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This may prove to be the largest issue the pharmacy profession has faced. You need accurate information now to position yourself and your business for successful implementation and patient retention.
The changes you will face in the coming months need your full and immediate attention today.
How The Patient Will Be Affected
The Medicare Discount Card is available to and voluntary for seniors as well as those who are disabled and currently covered by Medicare A and B. Persons receiving out-patient drug benefits through Medicare are not eligible for the discount card program.
There will be a $600 subsidy for people whose incomes are 135% of the poverty level, which is $12,123 for singles and $16,362 for married couples. CMS will be the watch-dog and verify financial status using IRS data. Co-pays will be from 5% to 10% and to maintain eligibility the patient must not have coverage from other sources. Enrollment for the beneficiary will occur at the pharmacy of their choice and they are limited to one discount card program. Enrollment is scheduled to start on May 3, 2004 with the benefit available June 1, 2004. The enrollment fee of $30 will be collected by the pharmacy for patients not covered by the $600 subsidy.
The one-time opportunity for patients to change discount card programs will occur November 15 through December 31, 2004. Patients whose residential status changes, whether they move outside their current service area or move into a long term care facility will be allowed to change programs. Those who are dis-enrolled from Medicare + Choice may change as well.
The discount card is meant to be a transition to the funded benefit, scheduled to be in effect January 1, 2006. At that time the discount card program will disappear.
Prescription Drug Benefit
Nearly all retail prescription drugs will be eligible. If a discount card program utilizes a formulary they must offer discounts on commonly used drugs, cover 209 classes of drugs and offer a generic drug for a negotiated price in at least 55% of the categories. Diabetic supplies such as syringes, needles, alcohol and gauze are all included.
All endorsed Medicare Discount Card programs must obtain manufacturer rebates and other discounts in order to help lower drug costs and the CMS is expecting a substantial share of rebates and discounts to be passed through to enrollees. OTCs may be included, but will not be part of the $600 subsidy for eligible beneficiaries. CMS is permitting endorsed programs to update pricing formulas as often as weekly.
Why is the Medicare Discount Card Program so important?
This is the last large growth segment for PBMs and health plans. Nearly one-third of the Medicare population is without prescription benefit. Estimates place this “un-owned” population at 7 million in 2004 and growing to 40 million by 2006 when the funded prescription drug benefit becomes available.
Insurance
