2010 Medicare Part D Program Information

Important Medicare Part D Dates for 2009-2010

• October 1, 2009:
  Medicare Part D Prescription Drug plan Marketing Activities can begin - At this time you will be able to once again gather information and evaluate the various Part D plan alternatives.
• Please note, no enrollments may be accepted before November 15, 2009.
• November 15 to December 31, 2009:
  Annual Coordinated Election Period - Here is your chance to join a Medicare Part D plan for 2010. If you already have a Medicare Part D plan, this is your time to look back over 2009 and make another decision for your 2010 coverage. Should you stay with your existing coverage or make a change? Here is your opportunity to decide. If you make no decision, you will remain in the same plan as you elected in 2009. There is no enrollment required to renew your present coverage. Don't forget the previous years! People who waited until the end of December also waited into January for the arrival of their Welcome Information. Bottom Line: Don't wait until the end of December to make your enrollment decision. (If you do not enroll during this period, your next chance for coverage is January 2011.)
• January 1, 2010:
  Your 2010 Medicare Part D plan becomes effective and you will be able to begin using your Part D benefits.
• January 1 to March 31, 2010:
  Open Enrollment Period (or OEP) - This special period is available for those people who enrolled into a Medicare Advantage Plan with Prescription Drug coverage (MA-PDs) and now wish to disenroll back to original Medicare coverage and a Prescription Drug Plan. As noted by CMS: "PDPs must accept enrollments for individuals enrolled in a MA-PD plan and who choose to elect Original Medicare during the MA OEP that occurs from January 1, 2010 through March 31, 2010. Since MA rules require these individuals to maintain prescription drug coverage, they MUST enroll in a PDP to accompany Original Medicare. This OEP allows MA-PD enrollees to enroll in a PDP and is limited to 1 enrollment."

Additional Proposed Changes for 2010

• Formulary Drugs - Beginning January 1, 2010, CMS proposes rejecting the inclusion of drugs on a formulary if the drug's national drug code (NDC) is one for which the FDA is unable to provide regulatory status determinations through their regular processes. Specifically, CMS is exploring the feasibility of establishing prescription drug event (PDE) submission edits based on a comparison of commercial databases that CMS uses to evaluate PDEs with information about drug products posted to FDA's NDC Directory. This comparison would help highlight NDCs for which it has not been affirmatively established that the product meets the statutory definition of covered Part D drug. CMS believes that it is best practice for Part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a Part D drug coverage determination.

• Specialty Tier Threshold - For contract year 2010, CMS will maintain the $600 threshold for drugs on the specialty tier. Thus, only Part D drugs with negotiated prices that exceed $600 per month may be placed in the specialty tier.
  
  
• Transition Notices in Long Term Care Settings - For contract year 2010, CMS is permitting Part D sponsors the option of sending required transition fill notices to network long term care pharmacies. In Lieu of sending enrollees residing in LTC facilities a model transition notice via U.S. mail within 3 business days of the transition fill, Part D sponsors may elect to send the beneficiary transition notice to the LTC pharmacy serving the beneficiary's LTC facility. The LTC pharmacy must then ensure delivery of the notice to the beneficiary within 3 business days of the fill.

• Utilization Management (Prior Authorization and Step-Therapy - Part D sponsors must post submitted step-therapy and prior authorization requirements on their plan websites. Part D sponsors will need to ensure that all utilization management criteria submitted to CMS, including step therapy criteria, are available on their formulary websites for display by November 15, 2009.
  
  
• Medication Therapy Management Program Requirements - CMS stated that MTM programs must evolve and become a cornerstone of the Medicare Prescription Drug Benefit. MDM program target beneficiaries who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur annual costs for covered Part D drugs that exceed a predetermined level a specified by the CMS Secretary. The existing threshold is $4,000 and will be lowered to $3000 for 2010. Plans will evaluate beneficiaries at least on a quarterly basis for automatic inclusion in the program. The beneficiary may choose to opt-out of the MTM program. The services provided in the MTM program, at a minimum, include: an annual comprehensive medication review (CMR), no less than quarterly targeted medication reviews, offer interventions targeted to providers to resolve medication-related problems or other opportunities to optimize the targeted beneficiary's medication use.

• Reference-Based Pricing - Under these programs, sponsors may require enrollees to pay a defined cost-sharing amount plus supplemental cost-sharing based on the differential in cost between the drug being dispensed and a lower-cost preferred alternative such as a generic equivalent. In contract year 2009, fewer than 10% of Part D contracts used reference-based pricing. Given the complexity of reference-based pricing formulas, it is very difficult to accurately convey the extent of expected out-of-pocket spending for formulary drugs subject to reference-based pricing. For this reason, CMS has been unable to have the Medicare Prescription Drug Plan Finder (MPDPF) calculate correct pricing for drugs subject to reference-based pricing, which may distort projections of out-of-pocket expenditures for some beneficiaries and significantly affect their ability to compare cost-sharing obligations under different plans and choose the plan that best meets their needs.
  
  Based on CMS' experience and the increased complexity, CMS has observed with these programs, CMS will eliminate the option of reference-based pricing in the Part D Prescription Benefit Program (PBP) beginning in CY 2010. The basis for this decision is CMS' belief that reference-based pricing may be inherently misleading to beneficiaries and inconsistent with their goal of improving transparency with regard to expected beneficiary cost-sharing under the Part D program.

• Reassignment of Low-Income Subsidy Eligible Individuals - In Fall 2009, CMS will reassign certain low-income subsidy (LIS) eligible beneficiaries from PDPs with premiums that exceed the LIS benchmark in 2010 to PDPs with premiums at or below the benchmark, effective January 1, 2010. They will continue to provide mailing to affected individuals. CMS will also work with plans that are losing members to identify appropriate ways to reach out to these members to explain how they can remain in their current plan and what their premium liability will be if they choose to do so.
  
  
• Retroactive Auto-Enrollment of Full Benefit Dual Eligible Individuals - Beginning on January 1, 2010, CMS intends to implement a demonstration in which it will assign new full benefit dual eligible individuals with retroactive coverage to a single contractor for those retroactive periods. CMS will conduct a competitive solicitation to select this contractor early in 2009. CMS will continue to randomly assign these individuals to qualifying PDPs on a prospective basis.