Access Denied?Access Denied?The Medicare Part D The Medicare Part D

Benzodiazepine Challenge Benzodiazepine Challenge and Maine’s Coverage and Maine’s Coverage

Solution.Solution.Stacie SparkmanStacie Sparkman

Medicare Prescription Drug Medicare Prescription Drug Specialist Specialist

Eastern Agency on AgingEastern Agency on Aging

Medicare Prescription Drug, Medicare Prescription Drug, Improvement and Improvement and

Modernization Act of 2003Modernization Act of 2003

Signed into law December 8, 2003.Signed into law December 8, 2003. Implemented outpatient prescription Implemented outpatient prescription

drug coverage for seniors and the drug coverage for seniors and the disabled population.disabled population.

Is a voluntary program. If a person has Is a voluntary program. If a person has state Medicaid and wants to continue state Medicaid and wants to continue to receive prescription assistance, they to receive prescription assistance, they must be enrolled into a Part D plan.must be enrolled into a Part D plan.

Medication CoverageMedication Coverage

• Prescription Drug Plan (PDP) formularies must include drugs within each therapeutic category and class of covered Part D drugs, though not necessarily all the drugs in each category or class.

• The legislation excludes from coverage the following drugs or classes of drugs, or their medical uses:

Excluded MedicationsExcluded Medications Agents when used for anorexia, weight loss, or weight Agents when used for anorexia, weight loss, or weight

gaingain Agents when used to promote fertilityAgents when used to promote fertility Agents used for cosmetic purposes or hair growthAgents used for cosmetic purposes or hair growth Agents when used for the symptomatic relief of cough Agents when used for the symptomatic relief of cough

and coldsand colds Prescription vitamins and mineral products, except Prescription vitamins and mineral products, except

prenatal vitamins and fluoride preparationsprenatal vitamins and fluoride preparations Non-prescription drugsNon-prescription drugs Outpatient drugs for which the manufacturer seeks to Outpatient drugs for which the manufacturer seeks to

require associated tests or monitoring services be require associated tests or monitoring services be purchased exclusively from the manufacturer or its purchased exclusively from the manufacturer or its designee as a condition of saledesignee as a condition of sale

BarbituratesBarbiturates BenzodiazepinesBenzodiazepines

All of the classes of excluded All of the classes of excluded medications have the potential to medications have the potential to

impact medical care in the elderly or impact medical care in the elderly or disabled population. Continuity of care disabled population. Continuity of care

issues could issues could include the use of:include the use of:

1.1. Benzodiazepines, widely used for management of Benzodiazepines, widely used for management of acute anxiety, panic attacks, seizure disorders, and acute anxiety, panic attacks, seizure disorders, and muscle spasms in those with cerebral palsy or muscle spasms in those with cerebral palsy or other disorders like Ativan, Xanax and Valium.other disorders like Ativan, Xanax and Valium.

2.2. Over-the-counter medications, including agents for Over-the-counter medications, including agents for pain, constipation, and other common conditions.pain, constipation, and other common conditions.

3.3. Medications used to treat weight loss, such as in Medications used to treat weight loss, such as in those persons who lose weight due to cancer or those persons who lose weight due to cancer or AIDS.AIDS.

4.4. Barbiturates like Phenobarbital, which is widely Barbiturates like Phenobarbital, which is widely used in the elderly for treatment of seizures.used in the elderly for treatment of seizures.

Hospitalization and

Stabilization

Discharge to a system where:

Medication is

Denied

Maine’s Coverage SolutionMaine’s Coverage Solution The Centers for Medicare and Medicaid The Centers for Medicare and Medicaid

Services authorized states to provide Services authorized states to provide coverage of –and receive federal matching coverage of –and receive federal matching funds for-medications the Medicare funds for-medications the Medicare Modernization Act excludes.Modernization Act excludes.11

Before Medicare Part D started on 1/1/06, the Before Medicare Part D started on 1/1/06, the State of Maine made the decision to continue State of Maine made the decision to continue coverage of excluded medications already on coverage of excluded medications already on the state’s preferred drug list. This coverage the state’s preferred drug list. This coverage included members who received prescription included members who received prescription assistance under state Medicaid and the Low assistance under state Medicaid and the Low Cost Drug Program. Cost Drug Program.

