The Med Diva

An insider's guide to Medicare Part D and more

Archive for the category “Medicare Part D”

Don’t toss my work in the trash: Give your Part D mail-order pharmacy a try!

Part D Mail-Order Pharmacy

The other night at our holiday party, the VP of my department asked me if I was still writing my Medicare blog. I told him I had taken a hiatus because I was simply “swamped” at work with a major campaign to entice Medicare beneficiaries to use their plan’s mail-order pharmacy (we call it home delivery pharmacy service).

For the past few weeks, I have been writing several letters that tout the benefits of home delivery in order to convince people who take drugs on a regular basis to switch from their retail pharmacy to mail order. I know for a fact that my company’s Medicare Part D plan bombards our Medicare members with such letters every year. I apologize—it’s not my fault, I swear! I also know that many people are reluctant to switch to mail order—or absolutely refuse to try it—and toss all my hard work in the garbage.

I have to admit I put off using my plan’s mail-order pharmacy at first, simply because I didn’t want to deal with the paperwork involved. I thought it would be a hassle to switch my one prescription from my favorite retail pharmacy. But when I used my plan’s price comparison tool and discovered I would pay about $100 less every 90 days with mail, I immediately made the switch. 

Guess what? It wasn’t a hassle at all! The customer service rep did all the work for me–she even called the doctor to get my prescription–and in a few days my medication arrived in a secure package in my mailbox.

I can’t say anything bad about home delivery. I can order up to a 3-month supply of my medication for a lot less money than a 30-day supply at my pharmacy. My drugs arrive in my mailbox, so I don’t have to drive to the pharmacy when I don’t feel well or the weather is bad. And I never have to wait in line to pay because there’s never a line at my mailbox!

If I have to work late, I don’t have to worry about the pharmacy closing before I get home — after all, my mailbox never closes!  Best of all, my mail-order pharmacy sends me automatic refill reminders by e-mail, so I never forget when it’s time to refill. I can order refills online, which takes about 2 minutes.

If the above sounds like a pitch, you’re right. But I really believe in it, and know it could save you time and money.

I like to tell my friends and family that using mail order for our drugs is no different from using mail order for buying books (Amazon), DVDs (Netflix), or any other product we buy online. So please don’t throw my letter in the trash – give mail order a try. If you really don’t like it, you can always switch back.


Medicare Part D premiums not expected to rise in 2013

Today the Obama administration announced that the average premium for basic Medicare Part D drug coverage will stay the same next year, at around $30 a month. This makes three years in a row that the monthly Part D premium has stayed in the $30 range for Medicare beneficiaries.

Because we’re dealing with Medicare, there is, of course, a caveat. The $30 amount is just an average, so some beneficiaries may pay a higher premium amount in 2013, while others may pay less. That’s why it’s so crucial to check your plan during open enrollment season this fall (October 15 to December 7) and shop around if your costs go up too much or you’re just not satisfied with your plan.

Why it’s important to choose a plan with the lowest total cost

Although premiums are important, if you’re shopping around for a new Medicare Part D plan, you should look for a plan that offers the lowest total cost based on the medications you take. I really can’t stress this point enough.

All too often, Medicare beneficiaries will choose a plan with the lowest monthly premium, only to find out weeks or months later that they’re going pay more in the long run. It may be that the co-payments for their medications are higher in this “low-cost” plan, or they have a higher annual deductible. As I have mentioned before, remember to consider the monthly premium plus the annual costs for all your medications when making your decision.


A question for Medicare: Why must a major Part D program depend on little ol’ me to save it from termination?

Medicare Part D worldIn my last two posts, I talked about how difficult it can be to convince Medicare beneficiaries to take advantage of the Medicare Medication Therapy Management program. One of the problems is that the Centers for Medicare & Medicaid Services (CMS) puts the responsibility on Part D sponsors to get members to opt into the free program. That means prescription drug plan employee peons like me have to write letters or make phone calls to persuade (in other words, beg) eligible plan members to participate in the program.

This week I am faced with a similar situation that involves convincing people to follow their doctors’ orders.  I must write a compelling letter to entice members who are not taking their medications properly to speak with a pharmacist. These members may be skipping pills, forgetting to take their medication, delaying their refills, or doing something else that is causing a gap in therapy (also called nonadherence). If members ignore this letter and don’t take their medication as directed, their Part D plan could be terminated.

