Medicare Part D plan providers are scrambling to make their 2012 prescription drug plans stand out. Coventry Health Care is the insurance company behind the First Health Part D brand. Coventry’s First Health Part D plans will see minor changes for 2012 but the big change is the addition of a new prescription drug plan to the line up. This article will address some of the changes for 2012 and give a sneak peak to the new First Health Part D plan. Part D plan benefits and formularies can vary by State so you should check benefits relative to the State where you live.
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Coventry First Health Part D Plan Preview
Coventry First Health Part D has released to us a preview of their 2012 PDP products. These product plans will offer broad formularies, a large national pharmacy network, and strong benefits all at a competitive price that leaves additional money for other product sales. Coventry First Health PDP product plans are widely available – Premier (PDP) and Premier Plus (PDP) are available in all 50 states and the District of Columbia as well as Value Plus (PDP) is available in 48 states and the District of Columbia, not in Hawaii or Alaska. New for 2012:
Coventry Announces First Health Value Plus Medicare Part D Plan
who is selling only a PDP to someone 80 years old. Think about it by the time they are 80 they have 4 kids 10 grand kids and 18 greats, they also have 30 neighbors and 40 people at church and 400 people in their circle of influence. Now you have 400 leads that all need medical, dental, life and disability insurance along with home auto and business coverage. What happened to the $30 comission that you complained about? I think many Agents just need to get out of the business anyway because they are smart enough to know what their doing in the first place.
Medicare Prescription Drug Plans Will Drop In Price By 4 Percent
“We believe our pricing in 2012 for Medicare Part D plans will provide beneficiaries with affordable options that will enable them to access many of the prescription drugs they need,” Aetna spokeswoman Susan Millerick said, “and will also make us more competitive in the Part D market. In 2012, Aetna will offer Part D plans with premiums lower than the Low-Income-Subsidy Benchmark in 40 states and the District of Columbia. This is historically an indicator of a Part D product that is well positioned to meet the needs of Medicare beneficiaries.”
IPBiz: Ranbaxy’s Lipitor copy goes on sale, but…
Ranbaxy’s Lipitor-copy goes on sale 1 Dec 2011, but the impact on consumers is a bit more complicated than one might think. For example, Watson Pharmaceuticals is selling a Lipitor copy under an agreement made with patentee Pfizer (thus, an authorized generic). And Pfizer has made deals with insurance companies. Bloomberg reports: UnitedHealth Group Inc., the biggest U.S. health insurer by sales, said Nov. 19 it will charge a lower co-pay for Pfizer’s pill than it does for generics for the next six months, taking advantage of a price reduction from the drugmaker. Looking at this a different way, the out-of-pocket expense for generic Lipitor can be different for someone without health insurance (who will likely buy generic) than with certain health insurance (who will keep buying Pfizer-made). Bloomberg also reported: Pfizer has struck deals with companies including Catalyst Health Solutions Inc. and Coventry Health Care Inc. to prevent generic Lipitor from reaching some patients until the end of May 2012. As one can see, the big price break for this statin is 6 months from today. Ranbaxy is 64 percent-owned by Daiichi Sankyo Co. Ranbaxy’s Lipitor-copy will be made in “Princeton,” NJ. See also What happened to the guy who developed Lipitor? Yes, Virginia, Ranbaxy Will Sell A Generic Lipitor Ranbaxy to Share Part of Lipitor Profits With Teva **UPDATE. Concerning other drugs, doctors frequently express “surprise” that a certain drug is NOT covered by a certain health insurance. From Consumer Reports on how Lipitor is being covered: For example, Cigna RX1 is reducing its co-pay from $31 in 2011 to $3 in 2012, CVS Caremark Value is going from $42 to $8, and WellCare Classic from $41 to $6. On the other hand, First Health Part D Premier appears to be dropping Lipitor from its formulary entirely. And Consumer Reports gets into generic substitutes for Lipitor (atorvastatin ), such as lovastatin or simvastatin. But note that the cleverly worded phrasing — if you need to need to lower your LDL by less than 30 percent — includes reducing LDL by 0 %. At least Consumer Reports acknowledges differences among the statins. [Some insurance companies will assert losartan is a reasonable substitute for Diovan (valsartan), and won’t pay for the latter. A study put out by Novartis (the patent holder for Diovan) asserted: The weighted average reduction in mean SBP and DBP for valsartan 160 mg was -15.32 mmHg (95% CI: -17.09, -13.63) and -11.3 mmHg (95% CI: -12.15, -10.52) and for 320 mg was -15.85 mmHg (95% CI: -17.60, -14.12) and -11.97 mmHg (95% CI: -12.81, -11.16); these are statistically significantly greater reductions compared with losartan 100 mg, which was -12.01 mmHg (95% CI: -13.78, -10.25) and -9.37 mmHg (95% CI: -10.18, -8.54) for SBP and DBP respectively. [See Int J Clin Pract. 