Drug Coverage Changes

Medicare Parts A and B. There is a monthly premium for this coverage (Medicare 2013 costs at

Whether you love it, hate it, support it, or detest it The Affordable Care Act as it stands, has been making waves across both news headlines and the medical community alike. For the most part, the focus of the act has been placed on the impact it will have on the consumer or the patient. However, the pharmaceutical division of the medical community is among the groups that are most impacted by the Affordable Care Act. In particular, retail pharmacies are feeling the effects of the act via the reimbursements and provisions surrounding the reimbursement policies that have been altered with the passing of the Affordable Care Act. Reimbursements and the provisions implemented upon retail pharmacies by the Affordable Care Act could prove to be detrimental towards the success and profits gained by private retail pharmacies.

Medicare part D is the prescription drug plan. Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different tiers on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost less than a drug in a higher tier. In some cases, if the drug is on a higher tier and the patient 's prescriber (the patient 's doctor or other health care provider who is legally allowed to write prescriptions) thinks the patient needs that drug instead of a comparable drug on a lower tier, the prescriber can ask the patients plan for an allowance to get a lower copayment. In the case of Mrs. Zwick Part D will cover the prescription drugs that she needs that are not covered by Medicare Part A and Part B unless those medications are on the unapproved list. What the patient will be responsible for paying

Within the formulary the drugs are divided into tiers. Co-payments are based on the tier that the drug is in and range from tier 1, the least expensive drugs, to tier 3 the most expensive drugs. Each insurance company plan is allowed to add or drop drugs from their formularies and move drugs from one tier level to another throughout the year. An insurance company can also drop a drug in the middle of the year, but must continue covering the drug for anyone taking it until the next reenrollment period, at which time a new plan will have to be chosen that covers that drug (Gustaitis, 2007). Although not used a lot there is a fourth tier that is for specialty drugs only. Some plans use a flat-rate or assign a percentage co-pay to the higher tier drugs (Gustaitis, 2007). Other characteristics of the insurance company plans that they have control over are requiring prior authorization for a drug, using step therapy, limiting the quantity, participating at certain pharmacies, and having preferred pharmacies (Gustaitis, 2007).

This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the Beneficiary Notices Initiative to alert the Medicare beneficiary prior to rendering the service. The Medicare beneficiary is notified via the Advance Beneficiary Notice (ABN) (see page 235 in Appendix B).

prescriptions reaches the $2930 prescription limit. In 2012, a plan will pay 14% and the patient

The generic prescription drugs that Plan A provides Impatient RX and does not give Outpatient RX. In Plan B, the generic prescription drugs are not covered. I would take generic prescription drugs for less serious illnesses such as headaches and pain. The Brand Prescription Drugs for Plan A are impatient RX are covered and Outpatient RX is not covered. Plan B’s Brand Prescription Drugs are not covered. Brand Prescription Drugs are medications that I would use for minor illnesses that are branded and patented by a company.

The Medicare offers three types of insurance coverage. Medicare part A hospital insurance covers inpatient care in hospitals, and skilled nursing facilities. It also helps cover hospice care and some home health care. This coverage does not cover custodial or long-term care (Center for Medicare and Medicaid Services, 2013). Medicare also offers part B Medical insurance that covers preventative care and outpatient care. Prescription drug

The first plan is Medicare A and it will cover any of your inpatient fees.

Medicare is an insurance program. Medical bills are paid from trust funds in which deposited money people covered. It helps mainly people over 65, no matter what their income, younger people with disabilities and dialysis patients. The patients pay part of the costs through deductibles for hospital costs, among others.

The passage of the Medicare Drug Price Negotiation Act will also inadvertently increase access to many types of medications for individuals who qualify for Medicare Part D. There is a clause within the bill that would establish rebates to be paid by pharmaceutical companies for low-income beneficiaries. These rebates, in addition to lowered costs, would considerably lessen the financial burden placed on low-income beneficiaries. This will allow more individuals greater access to expensive medications. As an example, each year, financial reasons hinder about 16% of diabetic Part D beneficiaries from filling at least one of their prescriptions (Williams, Steers, Ettner, Mangione, & Duru, 2013). This increase in access will help mitigate the occurrence of cost-related nonadherence to prescription medications, and other such consequences

Medicare also does not pay for long-term care services, routine dental care and dentures, routine vision care or eyeglasses, or hearing exams and hearing aids. The deductibles are extremely high for the enrollee and their beneficiaries and there is not a limit on the annual out-of-pocket expenses that one could accrue. (Carroll L. Estes, 2013)

It is not uncommon for people approaching retirement years to misunderstand the coverage that Medicare provides. Many people are under the false assumption that Medicare will cover all of their bills. This is simply not true. What you will be responsible for depends upon many factors, but with Medicare Part B, you will be responsible for paying approximately 20 percent of the bill. It is for this reason, that supplemental insurance policies are so important.

One of the most important factors before taking steps is ensuring that the patient is part of the process. One of the strategies that a health care provider can do is assess the therapeutic and overall care goals, which means reviewing medications. The therapeutic goals should fit into the overall care goal. The choice of drug, formulation, and dosage should reflect this goal (Oboh, 2013). The second strategy is about gathering information. This intervention shows the provider drugs that may not be taken as prescribed and possible reason for therapeutic failure. This is the time to check that each drug is still relevant to the patient’s condition. It is also important to ask about perceived and actual harm or benefit of the drug (Oboh, 2013). There are several tools that can be used to identify potential polypharmacy in older people. The two most commonly used tools in Canada are known as the Beers and STOPP criteria. Beers are a list of medications that are divided into three classes allowing providers to see medications to be avoided regardless of the disease, medications considered inappropriate when used in patients with certain diseases, and medications used with caution (Kwan & Farrell, 2014). STOPP on the other hand, are clinically significant criteria for inappropriate prescribing, grouped by physiological system including clinical context and stopping rules (Kwan & Farrell, 2014). According to Kwan & Farrell, “using these criteria does not replace the need for clinical judgments and understanding of a patients values and needs; sometimes potentially inappropriate medications (PIMs) might be appropriate if the benefit outweigh the benefits (2014)” The last strategy that can be use is discontinuing unnecessary drugs. The decision on which drugs should remain or be discontinued is based on the risk associated with discontinuing the drug, available guidance, and

Any changes in existing regulation could pose a threat to the company since it operates in regulated markets. Failure to keep up with the regulation and abide by new rules immediately could have negative impacts for the company. Prasant Manandhar, head pharmacist at Hemel Hempstead noted, “These companies could face problems with licensing, processing prescriptions or even with regulations of product traceability and how products need to be stored etc. quite easily if the regulations change even slightly.”