Honestly, it sort of feels like the world is on my shoulders.

It’s all in the Medicare stars

To make a long story short, it all has to do with the Medicare star ratings.

CMS uses a star rating system as a guide to help beneficiaries compare the quality of private health plans in the Medicare Part D and Medicare Advantage (Part C) programs. These ratings measure everything from customer service issues such as call wait times to clinical issues such as adherence rates for members taking diabetes and hypertension medications. Based on these measurements, a plan’s overall star rating can range from 1 (poor) to 5 (excellent) stars.

Starting in 2015, CMS can cancel the contracts of Part D and Part C sponsors that fail to receive at least a 3-star (average) rating for 3 years in a row. Potential termination is a great “incentive” for Part C and Part D plans to deliver better care and value. The problem is that not all ratings are created equal: In 2012, clinical measures, such as adherence rates, were weighted three times heavier than other measures.

Many Part D plans received low star ratings in 2012 – even the plan I work for, which got a 5-star rating in 2011, dropped to 4 stars in 2012.  Many of the lower ratings were not due to poor customer service or low member satisfaction, but due to poor medication adherence rates. In other words, because many people are not following doctors’ orders and taking their medication the right way, Part D plans are getting lower star ratings. If these low medication adherence rates do not improve over the next two years, these Part D plans could be shut down by CMS.

CMS: Why is the burden on Part D plan sponsors?

Once again, I ask CMS why all the responsibility is placed on the shoulders of the Part D plan.

Although some plans do have very effective medication management tools in place—such as pharmacist outreach calls—it can be difficult and expensive for plans to ensure their members are following doctor’s orders and taking their drugs as prescribed. Plus, how do strangers at a Part D plan convince people who are not following their doctors’ orders to listen to them? If a doctor can’t make their patients take their medications as prescribed, what chance do I have?

CMS, I really hope you can give me an answer. Because right now, if I can’t convince a few thousand people to get back on track with their medications within the next few months, a large Part D program with a major health plan may soon be getting the boot from you. How wrong is that?

The Medicare MTM Program —Part I: Providers Say Yes, but Seniors Say No Thanks

Seniors say no to Medicare medication therapy managment

Most Medicare beneficiaries reject the free services provided by MTM programs.

Like all Medicare prescription drug plans, the Part D plan that I write for offers a special health benefit called a Medication Therapy Management (MTM) program. MTM programs are designed to help Medicare beneficiaries ensure their medications are working safely and effectively for the best possible clinical outcomes.

My assignment this week was to write a letter to all our plan members who are eligible for MTM this year. Not just any letter, but a compelling letter that encourages seniors to say “yes” to a free service that even many doctors recommend for patients who are taking multiple medications.

Easier said than done.

The MTM comprehensive medication review

The standard Medicare MTM program includes an annual comprehensive medication review for the beneficiary, which includes a review of all medications, vitamins, and supplements with a pharmacist; a written summary of the consultation and medication action plan to share with doctors; and a personal medication list.  All Medicare Part D sponsors are required to provide this service at no extra charge for members meeting the following MTM eligibility criteria:
• Have multiple chronic diseases
• Are taking multiple Part D covered drugs
• Are likely to spend more than a specific amount on Part D drugs during the year ($3,100 in 2012)

Although the people who concocted the Medicare Modernization Act of 2003 probably had good intentions when they set the guidelines for the MTM program, it appears that few seniors are actually taking advantage of the services the program provides.

Part of the reason why MTM participation is low is because the Centers for Medicare & Medicaid Services (CMS) places all the burden on the Part D sponsor: Plans must offer MTM services to all eligible beneficiaries each year, but participation is optional and must be sought out through letters or phone calls. Hence, my assignment to write a letter that makes members want to accept the free offer.

Low participation could also be due to neutral or even negative perceptions of the MTM program, and in particular, of comprehensive medication reviews (CMRs).  In a 2011 focus group study conducted by the University of Iowa College of Pharmacy, the majority of participants said they were not interested in the CMR, even though they are taking multiple medications and have a high medication risk rating.

