Choosing a program in MD

Johns Hopkins Medicine - Department of Psychiatry and Behavioral Sciences

TALKING TO YOUR PATIENTS
ABOUT MEDICARE PART D

Chapter 3 - Choosing a Program in Maryland

Select a link below for quick reference:

There are two kinds of Medicare programs that offer the drug benefits, standard Medicare and Medicare Advantage programs.

People who have standard Medicare in Maryland may enroll in any of 47 “Stand Alone” programs, also labeled PDPs. These plans are being offered by twenty-one different companies. Several of the companies only have one program. Many companies offer two or three programs, with different costs and benefits.

Fifteen of the basic programs have been designated as open to people who qualify for the full low income subsidy. They will pay no deductibles, no monthly premiums, and minimal copays. People who are being automatically enrolled by Medicare, the dual eligibles, are being randomly assigned to one of these fifteen programs:

• AARP Medicare Rx Plan
• Aetna Medicare Rx Essentials
• Elder Health PDP Mid-Atlantic
• First Health Premier
• Humana PDP Standard
• Medco Health Solutions Your Rx Plan
• Memberhealth Community Care Rx Basic
• PacifiCare Saver Plan 
• Prescription Pathway Bronze Plan Region 5 
• Qcc AmeriHealth Advantage Rx Option 1 
• Rx America Advantage Star Plan
• SilverScript
• Unicare Medicare Rx Rewards
• United Healthcare United Medicare MedAdvance
• Well Care Signature

People who qualify for the full low income subsidy may join any of the 47 programs, but they will have to pay a portion of the monthly premium if they join an enhanced program.

The Medicare Advantage programs (Medicare HMOs and PPOs) will offer their members choices of drug programs that are more limited. Medicare Advantage programs will communicate the options open to their members. This study did not look at the Medicare Advantage programs or the drug program options they are offering. (People who currently belong to Medicare Advantage Programs may choose to leave their program and rejoin standard Medicare. They may then join a Medicare PDP.)

All of the Medicare Part D programs are required to carry medications from all classes of drugs. This includes medications for mental health conditions. The notable exceptions to this requirement are the specific exclusions of benzodiazepines and barbiturates. The Medicare Part D guidelines follow the Medical Assistance formulary guidelines, which currently exclude benzodiazepines and barbiturates.

Every program has a unique formulary. But each program carries drugs in each of the following categories:

• Anti-anxiety medications
• Anti-convulsant medications
• Anti-dementia medications
• Anti-depressant medications
• Anti-parkinsonian medications
• Anti-psychotic medications
• Bipolar medications: anti-mania 
• Deterrents: alcohol and smoking 
• Sleep disorder medications 
• Stimulants: attention deficit medications

Medicare program guidelines require each program to carry essentially all of the medications in the categories of anti-depressants, anti-psychotics, and anti-convulsants.

There are two sources of information available online to determine if a particular medication will be available to a patient. The first source is the formulary published by the drug program provider. The second source is the Medicare Formulary Finder. The drug program formularies published online are not required to have all of the medications that the program actually may provide. The Medicare Formulary Finder provides information about individual medications, and lists the drug programs that carry that particular medication.

The Medicare Formulary Finder appears to have more complete information at this time. Some of the drug programs have not yet published their formularies online. Some of the drug programs have published only partial formularies. There are some discrepancies between the information on the Medicare Formulary Finder and the drug program formularies. In the beginning of this program it will be important to call the drug program to find out if the drug is actually covered.

What does the formulary data look like?

To test this requirement a study was done to look at the formularies of the basic programs, and to look at the formulary information available through Medicare to see if the medications that patients need will be available to everyone, including patients with limited resources.

This analysis of formulary data looked at the medications for mental health conditions in the following categories: anti-convulsants, anti-dementia, anti-depressants, anti-psychotics, and bipolar agents. (The other classes of medications for mental health conditions will be looked at closely at a later time.) A group of 66 essential medications was identified, based primarily on current usage at JHH in the Department of Psychiatry.

Each basic drug program whose formulary was available was looked at in two ways: the published formulary on the program’s website, and the Medicare Formulary Finder.   Many of the drug programs have several levels of coverage. This analysis looked only at the most basic program that a program provides. This was to determine if everyone with low income will have access to the medications they need. The data was compiled and tabulated on the following spreadsheets.

Select a link below to see a PDF of formulary spreadsheets by medication classification:

	Anticonvulsants 1
	Anticonvulsants 2
	Antidementias
	Antidepressants 1
	Antidepressants 2
	Antipsychotics 1
	Antipsychotics 2
	Bipolar (anti-manias)

For each basic drug program a figure was obtained that represented the sum of the drugs available in that program out of the essential medication list. That figure was then divided by the total possible (66) to obtain a percentage.

The basic drug programs were divided into two groups. The first 15 programs are the programs which are available to individuals receiving the full low income subsidy, and which require no annual deductibles or monthly premiums for these enrollees. The drug programs were ranked in order of the availability of these essential medications:

The second group is made up of the other 5 programs which are available in Region 5 (MD, DE, and DC). Anyone can join any of the 20 programs, but if a person with the full low income subsidy joins one of these five, they may have to pay a small monthly premium. These programs were ranked in the same fashion:

There is a significant range of availability in the 20 programs, from 79% to 98%.

