|
New Words for Medicare Prescription
Drug Program
By: Stephen H. Paul, R.Ph., Ph.D., Temple University, School
of Pharmacy
Member, PPA Medicare Task Force
This new drug and services program for patients’
necessitates the learning of a new lexicon of words and
phrases. Listed below is a group of additional information
for all pharmacy practitioners.
ASP (Average Sales Price): The quantity volume weighted
average of the manufacturers’ average sales prices for all
National Drug Codes (NDCs) assigned to the drug or
biological product. The calculation is developed by taking
the multiplication sum of the average sales price and the
total number of units sold and dividing that numeric value
by the total number of units sold for each NDC assigned to
the drug product.
Auto Assignment: Dual
eligible beneficiaries may automatically enroll in a Part D
plan. They cannot be automatically assigned to a specific
plan. The state must randomly enroll the beneficiary in a
plan. The patient may change the approved drug carrier at
any time.
Auto Enrollment:
Patients who are eligible for both Medicaid and Medicare are
classified as dual eligible beneficiaries. These patients
will be automatically enrolled in the Medicare Part D drug
program by January 1 if they are not already enrolled. The
state will automatically place them in one of the state
approved plans on a random basis. Auto enrollment does not
prevent dual eligible patients from changing plans or even
declining to enroll in Part D.
CAP (Competitive Acquisition
Program): A new nationwide drug acquisition program for
181 physician drugs that is scheduled for implementation
sometime in late 2006. Physicians would receive the drugs
directly from CMS-approved vendors. The vendor would be
responsible for deductible collection from patients and also
submitting the claims to Medicare. Not all Medicare Part B
drugs will be included in this program.
Community Care Rx:
This pharmacy provider card program functions because it is
under the sponsorship of MemberHealth, Inc. that is one of
the national prescription drug plans for the Part D benefit.
CPT® (Current
Procedural Terminology): A medical coding system
developed to bill health insurance carriers for medical
procedures and tests. Please see the phrase “HCFA
Common Procedure Coding System.”
Creditable Coverage: The
receipt of a prescription drug benefit that is at least
equivalent to the standard Part D prescription benefit for
traditional Medicare beneficiaries. It can come from the
prescription drug benefit in a current health care insurance
program, a prior employer’s drug benefit program, or having
coverage in the PACE. The PACENET program should be
examined carefully to see it the patient should remain in
that program or sign up for the federal Medicare Part D
program.
Drug Exclusions: Drugs
that are not on formulary or specifically excluded from
reimbursement due to the Medicare Modernization Act of 2003
(MMA). Drugs that are available or would be available under
Part A or Part B will not be eligible for reimbursement
under Part D. Certain drugs are not covered because they
are not covered under Medicaid programs.
The drugs include: Products
used for specified purposes including anorexia, weight loss
or gain, fertility, cosmetic uses, hair growth, symptomatic
relief of cough and cold. Prescription vitamins and
mineral preparations (prenatal vitamins and fluoride
prescriptions are covered).
Nonprescription drugs.
Barbiturate pharmaceuticals.
Benzodiazepines.
Drugs that require associated tests or monitoring services
be purchased exclusively from a specific source.
Dual Eligibles:
Beneficiaries who are entitled to Medicare Part A and B and
are eligible for some form of the Medicaid benefit. These
patients can enroll in the Part C (Managed care
comprehensive) option or Part D (just drugs) programs
starting November 15, 2005. Coveraage for pharmaceuticals
can not commence until January 1, 2006. If they have any
transitional assistance credit remaining on their approved
Medicare Discount Cards you should help them make a decision
on whether it would be more advantageous to sign up for the
new prescription programs starting January 1, or wait until
they use up the credit on their cards.
Enrollment Period: This year a beneficiary who is first
eligible to enroll in a Part D plan has an initial
enrollment period that starts November 15, 2005 and ends May
15, 2006. For beneficiaries who do not qualify during the
initial enrollment period, their enrollment period starts
three (3) months before becoming eligible, the month of
eligibility, and three (3) months following eligibility.
