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How it may affect the care and treatment of mental health patients
By Joseph Ferguson, Pharmacist
Beginning January 1, 2006 individuals that are currently covered under Medicare will be able to obtain help in covering their prescription medication. This coverage will be provided under a new Medicare program call Medicare Part D. Under this new program enrolled individuals will obtain financial help in paying for selective prescription medications.
To better understand how Medicare Part D works a brief review of Medicare in general is needed. The inception of Medicare occurred in 1965. On December 8, 2003, Congress updated this act by passing the Medicare Modernization Act under which the coverage of outpatient prescription medication was added.
Medicare was conceived as a health insurance plan for all Americans age 65 or older or adults who have a permanent disability.
To be eligible to receive Medicare an individual must be a U.S. citizen or a permanent legal resident for 5 continuous years. In addition the individual must meet at least one of the following four criteria. The person must be 65 years or older and eligible to receive Social Security. For individuals under 65, they must be permanently disabled and be receiving Social Security disability insurance payments for at least 2 years. A person must be receiving continued dialysis for a permanent kidney failure or be in need of a kidney transplant. Lastly, the individual must have amyotrophic lateral sclerosis (ALS- Lou Gehrig' disease).
Currently the Medicare benefits are broken out into three categories or parts. They are called Part A, Part B, and Part C. The newest component, Part D goes into effect January 1, 2006.
Medicare Part A is a hospitalization insurance which covers inpatient stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B is a supplemental insurance. This component assists in covering physician's services, out patient hospital treatment, medical supplies and equipment, and some services not covered under Part A.
Medicare Part C offers more choice for individuals regarding their health plan. Medicare beneficiaries who have Part A and Part B are eligible, with some certain exceptions. The Part C component is a single managed care plan which incorporates elements of both Part A and Part B.
Medicare Part D is the newest component to the Medicare program and covers outpatient prescription medications. In Ohio, this program affects 1,794,000 beneficiaries. Any individual who is eligible for Medicare Part A will be offered this prescription medication component. There is a monthly premium for Part D. The premium will vary as to the provider's plan selected to provide the prescription drug benefit. One type of plan that can be selected is called a "stand alone" drug program. A stand alone drug plan covers only prescription medications. In Ohio there are 3 stand alone prescription drug plans that will have monthly premiums under $20, 5 plans will have premiums between $20 and $25, 6 plans will have premiums between $25 and $30, and there are 14 plans with monthly premiums between $30 and $35.
Among those eligible for Medicare is a group of who are described as dual eligible beneficiaries. These are individuals who are currently obtaining prescription medication coverage through other sources such as State funded programs, Medicaid, and employer sponsored retiree health plans. In Ohio the Medicaid program will automatically enroll all dual eligible individuals into Medicare Part D. Medicaid dual eligible patients will be enrolled in a program by November 1, 2005. They will have an opportunity to switch programs before the January 1, 2006 start.
For the general Medicare population enrollment in Medicare Part D starts November 15, 2005 and continues until May 15, 2006. The regular annual enrollment period will be form November 15 through December 31 of each year. At that time an individual may choose to select a different provider for their prescription drug coverage. Ohio Medicaid clients are allowed to change monthly and will be responsible for any additional cost in monthly premiums incurred because of a change. It is also important to note that for all prescriptions drug plans offered under Medicare Part D, the premium may increase annually.
After the initial enrollment period has passed, an individual who becomes eligible outside the open enrollment period has seven months to enroll into Medicare Part D without facing any penalties. This includes three months prior to eligibility, the month of eligibility, and three months after eligibility. Failure to enroll in a Medicare Part D program during their initial eligibility period will result in a one percent increase in premium payment for each month that they wait to enroll.
The prescription drug plan offered under Medicare part D will cover a variety of prescription medications. Each plan may utilize a drug formulary as long as it follows the guideline established by the Center for Medicare and Medicaid Services (CMS). CMS requires that the drug formularies provide a choice of medications within each category and class. The choice of medications to be included in the formularies must appropriately reflect current medical practice.
Each drug plan must cover the following:
As with any prescription drug program there are exclusions. Groups or classes of medications that can be excluded are non-prescription medications, benzodiazepines, barbiturates, weight loss and weight gain products, fertility medications, prescription vitamins and minerals. For those individuals who were previously obtaining medications under the Medicaid prescription program will find that some of their medications may not be covered by Medicare Part D.
So how does Medicare Part D work? The Part D prescription drug plan is broken down into 4 stages. In the first stage the beneficiaries are responsible for the annual $250 deductible. It is important to note that any medications that are excluded by the program may not be applied toward the beneficiary's deductible or toward the total out of pocket expenditures.
In the second stage, after the $250 deductible has been met, there is a copay of 25% for the next $2,000 dollars in prescription drug expenses. This will bring the total out of pocket expense for covered medications to $500.
In the third stage a coverage gap exists. This gap is referred to as the "doughnut hole". At his stage the beneficiary is responsible for the next $2,850 in expenses. This is 100% out of pocket. Exclude medications that are purchased may not be applied toward this gap coverage.
