The Medicare Part D Drug Program: Making the Most of the Benefit

Provides an easy-to-understand explanation of the Medicare Part D Program

Discusses decisions seniors face and how to advise a family member or client on how to determine what is best for the individual

Offers information on extra benefits available to seniors and how to determine eligibility

Presents important information on what drugs are covered and excluded in the formulary structure of plans, as well as ways to petition to have drugs added for coverage

Contains key information on the rights of seniors in the Program

Includes helpful information on how to choose a pharmacist, what patients can obtain from the medication management programs in Medicare Part D, coverage for Part D preventive services, as well as how to help seniors get their medications and take them in order

Introduction 
Chapter 1 - The  Part D Program of Medicare
WHAT IS MEDICARE?
     Medicare Part A.
     Medicare Part B.

     New program in Medicare.
     What is this new program in Medicare? 
     Caution about scam artists.

     Complaints about Medicare Part D.
     So how can I benefit from Medicare Part D?
     When did Medicare Part D start?
     What pharmacies can I use to obtain my prescriptions?
     Are your drugs covered? 
     What about other assistance programs? 
     Signing up for Medicare Part D.
     So what do I need to know to get started?

Chapter 2 - How will this program work and how can I determine what is best for me?
PRIVATE PRESCRIPTION DRUG PLANS (PDPS). (THIS MATERIAL IS ADAPTED FROM THE www.cms.gov WEBSITE).
     The name of the organization.
     The actual plan name.
     Coverage.
     Type of Additional Coverage Offered in Drug Coverage Gap (the “donut hole”).
     Most commonly used drugs..
     Convenience.
     Network pharmacy.
MEDICARE ADVANTAGE PLANS (THIS MATERIAL IS ADAPTED FROM THE www.cms.gov WEBSITE).
     Location – County.
     Organization Name
     Plan Name: The name of the Medicare drug plan.
     Type of Medicare Advantage Plan
     Cost
     Number of Top 100 Drugs on Formulary. 
     Convenience.
     Network pharmacy.
GENERAL ISSUES ACROSS BOTH PRESCRIPTION DRUG PLANS AND MEDICARE ADVANTAGE PLANS.
     Maintaining drug coverage for major diseases.
     Extra help for those with extra needs
     What do I do now?
     Learning about different plans. 
     Know when you need to sign up for coverage.
Chapter 3 - Are you eligible for extra help with the Medicare Part D program?
EXTRA HELP IS AVAILABLE FOR MANY.
     You will need to do several things to make sure you get the help you deserve.
     The Social Security Administration will mail applications to many eligible
     Extra help in addition to regular assistance. 
     How to find out if I qualify? 
PERSONS WITH MEDICAID COVERAGE
     What if you previously were on Medicaid and Medicaid paid for your medications? 
     Do you have a limited income but do not qualify for Medicaid coverage for your prescription drugs?  
     Pharmaceutical assistance programs. 
Chapter 4 - Choosing a Medicare Part D insurance drug plan.

DIFFERENT PLANS AND OPTIONS
     Decisions to sign up for Medicare Part D.
     The Medicare Prescription Drug Plans.
     Medicare Advantage Plans.
     New members in drug plans and what they can expect with their drug coverage.

     Starting your coverage, but you do not have your prescription drug plan card.

     Creditable coverage.

     There are consequences if you do not sign up when you are eligible.

     Penalty fees.

     Initial enrollment periods.

     What happens when people first become eligible to enroll in a Medicare drug plan?

     What happens if I go into a nursing home?

     Refunds for overcharges.

     How can I pay for my premiums? 

     Medicare Errors in Billing.

     Maintaining coverage for your drugs.

     Challenging a prescription drug plan action.

     Appealing plan decisions that are not in your favor.

     Other considerations.

     You can apply for extra help at any time.

     How does CMS know about all of this?

     Special enrollment periods.

     Coordinated election period.

     Medicare Advantage special plans for special needs individuals. 

     Changes in the standard benefit for 2007 (6). 

     True out of pocket (TrOOP) costs.

     What else might I do to see what is available for me?
Chapter 5 - What drugs are covered?

DRUGS FOR ALL DISEASES AND AILMENTS-BUT NOT ALL DRUGS

     Drugs covered in the model formulary guidelines.