HCFA Common Procedure Coding System (HCPCS):
A set of rules that are composed of Level I codes (CPT®
codes), Level II codes (national codes), and Level III codes
(local codes). Level I (CPT®) codes are five
digit numeric codes that describe procedures and tests. CPT®
codes are developed and maintained by the AMA with annual
updates. Level II (national) codes are five digit
alphanumeric codes that describe pharmaceuticals, supplies,
procedures, tests and services. Level II codes are developed
and maintained by CMS with quarterly updates. Level III
(local) codes are five digit alphanumeric codes that are
being phased out by fiscal intermediaries.
Late Enrollment Penalty:
Beneficiaries will be subjected to a late enrollment penalty
if they do not sign up for Part D when first eligible. Even
though Part D is voluntary there is a limited opportunity to
sign up for this insurance program.
The
premium will increase 1 percent of the base premium ($32.20
for 2006) per month for every month that the beneficiary
waits to enroll. In 2006, this rate will be $0.32 per month.
If the patient delays enrolling for seven months, then the
increase in premium is 7 times $0.32 or $2.24 per month in
addition to paying their prescription benefit premium. The
individual will have to pay this surcharge for their entire
lifetime. This percentage may increase each year.
Patients do not have to pay this late enrollment penalty if
they are currently receiving retiree coverage at least as
good as Medicare Part D (also known as creditable coverage).
Beneficiaries should be receiving notification from their
retiree benefits coordinator this fall to indicate whether
their current coverage is creditable. If they do not receive
or cannot find this notice, Medicare patients should call
their retiree benefits coordinator to make this
determination.
MAP (Medication Action Plan)
A document the patient received from the pharmacists at the
conclusion of the Medication Therapy Management (MTM)
session. The document is patient centered and designed to
have the patient as an active participant in the program.
The document should encompass the medication related issue
and action plan, the person(s) responsible for its
implementation and its outcome. Starting date and date of
verified results should be listed.
MTMP (Medication Therapy
Management Program): Designed by a plan sponsor to
ensure that covered drugs prescribed to targeted
beneficiaries are appropriately used in order to optimize
therapeutic outcomes through improved medication use. The
program is designed to reduce the risk of adverse events for
targeted beneficiaries. The MTMP must be coordinated with a
managed care management plan established for a targeted
individual under a chronic care improvement program (CCIP).
This term has the same meaning as the medication therapy
management. MTMP in community pharmacy includes
the core components of medication therapy review (MTR),
personal medication record (PMR), medication action plan
(MAP), intervention and referral and documentation and
follow-up.
Medicare Prescription Drug Plan Cost Estimator:
This is a simple tool available on the CMS website. By
entering a beneficiary’s monthly drug costs and our State,
users will get an estimate of annual savings if they join a
Medicare prescription drug plan. The calculation is based
on the defined standard benefit and the lowest premium
amount offered by the lowest cost plan for Pennsylvania.
Formulary status of the drugs being prescribed is NOT taken
into account.
MemberHealth, Inc. A
prescription benefit management organization that is an
approved Medicare Plan D provider. The firm administers
numerous health benefit discount programs. Its marketing
activities for these programs are conducted through three
distribution channels: insurance and brokerage agencies,
consumer direct marketing, and pharmacies.
MTR (Medication Therapy
Review): This is a consultation between the pharmacists
and the patient (or caregiver) to review the pharmaceuticals
utilized by the patient. The one-on-one relationship
enables the pharmacist to observe signs of and visual clues
to the patient’s health problems including adverse reactions
to prescription, non-prescription and health supplements.
Modifier: A modifier
indicates that a service or procedure was altered by
specific circumstances, but not changed in its definition or
code. Modifiers are two-digit numeric or alphanumeric codes
that are appended to the end of CPT/HCPCS codes.