Here are some responses they gave when asked why they did not want a CMR:
• Although I have multiple doctors and multiple medications, I consider myself at a low risk for a medication-related problem.
• The counseling I receive from my pharmacist is adequate so I don’t need a comprehensive review.
• This would be a waste of time for me because my pharmacist already talks to me whenever I have a new medication.
• My doctor should do this; not my pharmacist.
• I wasn’t aware that my Part D program offered this.

My recommendation to CMS: If you really want to help Medicare beneficiaries ensure all their medications are working together safely and effectively, don’t put the onus on Part D sponsors. Make the MTM program truly mandatory: Everyone who is eligible for the program must show proof of active participation in order to receive the prescription drug benefit. If that’s not possible — and it probably is not — than at least help sponsors out with outreach on your own CMS letterhead. Maybe a letter or phone call from CMS will work better — it’s worth a try.

Then maybe I won’t have to write a compelling letter that gets, at best, 5% of our eligible members to participate in MTM.

In Part II next week, I’ll talk about why CMRs are just what the doctor ordered.

Eliminating nonadherence to medications could help solve the Medicare insolvency crisis

Medication nonadherence costs US healthcare system over $317 billion

In 2001, medication nonadherence cost America more than $317 billion.

“Curing nonadherence could pay for the health care of 44.8 million Americans.” Express Scripts 2011 Drug Trend Report

According to the Express Scripts 2011 Drug Trend Report, 30 percent of adults with high cholesterol do not take their medications as prescribed. For those with high blood pressure or heart disease, 31 percent do not adhere to their therapy. An even greater number of patients with diabetes—43 percent–are nonadherent.

These are very disturbing numbers, especially when Medicare is allegedly on the verge of bankruptcy.

Nonadherence—not taking drugs as prescribed by the doctor—is our nation’s most costly health condition. According to Express Scripts, in 2011, medication nonadherence cost the U.S. health care system over $317 billion in treating medical complications that could have been avoided if patients had taken their medication. This amount is actually higher than the total cost of treating diabetes, congestive heart failure, and cancer combined.

Patients who are nonadherent and do not take their medications the right way are more likely to experience:
• Long-term complications
• More emergency room visits
• Unnecessary hospital admissions
• Additional physician visits and lab tests, and
• Other related medical expenses

What you can do if you are not taking your drugs correctly

Most people are nonadherent because of behavioral factors, such as forgetfulness, inattentiveness, or procrastination. For example, based on findings in the 2011 Drug Trend Report, 39 percent of nonadherent patients said they just forgot to take their medication while 30 percent said they didn’t renew or refill their prescription.

If you find yourself in one of the categories above, you may want to consider asking your Medicare prescription drug plan if it offers refill reminder alerts (by cell phone or email) or automatic prescription renewal programs with mail order.  If you have cut back or stopped taking certain medications because of high costs, ask your Part D plan about lower-cost medication alternatives or lower-cost pharmacy services such as home delivery. If you are eligible, you should also take advantage of your plan’s Medication Therapy Management (MTM) program, which I’ll talk more about next time.

Do Medicare cover Viagra for erectile dysfunction? No it do not. (But sometimes it get screwed anyway.)

Medicare Part D gets screwedOne of the ways I stay on the top of the Medicare industry is by using Google Alerts to monitor the Internet for information about Medicare benefits and regulations. Each day I receive about three or four email updates from Google Alerts, which include links to news articles, blog posts, and miscellaneous Web content.

Although the news articles and blogs are always legitimate, the links under the miscellaneous Web category are almost always spam, with such gramatically-incorrect headlines as “Do medicare cover viagra?” or “Get you cialis with Medicare.” Inevitably, the links take me to some article or advertisement that has nothing to do with either erectile dysfunction (ED) or Medicare.

Just in case anyone is still falling for this spam, Medicare does not cover ED drugs – for the most part.

According to P.L. No. 109-91, section 103, amended section 1860D-2(e)(2)(A) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Medicare Part D program does not cover ED drugs “when used for the treatment of sexual or erectile dysfunction.”  But here’s the catch (of course there’s a catch; we’re talking about Medicare): ED drugs such as Cialis®, Viagra®, and Levitra® are covered by Part D when prescribed for medically accepted indications other than sexual or erectile dysfunction (such as pulmonary hypertension).