In the fourth and final stage the catastrophic coverage begins. Once this level is hit, the beneficiary will have copays that will vary and be based on the individual's income and asset level. The co-pays will vary from no co-pay, $2 for generic and $5 for brand medication, up to and including 5% of the cost of the prescription medications.
It should be noted that while these are the guidelines for the prescription drug plans, in Ohio, there are plans that have zero deductibles or deductibles that are lower than the standard $250 Medicare benefit. All the prescription drug plans in Ohio must provide access to pharmacies. This includes convenient neighborhood pharmacies, pharmacies serving long-term care facilities, and pharmacies providing home infusion treatments. There is also an option for using mail-order prescription services. It is important that a mental health agency and providers check with their local pharmacies to verify which plans they will accept.
Besides the standard "stand alone" prescription drug plan there is also an advantage prescription drug plan being offer in Ohio under Medicare Part D. Most of these programs will offer additional coverage beyond the standard Medicare benefit. This includes low, or no deductibles and additional coverage. These managed care plans provide both health care and prescription drug coverage.
So just how will this program affect the treatment of mental health patients? In southwest Ohio one large mental health agency caring for over three thousand patients has found that 40% of their clients will be affected by this program. Another smaller agency the number of patients affected was around 25%. As you can see, there are a significant number of mental health patients that will be impacted by this program.
For those agencies which treat mental health patients, they will need to evaluate their client list. Identification of those individuals who will now be covered under Medicare Part D is very important. They will need to know and understand the programs that their clients have been enrolled. It will be vital that they learn all that they can concerning the Medicare Part D providers.
There is some "Extra Help" available that will help some individuals reduce or eliminate their out of pocket deductibles, co-pays, and expenses associated with the "doughnut hole" coverage gap. To qualify for this help, the income must be $14,355 or less with no more than $10,000 in total assets for a single person. For a couple, the income must be $19,245 or less with total assets of no more than $20,000. Personal assets in this case do not include a home or car. To find out if an individual qualifies for extra help, they must obtain an application from the Social Security Administration (SSA) by calling (800) 771-1213, or visit the local SSA office or apply on line at www.socialsecurity.gov. Each mental health care provider and agency should make sure that all their clients apply for "Extra Help".
For individuals currently covered by Ohio Medicaid and have met their monthly Medicaid spend down at least once between August 2005 and November 2005 will automatically be enrolled in a Medicare Part D program and will obtain "Extra Help". After January 1, 2006 those Medicare beneficiaries who have dual eligibility and meet their Medicaid spend down will be automatically enrolled and will obtain "Extra Help" within two months of meeting their spend down. They will receive the "Extra Help" for the rest of the calendar year. To qualify for other Medicaid benefits, such as durable medical equipment, they will still be required to meet their spend down obligation each month. Their prescription co-pays and deductibles can be used toward meeting their monthly obligation. These co-pays must be paid by the client/patient and cannot be waived by a pharmacy.
In some case, it may be necessary for mental health agencies to enroll with those providers that are listed as a Medicare advantage prescription drug plan. Medicare advantage programs are insurance programs that have a managed care component attached to the prescription drug program. This would allow the agencies to continue to provide uninterrupted care. Medicare advantage programs are insurance programs that have a managed care component attached to the prescription drug program.
Providers of Medicare advantage prescription drug plans in Ohio are as follows: Aetna, Anthem, Coventry/First Health Life & Health Insurance, Humana, Health Plan of Upper Ohio, Hometown Health Plan, McKinley Life Insurance Company,
Mt. Carmel Health Plan, Paramount Care Inc. (Promedica), Qualchoice Health Plan, Summacare Inc., and United Healthcare.
Providers for the Medicare prescription drug plan, which are stand alone drug plans, are as follows: Aetna, Anthem, Connecticut General Life Insurance, Coventry/First Health Life & Health Insurance, Humana, Marquette National Life insurance Co., Medco Containment Life Insurance, Memberhealth Inc. (Community Care Rx), Pacificare Life & Health Insurance Company, QCC Insurance (Amerihealth), Silverscript Insurance (Caremark), Sterling Life Insurance Co., Unicare, United American Insurance Comp. (Medco), United Healthcare, and Wellcare Health Plans.
It is important that each agency and provider contact these insurance companies and obtain a copy of their prescription drug formularies. At the time this article was written only two formularies were available for review. One is Silvercript Insurance and the other is United Healthcare.
Here are some examples of co-pays and general drug coverage for a few select plans that are providing Medicare Part D. They are broken out into three types of formularies: a tiered drug formulary, an open drug formulary, and a standard drug formulary. A tiered drug formulary will cover a basic list of drugs and provide for all additional drugs at a higher price. This does not include medications excluded by Medicare. An open formulary covers a large list of prescription medications and will allow the purchase of non-preferred drugs by paying a higher co-pay. A standard formulary will cover only a basic list of prescription drug products. Here is an example of each of the three types of formularies and their respective co-pays.