OON (Out–Of-Network
Pharmacy) Plan D sponsors must enable enrollees to have
reasonable access to covered Part D drugs when the
medications cannot be expected to be at a network pharmacy
and beneficiaries do not access covered drugs at an
out-of-network pharmacy on a routine basis. These
pharmacies do not have to inform a beneficiary of any
differential between the price of brand name drug and the
price of the lowest priced generic equivalent of the covered
Part D drug that is therapeutically equivalent and
bioequivalent.
Part D drugs: Drugs
that are on the formulary of an approved sponsor in the
state where the beneficiary resides. Part D drugs can vary
from different carriers.
PMR (Personal Medicationl
Record): The individual’s electronically generated or
manual record of prescriptions, non-prescriptions, herbal
preparations and dietary products used. This comprehensive
record should include demographic and PBM provider
information in addition to the medication name strength and
dosage form. It should also include the directions for
usage and its intended benefit. The starting and
termination dates of therapy should be included. Pharmacist
or Pharmacy name, prescriber and phone or other contact
information should be included. Date of last update must be
included. If the patient shares the information with
providers and they update the document all practitioners
should be able to make maximum therapeutic use of the
information.
PSTAC (Pharmacist Services Technical Advisory Coalition):
Formed in 2002 with the goal of improving the coding
infrastructure necessary to support billing for pharmacists'
professional services. The coalition works to provide the
necessary leadership to position and secure pharmacy's place
in the electronic data interchange (EDI) health encounter,
claims processing and payment environment relating to all
providers of professional services.
SHIP (State Health Insurance Assistance Programs)
Individual State programs funded by CMS that provide direct
counseling and assistance to individuals with Medicare.
States have substantial discretion in providing their
services. Program staff will aid in minimizing the
administrative burden of Medicaid administrative costs
associated with Medicare Part D and assisting in reaching
potential beneficiaries and aid in their enrollment in the
prescription program. This program also aids beneficiaries
in understanding their rights under Medicare and the choices
of Medicare plans available as traditional and managed care
options. In Pennsylvania, the program is known as
“APPRISE.”
Special Enrollment Period
(s): For an enrollment or change of enrollment made
during a special enrollment period, the effective date of
prescription coverage is determined by CMS. The federal
agency will do so in a manner consistent with providing
continuity of drug coverage.
A
beneficiary may enroll or disenroll if one of the following
circumstances occurs.
Involuntary loss of creditable coverage.
Beneficiary was not adequately informed that she or he had
lost drug coverage
or never had the insurance benefit.
Enrollment on non-enrollment was unintentional, inadvertent,
or in error due to an action or inaction by any individual
authorized to act on the government’s behalf.
The beneficiary is a full-benefit dual eligible recipient.
The beneficiary disenrolls from a MA-PD program and selects
the traditional Medicare program.
The sponsor’s contract is terminated by the sponsor or by
CMS.
The plan is no longer offered in the locality where the
enrollee resides.
The beneficiary moves to a residence outside of the service
region for the sponsor’s program.
Plan sponsor violates an important provision of its drug
contract
Targeted beneficiaries:
Targeted beneficiaries for the MTMP or MTM are enrollees in
the sponsor's Part D plan who have multiple chronic
diseases; are taking multiple Part D drugs; and are likely
to incur annual costs for covered Part D drugs that exceed a
predetermined level as specified by the Secretary of HHS.
Transition Process: A
program that a plan sponsor sets up to enable continuity of
care to be given to patients whose medications are not on
the formulary. The plan would deal with the review of
non-formulary drug requests and a process for switching the
enrollees to therapeutically appropriate alternatives if a
medical necessity determination for the patient failed. The
plans have to develop an appropriate transition process for
enrollees who are coming from other programs and the current
drugs are not in the new sponsors formulary.
USP (United States
Pharmacopoeia): The organization responsible for the
development of the formulary category and class structure.
Plans that utilize the USP formulary categories and classes
will satisfy the nondiscrimination requirement.
Your Feedback needed!
Tell us what else you need to know about Medicare.
Send your questions to
ppa@papharmacists.com
and mark Medicare ? in the subject line.
We will work on establishing a Frequently Asked Questions
(FAQ) section next.
|