Medicare has been screwed to the tune of $3 million

According to a March 2011 report from the Department of Health and Human Services Office of Inspector General (OIG), of approximately $133 billion in gross drug costs for the years 2007 and 2008, Medicare covered more than $3 million in drug costs for ED drugs approved for the treatment of sexual or erectile dysfunction. Part D should not have covered these drugs.

Based on the findings of the study, titled “Review of Erectile Dysfunction Drugs in the Medicare Part D Program,” the OIG recommended the Centers for Medicare & Medicaid Services (CMS) maintain a comprehensive list of ED drugs that have been approved by the FDA for the treatment of sexual or erectile dysfunction. The OIG also recommended CMS distribute this list to all Medicare Part D plan sponsors.

Although this news is two years old, so far I have yet to see this comprehensive list of ED drugs. I also haven’t seen any more reports of Medicare mistakenly covering these drugs. Hopefully this means that CMS has its act together despite the lack of a list. But then again, maybe these spammers who keep cropping up on my Google Alerts know something we don’t know.

Oops: Medicare Plan Mistakes Happen — More Often Than You’d Like to Think

Medicare errors happen

Medicare plans do make mistakes from time to time.

Last week I received a Google Alert about CVS Caremark Corp. and the Tufts Health Plan Medicare Preferred Plan. It seems that CVS mistakenly sent letters with information about the medical conditions of people in the Tufts Medicare plan to about 3,500 people enrolled in another plan. The letters also included information about some of the medications the Tufts Medicare members were taking.

According to The Boston Globe, CVS Caremark said a “programming error” was the cause of this information breach. The company said the information went to the wrong addresses in January and February, and included another member’s name, the name of a prescribed medication, and what the medication is used for. Fortunately, the letters did not include financial account numbers. CVS Caremark also said it doesn’t believe the information was used improperly.

“We are writing today to apologize for a system error”

For the past six years or so, I have been writing apology letters to members of Medco Medicare Prescription Plan for all kinds of system errors. Although I can only recall one time when the company sent information to the wrong addresses, I have written apology letters for many other kinds of mistakes. For example, we’ve had to apologize for inadvertently:

  • Failing to send a communication required by Medicare on time
  • Overcharging for  medications
  • Rejecting drug claims
  • Sending members the wrong plan materials

Medicare is a moving target

Thanks to the constant guideline changes and the enormous number of complex rules and regulations in the Medicare program, every Medicare plan is like a moving target; a constant work in progress. And now with all the changes under healthcare reform—such as the Coverage Gap Discount Program—that target is moving at the speed of light.

I can’t even tell you how many employees we have who are responsible for constantly updating our computers and databases to accommodate these changes—not because I literally can’t tell you, but because I simply don’t know. If I had to guess, I’d say a few hundred or more.

Medicare plan employees are sincerely sorry for these errors

So yes, system errors happen quite often, simply because it’s impossible for humans to keep up with all the changes coming at us from the Affordable Care Act and the Centers for Medicare & Medicaid Services. We try our hardest to prevent these mistakes from occurring, but sometimes a piece of computer code falls through the cracks. When that happens, we send every affected member an apology letter right away. It may not seem like much, but I want to ensure you that our apologies are sincere.

More drugs on OTC status would mean more costs for Medicare beneficiaries

The FDA is considering making more medications available over the counter.

Imagine being able to get your high blood pressure pills, diabetes medications, or asthma inhalers over the counter without a prescription from your doctor. All you would need to do, at most, is have a brief discussion with the pharmacist to make sure you know how to take the medication the right way. You would never have to worry about running out of pills on a weekend or having to get a new prescription when your refills run out.

Sounds pretty good, right? Don’t say yes to fast. Allow me to explain.

A few weeks ago, the Food and Drug Administration (FDA)  told a group of health reporters that it was thinking about moving some commonly prescribed medications to over-the-counter (OTC) status. Some of the medications the FDA is considering switching include drugs to treat such chronic conditions as diabetes, migraines, asthma, high cholesterol, and high blood pressure.

According to an article published in Pharma Times last week, the FDA proposal states that making these drugs available OTC  would reduce the number of routine doctor visits and thus “could free up prescribers to spend time with more seriously-ill patients, reduce the burdens on the already-overburdened health care system and reduce health care costs.”

