Understanding the Maze of Medicare Part D

Author: Mike Faden

The intricacies of the Medicare Part D prescription benefit may seem overwhelming, but a new outreach and education program promises to help patients and pharmacists navigate the maze. The program, called Beneficiary Centered Enrollment (BCE), will focus on "dual eligibles" —the more than 6 million people, mostly seniors and those with disabilities, who currently get their prescription drug benefits through Medicaid and their other health care through Medicare.

On January 1, 2006, these people's drug benefit will switch from Medicaid to one of the new Medicare-approved plans. If they do not specify which one they want, they will find themselves in a plan that the government chooses for them—which may not be the one that provides the best coverage for the drugs they need.

The BCE program will focus on helping dual eligibles choose the best Medicare plan and on helping pharmacists to assist them, according to David Medvedeff, president of Informed Decisions. The company, a unit of the clinical drug information provider Gold Standard, located in Tampa, Fla, is providing the service. Also in development is a free 1-hour accredited continuing education course about the Medicare prescription benefit.

The program is funded by the National Association of Chain Drug Stores (NACDS), Eli Lilly, and AstraZeneca and is getting other support from the National Community Pharmacists Association. The program aims to solve a problem resulting from the way the Medicare benefit is being rolled out. To ensure that dual-eligible people get continuing coverage, the government is automatically and randomly choosing a Medicare prescription plan for them in October, when the formularies and other details of approved plans are officially announced. These people will not be officially enrolled in the plan, however, until their Medicaid drug benefit stops at the end of 2005.

The problem, according to officials of NACDS and Informed Decisions, is that the plan Medicare chooses may not be the one that best covers the beneficiaries' prescription drug needs. As a result, when their benefit switches to Medicare, they could suffer an interruption in coverage. Fortunately, they have until the end of the year to compare other plans available and to switch to one that is a better fit. Medvedeff thinks that at least a handful of plans will be available in each state: "enough to create options, but also to sow confusion," he said.

BCE aims to help dual-eligible people compare plans. It works this way: Participating state Medicaid agencies will provide Informed Decisions with information about the dual-eligible individuals living in the state, including the medications that they take. Informed Decisions will compare those individuals' prescription needs with the formularies of each Medicare-approved plan operating in the state. Then each dual-eligible person will be sent a letter that includes a personalized "scorecard," describing which medications are covered by each plan. People will be able to enroll in the plans starting November 15.

Pharmacists also will be able to help dual-eligible people analyze their options, because they will be able to access the scorecard information for each individual via the Internet, Medvedeff said. There will be no charge for accessing the information, but pharmacies will need to be state Medicaid-approved, and they will have to get each person's permission, he said.

Officials of 3 states already have said that they intend to use the service, according to Medvedeff. One of them is Louisiana, which has ~100,000 dual eligibles. Discussions are in progress with officials of another 14 states, including California, New York, and Texas, he added.

As already mentioned, another element of the program will be a 1-hour accredited continuing education course, which will be available free on-line and on CD. The course is aimed at pharmacists and other health care professionals. It will cover the basics of the Medicare prescription benefit, as well as focusing on the limited-income and dual-eligible groups, who will be most affected by the benefit in the short term.

The involvement and education of pharmacists are key, because, "when people get a letter from Medicare, often the first person they talk to is their pharmacist," said Stacey Swartz, director of management and educational affairs at the National Community Pharmacists Association.

One goal is to provide pharmacists with the education and tools to help make the transition to Medicare Part D smoother than the introduction of Medicare discount cards was in 2004.

One change that pharmacists may have to explain to dual-eligibles switching to Medicare is the need for copayments, which often are not required under Medicaid. The copayment amount will depend on income, starting at $1 for generics and $3 for branded drugs.

Many other less-specific efforts are under way to educate those most affected by the prescription benefit. In October the Centers for Medicare and Medicaid Services (CMS) plans to introduce an on-line tool for analyzing Medicare prescription plans, a spokesperson said. It is expected to be similar to a tool that CMS currently provides at its Web site, www.medicare.gov, to help patients compare drug discount cards. This tool lets them enter information such as where they live and the medications they take, then shows a list of cards available, which drugs are covered by each card, and the copayments required.

Mr. Faden is a freelance medical writer based in Portland, Ore.