Beginning January 1, 2006, nursing home residents, including all those dually eligible for Medicare and Medicaid (the dual-eligibles) and many Medicare-only residents will enroll in the Medicare drug benefit (also known as Part D). The benefit will be administered by private health plans, managed care organizations, and pharmacy benefit managers (PBMs) acting as prescription drug plan sponsors. It is likely that your patient population will be enrolled in different Medicare drug plans offered by the various sponsors. KPS Pharmacy can continue to serve your needs, even as your customers enroll in new plans and switch from one plan to another.

The Medicare drug benefit is both similar to and different from commercial drug benefits. To manage drug costs, drug plans are expected to use the same types of pharmacy benefit management tools that are common in commercial plans, such as preferred drug lists, step therapy, prior authorizations and tiered copayments. Most plans will require enrollees to pay a monthly premium (around $32 in 2006 for a basic plan), an annual deductible, and a share of the cost of prescriptions. The out-of-pocket costs will vary depending on the drug plan. Some of your customers may qualify for reduced or no cost-sharing, if they meet certain income and assets requirements.

The Centers for Medicare and Medicaid Services (CMS), and other government agencies (like the Social Security Administration (SSA) and state Medicaid offices) are very active on several fronts in preparation for the January 1st launch of the new benefit. These agencies are undertaking several key actions, including:

• The SSA and state Medicaid programs have identified beneficiaries who may be eligible for reduced or no cost-sharing due to low-income or disability,
• CMS has reviewed plans and plan marketing materials,
• All three agencies are conducting outreach and beneficiary education, and
• The SSA and state Medicaid offices are automatically enrolling the dual-eligibles (randomly assigning people to plans) and facilitating the enrollment of other subsidy-eligible individuals into plans.

CMS and other agencies may approach you in their outreach and identification efforts. KPS Pharmacy also will be monitoring these activities and will provide you with details about these agency activities and help you with access to and in understanding agency resources. You may be asked by patients and their families to explain the Medicare Part D benefit, the particular plans offered to your residents, and other enrollment issues. KPS Pharmacy has created a brochure to explain the Part D Drug benefit to residents and their families. Please click here to open a PDF of the brochure.

Q: Can my customers continue to be served by KPS Pharmacy?

KPS Pharmacy can continue to be your pharmacy provider. KPS Pharmacy is continuing to develop relationships with potential Medicare Part D plan sponsors in order to be able to serve your patients as in-network pharmacy providers. Please click here to see a list of KPS Contracted PDPs.

Q: Are dual-eligible residents of ALFs considered institutionalized, and therefore eligible for zero cost-sharing?

Dual-eligible residents of ALFs are not considered institutionalized as it relates to the Part D benefit. Dual-eligibles should expect to pay nominal copays for the drugs they receive.