Medicare_2025_SOLE

Introduction to Medicare

• Introduction presented by Dr. Gretchen K. Garofoli, PharmD, BCACP, CTTS, FAPHA

Objectives

• Define Medicare and explain its coverage.

• Describe Medicare Part D benefits.

• Explain key financial terms: copays, deductibles, premiums, formularies, and gap coverage.

• Discuss important factors for helping patients choose Medicare Part D plans.

Medicare Overview

• Historical Context:

  • Established under the 1965 Social Security Act, Title XVIII.

  • Known as "Health Insurance for the Aged and Disabled."

  • Managed by Centers for Medicare and Medicaid Services (CMS).

• Eligibility:

  • Available to Americans over age 65, those with long-term disabilities, ALS (Lou Gehrig’s Disease), or End Stage Renal Disease (ESRD).

• Enrollment Statistics:

  • Approximately 66.4 million Americans enrolled in Medicare Part A and/or B as of 2023.

• Major Components:

  • Part A: Hospital Insurance

  • Part B: Medical Insurance

  • Part C: Medicare Advantage

  • Part D: Prescription drug coverage

Medicare Parts

• Part A: Hospital Insurance

  • Covers inpatient hospital services, nursing home, hospice, and home health services.

• Part B: Medical Insurance

  • Covers physician services, outpatient services, durable medical equipment (DME), immunizations, and ambulance services.

• Part C: Medicare Advantage

  • Includes various plan types like PFFS, HMO, or PPO.

  • Provides basic coverage and potentially additional benefits.

Medicare Card

• Medicare ID number card issued to patients, previously included Social Security number.

• Contains numbers 0-9 (letters S, L, O, I, B, Z are never used).

Exclusions from Medicare Coverage

• Long-term care (custodial care).

• Most dental care, eye exams for glasses, cosmetic surgery.

• Massage therapy, routine physical exams, acupuncture, hearing aids and exams for fitting.

• Concierge care.

Medicare Part D

• Overview:

  • Medicare Prescription Drug Plan introduced on January 1, 2006.

  • Covers approximately 17-23 prescriptions per member per year, generally excluding prescriptions under Part A or B unless condition-specific (e.g., transplants).

  • Includes:

    • Prescription Drug Program (PDP) for Fee-for-Service members.

    • Medicare Advantage Prescription Drug program (MAPD).

• Enrollment Requirement: Prescribers must be enrolled with Medicare or have an opt-out request.

Coverage under Part D

• Medications Covered:

  • Prescription drugs, medication therapy management programs, medically necessary vaccines recommended for seniors (e.g., Shingrix, Tdap).

  • COVID-19 vaccines covered under Medicare Part B starting January 1, 2023.

  • Inflation Reduction Act eliminates out-of-pocket costs for vaccines endorsed by Advisory Committee on Immunization Practices.

• Exclusions:

  • Weight loss, fertility treatments, cosmetics, cough/cold treatments, nonprescription drugs.

Opioid Policies

• Implemented January 1, 2019:

  • 7-day supply limit for opioid-naïve patients.

  • Cumulative morphine milligram equivalent (MME) alert for patients exceeding 90 MME.

  • Drug management programs for patients prescribed opioids or benzodiazepines.

Insulin Savings

• Effective January 1, 2021, capped insulin costs at $35 for a 30-day supply.

Enrollment Details

• Agent enrollment during:

  • 7-month window around turning 65.

  • Annual enrollment period from October 15-December 7, with changes effective January 1.

  • Option to change to a 5-star plan from December 8-November 30.

Medicare Star Ratings

• Ratings for Part C & D based on 44 performance measures (1 to 5 stars).

  • Metrics include Medication Adherence, Influenza Vaccines, High-Risk Medication Use in Elderly, and Suggested Therapy.

  • Plans attaining higher ratings receive financial bonuses; beneficiaries can enroll in 5-star plans any time.

Late Enrollment Penalty

• Imposed for not having a Medicare drug plan for 63 days or more after Initial Enrollment Period.

  • Patients qualifying for "Extra Help" are exempt from the penalty.

  • Penalty calculated as 1% of the national base beneficiary premium times months without coverage.

Definitions of Key Terms

• Annual Deductible: Maximum of $590 for Part D plans in 2025.

• Copayment: Fixed amount per prescription, varying by medication tier.

• Coinsurance: Percentage paid for each prescription.

• Monthly Premium: Paid for insurance coverage; additional fees may apply based on income.

• Estimated Annual Drug Costs: Total out-of-pocket for prescription coverage including premiums, deductibles, copayments.

Financial Assistance Programs

• Extra Help Program: For individuals with limited income/resources, covering costs related to Medicare Part D.

• Limited Income Newly Eligible Transition: Provides immediate prescription drug coverage for those qualifying but not enrolled in a plan.

Drug Formulary

• Medications covered by the plan, developed by Pharmacy and Therapeutics (P&T) Committee consisting of healthcare professionals.

Discussion Prompts

1. Address patient dissatisfaction with high copayment.

2. Factors for reviewing new drug addition to the formulary.

Mail Order and Refill Policies

• Approval required for automatic refills to mitigate costs and reduce waste.

New Developments for 2025

• Updates on coverage gap, maximum out-of-pocket spends, Medicare Prescription Payment Plan (MPPP), HIV medication coverage, and drug pricing negotiations.

Coverage Gap

• Defines threshold beyond which beneficiaries incur higher out-of-pocket costs.

Maximum Out of Pocket Spend

• Capped at $2,000 annually (down from $8,000 in 2024).

  • Catastrophic coverage begins upon reaching this threshold, covering 60% of drug costs.

Medication Prescription Payment Plan

• Allows cost spreading over the year; designed to assist those with high medication costs.

Example Comparisons

• Illustrating monthly costs under the MPPP for high-cost drugs and overall yearly costs compared with traditional out-of-pocket expenses.

HIV Medication Coverage

• PrEP medications included in Part B; treatment medications continue under Part D.

Drug Pricing Negotiation Plan

• Enables CMS to negotiate the prices of select high-cost, single-source brand medications, affecting pharmacy stock decisions.

Choosing a Medicare Part D Plan

• Considerations include: monthly premium, annual deductible, formulary, total costs, and network availability for pharmacies and providers.

Log In Help and Drug Search Preferences

• Instructions on how to access Medicare resources, search for plans, and enter drug information to find the best coverage.