1 Policy Guidance Regarding Medicaid Coverage of Prescription Drugs Excluded from the New Medicare 1 Policy Guidance Regarding Medicaid Coverage of Prescription Drugs Excluded from the New Medicare Prescription Drug Benefit, Prescription Drug Benefit, http://www.cms.hhs.gov/letters/smd060305.pdf

Low Income SubsidyLow Income Subsidy

The Medicare Modernization Act The Medicare Modernization Act gave three groups automatic Low gave three groups automatic Low Income Subsidy.Income Subsidy.

1.1. Individuals with State Medicaid.Individuals with State Medicaid.2.2. Individuals with Supplemental Individuals with Supplemental

Security Income.Security Income.3.3. Individuals with their state’s Individuals with their state’s

Medicare Savings Program.Medicare Savings Program.

Medicare Savings ProgramMedicare Savings Program

Pays for the Medicare Part B Premium-Pays for the Medicare Part B Premium-$93.50 in 2007 and $96.40 in 2008$93.50 in 2007 and $96.40 in 2008

Enrollment into the MSP will deem a Enrollment into the MSP will deem a person eligible for full Low Income person eligible for full Low Income Subsidies for Part D which includes:Subsidies for Part D which includes:

1.1. Payment of the part D premium for Payment of the part D premium for approved plansapproved plans

2.2. Payment of the deductiblePayment of the deductible3.3. Small co-pays of between $1 and $5.35Small co-pays of between $1 and $5.354.4. No Coverage GapNo Coverage Gap5.5. Catastrophic CoverageCatastrophic Coverage

Medicare Savings ProgramMedicare Savings Program Each state sets the income and asset levels for the Each state sets the income and asset levels for the

MSP.MSP. The state of Maine did away with the asset test on The state of Maine did away with the asset test on

1/1/06 and raised the income limit to 185% of the 1/1/06 and raised the income limit to 185% of the federal poverty limit on 4/1/07.federal poverty limit on 4/1/07.

The Department of Health and Human Services The Department of Health and Human Services determines eligibility and countable income. There determines eligibility and countable income. There are some instances where individuals or couples are some instances where individuals or couples may be eligible for the MSP even if their income is may be eligible for the MSP even if their income is higher than 185% of the federal poverty limit.higher than 185% of the federal poverty limit.

Maine also provides a wrap benefit through the Maine also provides a wrap benefit through the state’s Low Cost Drug program. This program state’s Low Cost Drug program. This program continues to provide coverage for excluded continues to provide coverage for excluded medications listed on the state’s preferred drug list. medications listed on the state’s preferred drug list. This benefit helps those transitioning, from the Low This benefit helps those transitioning, from the Low Cost Drug Program and Mainecare into Medicare Cost Drug Program and Mainecare into Medicare and Medicare Part D, continue to receive their and Medicare Part D, continue to receive their medications without interruption.medications without interruption.

Direct SavingsDirect Savings

Since Medicare Part D started in 2006 Since Medicare Part D started in 2006 Maine has covered benzodiazepine and Maine has covered benzodiazepine and barbiturate prescriptions.barbiturate prescriptions.

The estimated total savings for the The estimated total savings for the consumer isconsumer is

We will never know the total cost of We will never know the total cost of savings related to hospitalizations and savings related to hospitalizations and mass confusion, but we know it is mass confusion, but we know it is priceless.priceless.

ResourcesResources Legal Services for the Elderly, Inc. Part D Legal Services for the Elderly, Inc. Part D

Appeals Unit 1-877-774-7772 Appeals Unit 1-877-774-7772 Maine Area Agencies on Aging/State Health Maine Area Agencies on Aging/State Health

Insurance Assistance Program (SHIP) Insurance Assistance Program (SHIP) 1-877-353-37711-877-353-3771

Maine Department of Health and Human Maine Department of Health and Human Services Regional Offices Services Regional Offices

Maine Office of Elder Services 1-800-262-Maine Office of Elder Services 1-800-262-22322232TTY 1-800-606-0215TTY 1-800-606-0215

Maine Pharmacy Helpdesk 1-866-796-2463 Maine Pharmacy Helpdesk 1-866-796-2463 Medicare 1-800-Medicare or 1-800-633-Medicare 1-800-Medicare or 1-800-633-

42274227TTY 1-877-486-2048TTY 1-877-486-2048

Social Security Office 1-800-772-1213 Social Security Office 1-800-772-1213 TTY 1-800-325-0778TTY 1-800-325-0778