I’ve highlighted that last part for a reason: Yes, making more drugs available over the counter would reduce costs — for employers, health insurance companies, and government programs that provide prescription drugs for beneficiaries. In other words, Medicare and Part D plans will save a lot of money if some of these common drugs get OTC status.  But you’ll have to pay a lot more. OTC drugs are not covered by Medicare, which means you will have to pay the full cost of your medications instead of a small co-payment.

As John LaMattina notes in Forbes, if the FDA does allow these medications to become available over the counter, “billions of dollars in prescription drugs costs would get shifted from the current payers to the consumer.”

I’m not even going to talk about the safety issues here – that’s a completely different subject that also needs to be addressed. But let’s think this through. Suppose you have high blood pressure and take just two medications to keep it under control. Right now these drugs are covered by Medicare Part D, so it’s worth it to pay the monthly premium for your Part D plan because you’re saving hundreds of dollars a year with the coverage.

Now let’s say the FDA decides it ’s safe to make your two medications available over the counter. Will it still be worth paying a monthly premium of $30 to $75  for a Med D plan if you have to pay 100 percent out of pocket for your drugs? Probably not. But Medicare has you there, too, because if you disenroll from your plan and go without coverage for 63 or more consecutive days, you’ll have to pay a late enrollment penalty if and when you decide to join a plan again.

 Let’s hope the powers that be also think this through before taking any action. What do you think?


NCPA applauds call for congressional hearing on PBMs, Medicare Part D | Drug Store News

NCPA applauds call for congressional hearing on PBMs, Medicare Part D | Drug Store News.

Medicare Part D Plans Must Ensure Prescription Drug Access in Disaster Areas

When a disaster is declared, Medicare beneficiaries must have access to their prescription medications.

This week the governors from Kentucky, Ohio, and Indiana all declared a state of emergency in response to Friday’s barrage of deadly tornadoes and widespread storm damage. By requesting the declaration, these states can expedite the process of getting Federal Emergency Management Agency (FEMA) assessment and assistance teams into communities that need it most. It also means that all Medicare beneficiaries who live in these communities will be able to get immediate refills of any prescription drugs lost in the storms.

When disaster strikes, there’s no such thing as “refill too soon”
According to guidelines from the Centers for Medicare & Medicaid Services (CMS), all Medicare Part D prescription drug plans must guarantee immediate refills of Part D medications for any members located in an area that has been declared a major disaster. In addition, because of certain conditions that might exist during an emergency, such as a reduced number of operational pharmacies, limitations on transportation and travel, and the disruption of U.S. mail service, plans must also allow an affected beneficiary to get the maximum extended day supply of the drug, if requested and available at the time of refill.

In other words, any time a disaster has been declared, Part D plan sponsors must remove what is called the “refill too soon” (RTS) edit for affected members, for the period of the emergency declaration.

What the “refill too soon” edit means to you
Even if your community has never been declared a disaster area, it’s important for you to know about the RTS edit and how it can affect your access to your prescription drugs. Most people outside of the insurance or pharmacy benefit industry don’t know about this edit, but I think it is very worth sharing this inside information with you.

If you’ve ever tried to refill a prescription for a long-term drug a few weeks early, your claim was probably rejected at the pharmacy. Your pharmacist would have told you to come back in a week or so, because your Medicare Part D plan wouldn’t pay for a refill yet. This is the RTS edit in action.

When your pharmacist receives the “refill too soon” message from your Part D plan, it means you are trying to refill a prescription before a certain percentage of your current medication has been used. For example, let’s say your Part D plan requires that at least 75 percent of your medication from the previous order be used before you can get a refill. If you order a 30-day supply (30 pills) of a certain medication every month, you must wait at least 23 days—in other words, you must have already taken 23 pills or 75 percent of your medication—before you can order another refill. 

The rationale behind the RTS edit is that it is an effective way for prescription drug plans to minimize excessive use, waste, and stockpiling of medication. I do agree that the RTS edit is a good rule to help prevent people from hoarding bottles of pills or using more drugs than their doctor has prescribed. But I’m also glad that CMS had the good sense to recognize that when disaster strikes, some rules must be broken.

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