While legally we may not recommend a specific program to an individual, we can use this information to steer patients toward the programs at the top of the tier of availability. While a patient’s current medication needs may be adequately met by a plan at the lower part of the list, that same patient may need different medications for the same mental health condition in the future. So patients should choose a plan with a broad formulary, given what we know about the possible future needs of patients.

What drugs for general medical conditions are covered?

It is impossible to evaluate the general formularies in the same manner as was used in the study of mental health medications, due to the sheer size and number of medications. But Medicare has provided its own “Top 100” medications and “Top 200” medication figures. These figures represent the most commonly prescribed medications for people who use Medicare.

It would seem prudent for most patients to choose a program that has good availability of mental health medications and good availability of medications for general medical conditions. For any individual, however, it is not the averages that matter, but the availability of specific medications. Programs that provide a wide availability will provide the best coverage for future, unforeseen needs.

How much do the programs cost?

The 47 programs in Maryland present a confusing array of choices when it comes to cost. There are multiple components to a plan’s cost/benefit structure.

 Please click here to view a PDF spreadsheet with costs for Maryland PDPs

The first component is the annual deductible. Some of the plans are based on an annual deductible of $250. Some of the plans have no annual deductible, but higher monthly premiums.  A few programs have an intermediate annual deductible of $100.

The second part of the cost/benefit structure is the monthly premium. Monthly premiums range from $6.44 per month to $32.13 for the basic programs, and $12.58 to $68.91 for enhanced programs.

Several of the basic programs that offer good availability of medications for mental health conditions and general medical conditions identified above have monthly premiums that are relatively low:

• Humana PDP Standard — $6.44 
• First Health Premier — $22.91
• AARP — $28.61
• United Medicare MedAdvance — $30.85
• Medi-CareFirst — $34.78
• Cignature Rx Value Plan — $36.75

The third component is the copayment for drugs. Some of the programs have a strict copayment of 25% for medications and have no tiers. Others have tiered formularies, with higher copayments for medications on the higher tiers. Copayments for generic drugs (tier 1) range from $0 to $10 for a month’s supply, or 25%. Copayments for preferred brand drugs (tier 2) range from $15 to $65 for a month’s supply, or 25%. Copayments for nonpreferred brand drugs (tier 3) range from $40 to $65 for a month’s supply, or 25-75%.

The “coverage gap” begins when the patient’s drug costs reach $2250. At that point the patient will have spent $750 out of pocket, and Medicare will have paid out $1500. From $2251 to $5100 in drug expense the patient must pay out 100% of the cost of his medications. When the total expenses reach $5101, the patient will have paid $3600 out of pocket. Six of the drug programs offer some coverage in the “coverage gap”.

All of the programs have the same costs when they reach the “catastrophic” level, after the patient has accrued $3600 in true out of pocket expenses. At that point patients pay 5% or $2 for generics and $5 for brands.  People will need to study the cost/benefit structure closely for any program they are thinking of joining.

What pharmacies participate in the programs?

Each program has a set of pharmacies that participate with that program. For many people the availability of a convenient pharmacy will not be an issue, as the programs are contracted with multiple pharmacies. But for people in certain areas, particularly rural areas, the choice of pharmacy may be limited. Also for people who are home bound or have no access to transportation, pharmacy location and convenience may be critical issues in making a choice of plan. Each drug program lists its participating pharmacy on its web site. Every pharmacy should be able to tell you which programs it participates with by calling on the phone. Many of the programs also offer the ability to mail order prescriptions.

How do the plans compare, based on availability of medications, cost, and availability of pharmacies?

The final decision about which program to choose will need to be based on availability of medications, cost/benefits, and availability of a participating pharmacy. Medicare has provided an online tool to help with this decision, the Medicare Plan Compare:
www.medicare.gov/MPDPF

This tool will provide options for the patient based on his current medication usage.

N.B.  Patients who travel will want to join a national program rather than a regional program.  They will be able to get their medications more easily if they need a prescription filled while traveling.

How do you enroll?

People can enroll directly with the drug program by telephone, online, or with a paper application. People can also enroll directly through Medicare by calling (1-800-633-4227) or online at www.medicare.gov. Applications can also be made through the local Senior Health Insurance Assistance Program (SHIP) office.

Janet A. Bachur, LCSW-C
12/12/05

CHOOSING A PROGRAM: RELEVANT LINKS and CONTACTS

Formulary finders:

Medicare Formulary Finder (finds medications by name)
http://formularyfinder.medicare.gov

Drug program formularies:

 Click here to see contact list for web sites and phone numbers.

Pricing information:

Medicare: list of stand alone Prescription Drug Programs in Maryland
www.medicare.gov/medicarereform/map.asp#MD

Medicare Rights Organization: “Medicare Drug Coverage 101”
http://www.medicarerights.org/101.html
“How much will the Medicare drug benefit cost?” Questions 8-16

Drug programs: 

  Click here to see contact list for web sites and phone numbers for pricing.

 Click here to view a PDF spreadsheet with costs for Maryland PDPs

Pharmacy participation:

Drug programs:

  Click here to see contact list for web sites and phone numbers for drug program providers.

Pharmacies: Call the pharmacy you use and ask if they participate with the programs you are thinking of choosing

Compare plans:

Medicare Plan Compare: www.medicare.gov/MPDPF

Applications to enroll:

Drug programs:

 Click here to see contact list for web sites and phone numbers to enroll.

Medicare: Call to enroll 1-800-medicare
Enroll online www.medicare.gov