Central Nervous system agents
Amphetamines
Drug Name • Drug Tier • Requirements
As you can see, the choice of which plan an individual decides to enroll will determine their medication expenses. The cost of medication often determines whether an individual will purchase and use prescribed medication. More than once in a community pharmacy setting, patients have refused medications because of their cost. Copies of drug formularies and consideration of mental health practitioner's prescribing habits will help mental health agencies and patient advocates determine the proper Medicare Plan D program to enroll their clients. You will wish to select a program that provides the lowest out of pocket cost to the patient for the medications that are prescribed.
In order to understand more fully the tier co-pay, it is necessary to understand the tier co-pay concept. Tier 1 covers mostly generic medication. Generic drugs usually have a lower cost than brand name medication. Tier 2 covers brand name (single source) medication. The drugs offered in this tier usually offer a clinical advantage and/or a lower price then medications that are covered at Tier 3. Tier 3 medications have a higher co-pay and cost associated with the product. If a tier 3 product is selected, very often a Tier 1 or Tier 2 product could be chosen as therapeutic substitute. Specialty Tier contains very unique and costly medication. This level of medication requires a level of cost sharing between the beneficiary and the plan. This is referred to as percentage co-pay.
Here are some examples of a Medicare Part D formulary dealing with medication used by mental health agencies. This is only a small portion of the original list Please note the tier level of the medications and any special requirements. PA stands for prior authorization required before dispensing. QL stands for quantity limits to the amount of medication that can be dispensed in a 30 to 90 day period. ST stands for step therapy. These medications can not be selected unless at least 2 other products have been tried on the patient first and with no success.
As you can see from this brief and partial list of covered medications, the amphetamine products require that a prior authorization be obtained by the physician or practioner before the medication can be dispensed at the pharmacy. This will require a commitment of extra time by the physician or practioner to call the plan an obtain approval for these medications before the patient/client leaves the agency or office.
With regards to the antidepressants, most generic products are covered. Popular brand products such as Lexapro, Paxil CR, and Zoloft have quantity limitation. Paxil CR is tier 3 and has a high co-pay associated with its dispensing. The formulary is designed to encourage the use of the tier 1 generic products. For Lexapro and Zoloft this would mean the possible selection of Fluoxetine or Paroxetine or one of the other tier 1 antidepressants as a replacement. Of course, Paxil Cr should be replaced by Paroxetine. These switches or changes need to be made at the discretion of the physician or practioner. It is important to get the physician or practioner actively involved in reviewing these formularies.
The implementation of quantity limits can make product selection and treatment difficult. An example of quantity limits that have come into play in the past concerns the sleep product Ambien. One insurance plan limits the dispensing of Ambien to 14 tablets every 30 days. Another plan only allowed a total of 30 Ambien tablets to be dispensed in a 30 day period, regardless of the strength. These types of limitations can make it difficult to use these products when a therapeutic doses exceeds the maximum allowable doses to be dispensed.
Another example concerns the product Zoloft. Many plans are eliminating the coverage of the Zoloft 50mg tablet in favor of dispensing Zoloft 100mg tablets and breaking them in half. When a patient requires Zoloft 75mg, the physician or practioner will be required to write for 2 products, Zoloft 100mg and Zoloft 25mg tablets in order to obtain the dosage that they desire.
Having reviewed the concept of the formularies and the effects the product selections have on co-pays, it is important to discuss the issue of co-pays. Medicare Part D does have co-pays. These are charges that must be paid by the patient or client to obtain their medications from a pharmacy. It is important that the mental health agency take time to discuss how these co-pays are going to be collected. A number of the patients/clients are probably covered by the state Medicaid program and under this program they are paying nothing out of pocket. For the few products that do require a prior authorization and have a $3 co-pay, this fee could be waived. The waiving of the co-pay fee is no longer able to occur under Medicare Part D.
Where patient compliance to medicine is a concern, the co-pay fee may create a new challenge. It is difficult enough to have patient medication compliance when the medications are free and the client does not want to take them. Not setting up some program to insure that the patient or client does purchase their medications could led to even more non-compliant patients. It is important that each agency takes this matter into strong consideration.
So what, out of all of this, is important to know for mental health agencies? The first thing is to learn about all the individual Medicare Part D plans. Find out their formularies and what medications are being covered by each drug plan. Talk with your local pharmacist and pharmacies and find out which plans that they will be participating. After gathering this information, find out which plans are best suited for your patients and clients and help them enroll in the most appropriate program.
In addition, develop a plan for dealing with the co-pays. Help your clients understand the co-pays. Getting an understanding of the co-pay and how the client will met this obligation will help insure that the medications will be obtained. Getting the medications into the hands of the patient is the first step in drug therapy compliance. Remember many of your clients probably have not had to pay for prescription medication. For those that are eligible, help them apply and get the "Extra Help", even if they are already participating in a Medicaid program. Helping your clients with this process lower their out of pocket expenses. To help ensure medication compliance this issue should be addressed.
Get the physicians and practioners involved in knowing and reviewing the drug formularies for the Medicare Part D plans. Their knowledge of the treatment choices before they perform an evaluation will reduce the need to make drug treatment changes later. The more they know the formularies and the drug product choices, the easier it will be for them when it comes time to prescribe medication.
January 1, 2006 is a new year. It is also a new for many Americans who did not have prescription drug coverage. For others, their medication coverage will change. Do not wait. Start preparing now.