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Medicare Compliance & Reimbursement

PART D:

Dodging The Donut Hole Gets Trickier Next Year

Published on Tue Sep 18, 2007

Watch for these Part D traps in 2008

For Part D prescription drug plans, the race is on to win seniors' 2008 business. That means community pharmacists need to stay a step ahead to help keep seniors' benefits--and pharmacy profits--on track.

The new Medicare Part D "plan year" kicked off on Oct. 1, so prescription drug plan (PDP) sponsors have already started marketing their 2008 plans to seniors.
The Centers for Medicare & Medicaid Services sent out a rose-colored take on coming Part D realities, suggest some experts knowledgeable about community pharmacists' concerns. CMS touted the "good news" that the PDPs had announced premium increases that were less than projected, but bad news may abound for many seniors--and for you as you strive to meet their needs.

As in 2006, the open enrollment period that starts mid-November gives Part D-enrolled seniors a chance to change PDPs. That can be a plus--but only for seniors who truly understand the product they're buying.

Key In On These Concerns

CMS achieved some media coverage with its news about Medicare Part D staving off major premium increases, says policy analyst Vicki Gottlich of the Washington, DC-based Center for Medicare Advocacy. And that could be a dangerous thing.

"Beneficiaries cannot rely on premium amounts alone in determining whether their existing drug coverage will remain the best option for them in 2008," Gottlich stresses. Beneficiaries may need your reminder that they'll need to research plans carefully, even if they don't plan to switch to a new plan.

To keep benefits on track, insurance companies should coach Part D customers on these concerns:

1. Formulary fallout. If beneficiaries don't check the old plan's new formulary, they may be surprised come January to find that the drugs they need are no longer covered, notes Deane Beebe of the Medicare Rights Center in Washington, DC.

2. Drug price increases. Price increases for certain drugs will also continue to be a reality for 2008, says attorney Anne Hance with McDermott, Will & Emery in Washington, DC. For beneficiaries, that means higher co-pays in some plans. Those in standard plans where the cost sharing is 25 percent of the cost of the drugs will be faced with steeper out-of-pocket costs, for example. Others at risk include beneficiaries who need specialty drugs with a 25 percent cost-sharing requirement.

3. Donut-hole woes. Rising prices also make it easier to drop into the "donut hole" coverage gap in the coming year. And in 2008, beneficiaries who do reach the coverage gap may struggle more: For starters, fewer plans in 2008 will offer significant coverage of brand-name drugs in the coverage gap. "That will mean that many people will pay significantly more for their medicine," says Gottlich.

4. Benefit restrictions. An existing PDP may have added new rules associated with benefits for certain drugs or classes of drugs.

Resource: To help beneficiaries learn more about open enrollment, refer them to www.cms.hhs.gov/center/openenrollment.asp.

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