     How to find out what drugs the prescription drug plans will pay for.

     Formulary finder.
     Coverage for drugs under Medicare Part B.
     Non-covered drugs in any formulary
     Over-the-counter drugs (OTC)
     Barbiturates.
     Benzodiazepines.   
     Vitamins.
Chapter 6 - How to choose a pharmacist.

     The importance of your pharmacist.

     Referrals from friends
     Is the pharmacist accessible?

     Can I call for more information and speak to the pharmacist every time?

     General concerns about drugs and drug use

     Concerns about certain medications if you are caring for an elderly individual.

     Counseling when obtaining new prescriptions.

     Brand and generic drugs.

     Charging for services.

     Refusal to fill your prescription.

     Furnishing you the best price available.

     Drugs and expiration (freshness) dating.

     Transfer of prescriptions from one pharmacy to another.

     Who owns your prescription? 

     Privacy and Respect.

     Who are those people back there (filling your prescription)?  

     What to do if you suspect something is not right with how you receive your prescriptions.
     Other services
Chapter 7 - The formularies in this program, and how they work.

FORMULARIES – DEFINITIONS AND CONSIDERATIONS
     Formulary definition.
     Formulary finder.
     Uncovered drugs.
     Formularies used to lower costs.
     Specific other formulary issues. 
     Step therapy. 
     Prior authorization. 
     Preferred drug lists. 
     Tiered co-payments. 
     Pharmacy networks. 
     Dispensing limits.
     Summary of formulary issues.
Chapter 8 -  The medication management programs and how to use them to your advantage.

MEDICATION THERAPY MANAGEMENT SERVICES
     Goal is to help you with your medicine taking.
     Who is eligible?
      Your rights.
     An example to show how it would work.
     Specialized contacts to you by phone or in person.
     Reducing the number of drugs that you take.
     Use these services if you can.
Chapter 9 - Coverage for preventive services in the Medicare Program
DISEASE PREVENTIONAND HEALTH PROMOTION
     Disease prevention.
     Seniors not aware of services available.
     My.medicare.gov
     Health promotion screenings and tests
     Physical Examination (Women and Men).
     Cardiovascular tests (Women and Men).
     Diabetes screening, supplies, and self-management training (Women and Men).
     Breast Cancer Screenings – Mammograms (Women).
     Bone Mass Measurement.
     Glaucoma tests.
     Cervical and Vaginal Cancer Screening (Women).
     Colorectal cancer screening (Women and Men).
      Fecal Occult Blood Test.
      Flexible Sigmoidoscopy.
      Screening Colonoscopy.
      Barium Enema.
     Prostate cancer screening (Men).
      Digital Rectal Examination.
      Prostate Specific Antigen (PSA) test.
     Various shots (Vaccinations) for Flu, Pneumococcal Pneumonia, Hepatitis B.
      Flu shot.
      Pneumococcal shot.
      Hepatitis B shots.
     Smoking Cessation Counseling.
     Smoking kills plain and simple.
     Smoking causes numerous health problems.
     Smoking causes many health problems including:
     Coverage of smoking cessation counseling.
      Drugs do not work as well when you smoke.
      What specific services are provide to help you stop smoking.
      Counseling.
      Medicare Part D coverage for stop smoking drug therapies. 
     New health promotion and disease prevention services for 2007.

     Use these services to help yourself to better health.

Chapter 10 - Getting your drugs and drug taking in order.

TIPS TO IMPROVE YOUR DRUG TAKING

     Take as few drugs as possible.
     Routine check-ups.

WHAT IS PATIENT COMPLIANCE?

     Various forms of patient compliance.

     The importance of patient compliance being the best it can be.

     Difficulties seniors face with medication compliance.  

     Social isolation

     Chronic disease

     Severity of disease

     Multiple drug regimens
     Complex drug regimens

     Advice on medication taking

     Answers to know about your medications.

     Please see the connect the dots diagram below.

     Summary

Chapter 11 - Summary and next steps.

SO WHERE TO YOU GO FROM HERE?

     Several changes for 2007 and beyond.

     Premium and deductible increases.
     Pilot programs for persons with chronic diseases.
     Miscellaneous Medicare provisions that are new.
     Health Savings Accounts.
     Ombudsman.
     Proof of citizenship.
     Qualifying for extra help.
     The coverage gap – “donut hole”.

