A Clinician’s Q & A on the Medicare Drug Cards

Q: Who is eligible for the new Medicare discount drug cards?

A: “Eligible beneficiaries” include all individuals enrolled under Medicare Part A or B, as long as they are not receiving outpatient drug benefits through Medicaid, including 1115 waivers.

Q: When can a beneficiary enroll in the plan? When do the drug cards take effect?

A: All “eligible beneficiaries” may enroll in one drug card plan beginning May 3, 2006. The new drug cards take effect on June 1, 2004 and will remain in effect until December 31, 2005. Medicare’s more extensive prescription drug coverage benefit will begin on January 1, 2006.

A beneficiary may change cards during a “special election period” under certain circumstances, such as if they change their residential status to or from a long-term care facility, move outside the area served by their current discount drug card, or decide to enroll in or un-enroll from a Medicare managed care plan.

Q: Who are the drug card sponsors? How many Medicare-approved discount drug plans can a beneficiary enroll in?

A: There are 71 Medicare-approved discount drug cards, including 28 national cards. Please click here for a complete list of drug card sponsors (Drug Card Sponsors).

Medicare beneficiaries can only be enrolled in one approved card at a time. However, beneficiaries will have an opportunity to enroll in a different card for 2005. The enrollment period to switch to a different card will be November 15 - December 31, 2004. Medicare will ensure that at least two choices of discount drug cards are available in the 50 states and the District of Columbia.

Drug cards differ in which drugs they discount, how much the discount is, the enrollment cost, and the pharmacies where the card can be used.

Drug card sponsors may offer mail order options, but they are prohibited from offering only a mail-order program, and may not require enrollees to use mail-order pharmacies.

Q: What if my patient already has a non-Medicare drug discount card, private drug insurance coverage, or Medicaid?

A: Medicare will provide a $600 credit for the purchase of prescription drugs in 2004 and up to an additional $600 credit in 2005 to people with incomes that are not more than 135% of the federal poverty level ($12,569 for single individuals or $16,862 for married individuals) if they do NOT receive outpatient drug coverage from other sources, including Medicaid, TRICARE, group health insurance, or Federal Employee Health Benefit Plans (FEHBP) - except if the drug coverage is through a Part C Medicare Advantage (formerly Medicare+Choice) plan or a Medigap plan.

Anyone who qualifies for the $600 subsidy will have his/her drug card enrollment fee ($30 for most cards) waived.

Beneficiaries who have incomes at or below 100% of poverty ($9,310 for individuals or $12,490 for couples) will pay 5% coinsurance for each prescription and those with incomes between 101% and 135% of the federal poverty level will pay 10% coinsurance for each prescription. The $600 subsidy can be used to pay for the coinsurances.

Please click here ($600 Subsidy) to find out more.

Q: Will beneficiaries who are currently enrolled in a Medicare managed care plan (Medicare Advantage) be permitted to choose any Medicare-approved drug card?

A: If a Medicare Advantage plan offers an “exclusive drug card program” (limited only to the plans’ enrollees), beneficiaries in that plan must use that plan’s drug card. Please click here (Drug Card Sponsors) for the list of the 43 exclusive drug card programs. Beneficiaries who are eligible for the $600 subsidy may use the subsidy to pay for co-payments and deductibles under the plan. They can also apply the subsidy to drugs covered under the card that are not under the plan’s benefit or beyond the plan’s benefit cap.

If a Medicare Advantage plan does not over an exclusive drug card program, plan enrollees may enroll in any Medicare-approved drug card plan.

Q: Are syringes and medical supplies for insulin self-injections (needles, alcohol, and gauze ) eligible for discounts and can low-income beneficiaries apply their $600 subsidies to purchase them?

A: Yes and Yes.

Q: Are over-the-counter (OTC) drugs eligible for discounts and can low-income beneficiaries apply their $600 subsidies to purchase OTC drugs?

A: Discount drug cards may offer discounts on OTC drugs. However, the $600 subsidy cannot be used to purchase these drugs.

Q: If a beneficiary does not use the full $600 subsidy in 2004, can the remainder of the subsidy be rolled-over to 2005?

A: Yes. The unused portion of the $600 subsidy will rollover to 2005, and eligible beneficiaries will get another $600 subsidy in 2005.

For the beneficiaries enrolling for the first time in 2005, the $600 subsidy will be prorated depending on when the beneficiary first applied for the funds. In most cases, any remaining credit not spent in one calendar year may carry over into the following year and will remain available through early 2006.

Q: How can VNA clinicians help their patients enroll in a Medicare drug card plan?

A: Instruct your patient that they need to do two things: first, select a card that is best for them, and next, fill out a standard CMS Enrollment Form (see link below).

Below you will also find links for “Medicare-Approved Drug Discount Card Tip Sheet” which provides 5 steps for helping clinicians and caregivers enroll a beneficiary in a plan. It also provides a “Personal Information Sheet” that clinicians can fill out for the beneficiary to help the beneficiary decide what discount drug card is best for him or her (from both financial and clinical perspectives).

Other CMS brochures, such as “Getting Started” help sheet and “Enrollment Tip Sheet” are listed below.

The following link will notify you if the patient qualifies for any assistance programs: (Assistance Programs)

Q: How will beneficiaries know which Medicare drug cards are most affordable based on their clinical needs and financial information?

A: Medicare’s web site now has an easy-to-use computerized price comparison tool that enables individuals to enter their zip codes and the medications they take (Quick Search) in order to compare drug cards and their prices for drugs. They will then be given information on which drug cards in their region offer the best prices for their medications and how far they would have to travel to obtain those medications.

Q: Do most drug card sponsors use formularies (i.e. specific list of discounted drugs)?

A: 1.Yes. However, Medicare-approved drug card sponsors must provide discounts on one drug in at least 209 different therapeutic classes.

2. If a drug is not on a beneficiary’s formulary, the $600 subsidy provided to certain low-income beneficiaries can still be used to purchase this prescription.

Q: How are states’ pharmacy assistance programs (SPAPs) affected by the Medicare drug card program?

A: States with SPAPs can coordinate with a drug card sponsor, or encourage their own privately run program to apply for the Medicare endorsement. Additionally, states may choose to pay the enrollment fees for non-low income beneficiaries and coinsurance for low-income beneficiaries receiving the $600 subsidy. However, no federal matching payments are available for these state expenditures.

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