In 2012, nearly 49.5 million Americans were eligible for Medicare benefits. That population includes people older than 65, early retirees who opted to receive reduced benefits at age 62 and adults with permanent disabilities. Overall, the Medicare population constituted 15% of adults in America.
Those figures may seem high, but the real news for federal budget makers and health care providers is that as baby boomers age into the government-sponsored health care program, Medicare beneficiaries will grow in number and need. By 2030, Medicare enrollment could reach or exceed 79 million.
For more than any other reason, this matters to pharmacists because each additional Medicare beneficiary becomes a patient with Medicare Part D prescription drug coverage. As people enter Medicare, they have the opportunity to choose a prescription drug plan, or PDP, in addition to their standard Part A and Part B coverage. The other choice if for Medicare Advantage coverage, which is also referred to as Medicare Part C, that combines the health care coverages in a single policy.
Making the choice for separate drug benefits can confuse or even overwhelm some patients. Fortunately, pharmacists can help seniors and disabled patients find their best Part D options.
Know Your Pharmacy's Plans
Pharmacists practicing in community, long-term care and hospital settings are particularly well-positioned to help patients sort through their Medicare Part D choices. To prepare to offer this insurance counseling, pharmacists need to do two things.
First, pharmacists must understand that every Medicare beneficiary may need some information and advice on Part D PDPs every year. The Centers for Medicare & Medicaid Services gives beneficiaries the option to change drug plans once every 12 months. Open enrollment runs from October to December, and patients can switch regardless of reason or how long they have been with another PDP.
Second, pharmacists need to check which Part D plans their pharmacy or practice accepts. Actually choosing to accept PDP coverage is really only a concern for independent and consultant pharmacists, but any pharmacist speaking with patients about Medicare Part D should be able to answer the essential, and sure to be asked, question, "Can I use that plan here?"
Advise, Don't Steer
By law, pharmacists cannot recommend a specific prescription drug plan to a Medicare patient. What pharmacists can and should do is help patients find as much relevant, unbiased information about Part D options as possible. When that information is found, pharmacists can help patients apply selection criteria.
The single best resource for learning about Medicare PDPs is the CMS Medicare Plan Finder. The online database guides users to answer questions designed to match their location, age, Medicaid status and medication history to PDPs that could meet their needs. Results include information on monthly Part D premiums and general co-pays by medication type and 30- or 90-day supply.
Patients and pharmacists can also get this information from CMS over the phone by calling 1-800-MEDICARE (800-633-4227).
Pharmacists should be prepared to supplement Plan Finder results with their own knowledge of how the PDPs they work with operate, other beneficiaries' experiences with available plans and literature or web-based information from the insurance companies administering the plans.
Cost Is Just One Concern
Medicare beneficiaries, like any patient, will probably focus on the bottom line when considering which Part D plan to opt into. Pharmacists need to broaden that focus, especially since some of the plans offered are likely to have very low premiums, zero deductibles and minimal or nonexistent co-pays for many drugs.
One consideration patients need to take is whether a plan is only available where they live or if they can use the benefit across the United States. CMS certifies regional and national Part D PDPs. Individuals who travel frequently or have residences in more than one state will be best served by a national plan.
Patients also need to understand that all "free" medications are not dispensed equally. Many plans offer the lowest premiums and co-pays to patients who get prescriptions filled and dispensed by mail service pharmacies. Patients who prefer community pharmacies may have to accept higher out-of-pocket costs.
The most important consideration patients need to take is which medications a plan covers. To qualify as a CMS-approved PDP, a drug plan must have a formulary that includes a minimum number of medications in an array of therapeutic categories. The Medicare Part D baseline formulary is far from comprehensive, however.
The Plan Finder will return a list of Part D plans that have a patient's current prescriptions on formulary, but each plans may not be appropriate to meet a patient's changing health care needs. For a pharmacist, this means that assessing the patient is as important as assessing a plan when offering advice on how to choose a PDP.