As of November 15, 2005, Medicare beneficiaries are able to enroll in Medicare Part D Prescription Drug Plans. 

As beneficiaries and their families attempt to navigate the information they receive from Medicare, the state pharmacy programs, and the 17 companies offering plans in the state of Vermont, confused patients will without a doubt be coming to their physicians asking for help about what they should be doing and which plan they should sign up for.

The Medicare Drug Benefit:  How Does it Work?

The Medicare Part D prescription drug benefit will provide federally subsidized prescription drug coverage beginning January 1, 2006.  Any of the 98,000 Vermonters eligible for Medicare Parts A or B may choose to enroll.  Medicare has contracted with 17 companies in the state of Vermont who are offering a total of 44 different drug plans from which eligible beneficiaries may choose.   While participation is optional, eligible beneficiaries who choose not to enroll in Part D between now and May 15, 2006 but who later decide to enroll will face a 1 percent penalty added to their premium for each month after May 15 that they have waited before enrolling.  Thus, eligible beneficiaries should decide whether or not the Part D benefit is right for them, and if so, select and enroll in a plan by May 15 of next year.

Drug Plans Offered in Vermont

17 companies have contracted with Medicare to offer 44 different Part D plans in the northeastern region that includes Massachusetts, Connecticut, Rhode Island and Vermont.  That is, all 44 plans are offered uniformly in all 4 states.  Of these, some are even offered nationally.  Beneficiaries will generally pay a premium, co-payments, and sometimes a deductible.  Additionally, each plan will have its own drug formulary. Every formulary is required to have at least two drugs from each therapeutic class as well as cover substantially all of the drugs in the following six classes:

o       Cancer medications

o       HIV/AIDS medications

o       Antidepressants

o       Antipsychotic medications

o       Anticonvulsive treatments

o       Immunosuppressants

While most companies use one formulary for each of the plans they offer, some have different formularies for each plan.  Based on currently available information, it appears that there will be about 25 different formularies that will be used by Medicare Part D plans in the four states including Vermont.  To download formularies for the plans, visit the Vermont Medical Society (VMS) website www.vtmd.org.  VMS is strongly encouraging the Centers for Medicare and Medicaid Services (CMS) to make the formularies available through the ePocrates software package.

Advising Patients Who Are Considering Enrolling in a Part D Plan

Over the next several months, Medicare beneficiaries are going to be weighing whether Part D makes sense for them and if so, which plan might work best for them.  According to a survey conducted by the Kaiser Family Foundation, most Medicare beneficiaries named their physician as the first place they would go to seek help.  Beneficiaries will need to consider what type of coverage they currently have, what premiums they can afford, what pharmacies are conveniently accessible, and what formularies cover the their medications.  Much of this falls beyond the type of advice a physician is able to give to a patient.  However, a physician may recommend that a patient get a list of all current medications from his or her pharmacist and then either visit www.medicare.gov, or call 1-800-Medicare or the local State Health Insurance Program at 1-800-642-5119 for assistance in choosing a plan.

Beneficiaries for whom Part D coverage would create a significant financial burden may be eligible for a Limited Income Subsidy.  Potentially eligible beneficiaries should have received an application directly from the Social Security Administration.  Additional applications are available at Social Security offices, Department of Children and Families offices, and are available on the web at www.ssa.gov/legislation/Part_D_application.pdf.  It is advisable that anyone who thinks they may be eligible apply.

Individuals who are eligible for Medicare Part D but who currently receive prescription drug coverage through a state pharmacy benefit program have been automatically enrolled in one of eleven “basic” Part D prescription drug plans in Vermont.  Beneficiaries are free to enroll in a different plan, but should be aware that enrolling in a plan with premiums higher than $30/month will be more expensive for them.  Beginning on January 1, 2006, the part D plan will become the primary payer of prescription drugs and the state will provide a wrap-around coverage, called V-Pharm, intended to provide a level of coverage and limited financial exposure equivalent to what the beneficiary is currently receiving under the state program.  V-Pharm will cover classes of drugs not covered by any of the Part D plans.  These include drugs for: anorexia, weight loss/gain, fertility, cosmetics,  symptomatic relief of cough and colds, prescription vitamins, non-prescription drugs, barbiturates, and benzodiazepine. However, this does not mean that V-Pharm will cover any drug that a patient is currently taking but that is not part of the formulary of the plan to which they have been automatically assigned.  Beneficiaries who have been automatically enrolled in a plan should therefore check that plan’s formulary and possibly switch to another plan if essential medications are not covered.

Individuals who are eligible for Medicare Part D but who currently have drug coverage from another source, such as an employer or union, should receive a letter from that insurer informing them as to whether that coverage is better or worse than the coverage offered by Medicare Part D.  If the current coverage is determined to be as good or better than Medicare Part D, the individual may decide to stay with that coverage and not enroll in Part D.  If, in a couple of years, the individual decides to enroll in Part D, the premium penalty will not apply (it is a good idea for the beneficiary to keep this letter as evidence to ensure that they are protected from the penalty). But if it is determined that the current coverage is not as good as Medicare Part D coverage, the individual may still decide to stay with that coverage, but would be subject to the 1 percent per month premium penalty if he or she were to decide to switch to Part D coverage after May 15, 2006. 

Assisting Patients Who Are Covered by a Part D Plan After January 1, 2006

Beginning in January, physicians are likely to get requests from patients, as well as their pharmacists, asking if they can switch medications to ones that are covered by their Medicare Part D plan’s formulary.  With 98,000 Medicare beneficiaries in the state of Vermont and approximately 25 different formularies in use, this is likely to be a difficult and time-consuming process.  The Vermont Medical Society has made formularies for each of the plans available through its website (www.vtmd.org) and continues to press CMS to make these formularies available through ePocrates.  Additionally, VMS will be working with clinical experts in Vermont as well as with state medical societies in the states sharing the same Part D plans in order to determine and help troubleshoot the most frequent problems physicians will face with patients beginning Part D coverage.

To help ease the transition process, Part D plans are supposed to provide a one-time 30-day refill of any drug a patient is currently taking for a chronic condition in order to give the patient time to consult with his or her physician about changing to a covered drug.  Drug plans must also have exceptions processes whereby a beneficiary can apply for coverage of a non-formulary drug or obtain a drug at a lower cost sharing level if the drug is medically necessary.  Medicare has established a multilevel appeal framework with defined timeframes to be observed by all plans in making such determinations.