     Best price.
     Generic drugs.

     State assistance plans and Medicare Part D.

     TrOOP.

     Changes in formulary coverage.

     Removing drugs from the market.

     Protection for you.

     Coverage determination.

     Approvals by you or your authorized representative.

     You or your doctor and the forms required.
     Yearly notification.

     Plans must respond promptly.
     Level of appeals.
     Your personal health information and privacy.

     Initial enrollment periods.

     Where else might you obtain help in enrolling.
     Enrollment materials.
     Annual Coordinated Election Period (AEP).

     Extra help.
     Automatic enrolling.
     Notification.

     Changes affecting your extra help situation.
     Special enrollment periods (SEPs).
     Losing coverage through no fault of your own.

     Special – Special enrollment periods.

     Notice of plan change requirements.

     Options during enrollment periods.

     Special circumstances.

     Penalty or not.

     Changes in the prescription plan finder for 2007.

SUMMARY OF CONSIDERATIONS AND NEXT STEPS.

     Cost
     Formulary coverage
     Peace of mind
     Creditable coverage
     What happens if you move during the year to another state?
     What if I am not happy with my plan?
     State resources that can help you.
     Types of problems that have occurred.
     Incorrect premium deduction
     Overcharging at the pharmacy.
     Prior authorization hassles.
     Doctors not being willing to fill out the prior authorization paperwork.
     Medicare Advantage plans.
     Deceitful marketing practices.
     Spouses of individuals in nursing homes.
     Nursing home residents.

• From the June issue of Consumer Connection:

   "This book ... would be a great addition to your book shelf or to the consumer health shelf at the public library. Jack Fincham shows his care and concern for patients and this is evident through his book."
  
  ~ Julie Johansen, Medtronic, Inc. Minneapolis, Minnesota

  More praise for The Medicare Part D Drug Program: Making the Most of the Benefit:

  “Dr. Fincham has done a superb job of making a complex topic easier to comprehend, digest and take appropriate action to get the best possible prescription drug coverage and medication management services under the new part D Medicare plan … This exemplary book represents the most rational and thorough approach to this topic with diagrams, details, reference sources and questions and answers that this senior care researcher and consultant pharmacist has seen in print to date.” 
  
  ~ James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP                                        
  Emeritus Professor of Pharmacy and Consultant Pharmacist,                                           
  College of Pharmacy, The University of Georgia

  “Last year colleagues and friends asked me to assist them with enrolling parents and I had great difficulty doing so, even though I have taught and conducted research in this area for over 25 years. Today, that dilemma has been eliminated with the arrival of this publication. Every social worker, advisors for senior citizens, H.R. department personnel, and even some seniors themselves should have access to this valuable resource.”                                 

  ~Professor Albert I. Wertheimer, Ph.D., M.B.A.    
  Temple University School of Pharmacy
  Center for Pharmaceutical Health Services Research

  “The Medicare Part D Program: Making the Most of the Benefit is a must-read for seniors who are trying to navigate the confusing waters of Medicare’s new prescription drug coverage.   This is an easy to read guidebook for determining eligibility, enrolling, choosing between plans, and managing one’s personal health through intelligent and effective use of medications.  Seniors, their caregivers, and students of health policy will find this text a valuable tool for understanding the complexity of this new government health benefit.”

  ~Phaedra S. Corso, PhD, MPA
  Associate professor of Health Policy
  Department of Health Administration, Biostatistics, and Epidemiology
  College  of Public Health  
  University  of Georgia  
  
  "The book contains a detailed and comprehensive explanation of all relevant aspects of the complex topic of the Medicare Part D Drug Benefit Program. The author clearly addresses not only the specifics of the Part D Program, but also offers many ideas for the reader who is trying to wade through the complexity of Medicare in order to obtain and make correct use of medications. The author strikes an excellent balance between providing complex information and offering simple ‘how to’ advice about the topic. The Medicare Part D Drug Program: Making the Most of the Benefit is a timely and useful text intended for the lay audience, but useful for health care professionals who want to understand the benefit and guide their patients toward enhanced medication management."
  
  ~ Sharon W. Utz, PhD, RN
  Associate Professor
  University of Virginia