 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
18What 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!
19Dual 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
20Dual 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
21Dual 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
22Dual 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)
23Medicare 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
24Formulary 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
25Excluded 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
26Medicare 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)
27Medicare 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.
28Medicare 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
29Medicare 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
30Medicare 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
31Solutions 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
32Medicare 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
33Donut 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
34Medicare 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
35Vaccines 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
36Options 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
37Coverage 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!
38Options 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
39Changes 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
40Successes 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
41Successes 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
42Successes 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
43Successes 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
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48Contact Information
- Kristin Fox-Smith Pharmacy Billing Manager,
University of Utah - Kristin.fox_at_hsc.utah.edu