2009 May;63(5):766-75. ] BUT, there is an interesting difference among the two as to uric acid: serum uric acid levels, which decreased from 6.0 to 5.7 mg/dL in the losartan group and increased from 5.9 to 6.0 mg/dL in the valsartan group (P = 0.001 for between-treatment difference, from Clin Ther. 2001 Aug;23(8):1166-79.] See also New generic version of Lipitor like an early Christmas present which includes: A month’s supply of Lipitor costs about $120. The first shipment of the generic version, atorvastatin, costs about 15 percent less, said Mike Koelzer, owner of Kay Pharmacy at 2178 Plainfield Ave. NE. But in about six months, the price for generic versions of Lipitor likely will drop to about $10 a month, he said. AND Still, Decker said he has been prescribing the other generics to many patients to keep costs down or because the insurance company requires they first try a lower-cost drug. The article omits the observation that even if one tries the lower cost drug first, and it comes up lacking, the insurance company may not provide any payment for the higher cost drug. One is “allowed” by the insurance company to pay full price for the higher cost drug.
Does Colonial Penn Offer The Best Medicare Supplemental Insurance?
Medicare Supplemental Insurance will cover costs which are not covered by medicare, these include by are not limited to ambulance transportation, extended hospital visits, and co-pays. The most important aspect of your health and well being is excellent medical care. Making decisions on what medical care to receive should not be determined by an apprehension of the overall costs. With Medicare Supplemental Insurance, you will be able to get the care you deserve without worrying about the costs.
Medicare Part D Insurance Made Easy!
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Canadian Pharmacy Brings Outside Perspective to Medicare Part D
The Government is enforcing Medicare Part D. Proof of this is evident if considering the penalties individuals will incur by not joining Medicare Part D by May15th. The accumulative 1% penalty (per month) can become expensive over time and looks counter productive. It seems more likely the Government agenda is geared towards herding the public into a central plan and closing the doors for international prescription imports.
OIG Identifies Part D Oversight Gaps : Health Industry Washington Watch
“Audits of Medicare Prescription Drug Plan Sponsors,” examined the extent to which CMS conducted seven types of audits developed to identify problems and correct deficiencies in the Part D program: auto-enrollment readiness audits; benefit integrity audits; bid audits; compliance plan audits; long-term-care pharmacy contract audits; pharmacy access audits; and program audits. Note that there is no legal requirement for CMS to conduct these audits; mandatory financial audits of PDP sponsors are being examined by the OIG for a separate report. The OIG found that CMS did not conduct any of the seven types of audits for 50 of the 125 stand-alone PDP sponsors in 2006 through 2009. For the audits that were conducted, 79% identified problems (the majority of which involved beneficiaries’ coverage status or payment issues). The OIG recommends that CMS establish a comprehensive Part D auditing strategy that ensures that each plan sponsor is audited within a certain timeframe. While CMS plans to complete a bid audit of every PDP parent organization, CMS believes a comprehensive oversight/performance monitoring strategy is more effective than an auditing strategy. CMS concurred with a second recommendation that it ensure that evidence is available to show that corrective actions have been implemented.
Medicare disenrollment allowed until Feb. 14
The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare, in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more. However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs. Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care. Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans. Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.” There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.” Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans. On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism. In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars. Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees. Others have reported that minority enrollment is not particularly above average. Another study has raised questions about the quality of care received by minorities in MA plans. The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.  Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Low Cost Health Insurance Plans and Companies: Medicare Part D Newsletter from Q1Medicare.com
For instance, people who use only low-cost generic medications, and choose a Medicare Part D plan with a low monthly premium and standard initial deductible, may find that they never get any cost-sharing benefits — because they must first satisfy the initial $320 deductible before their low-cost generics are covered by their plan.