The new Medicare Part D drug benefit has been in effect since January. News stories everywhere have told us about confusion among beneficiaries caused by multiple plan offerings, failures in coverage (especially for dual-eligibles), high out-of-pocket costs for some enrollees, long delays in getting prescriptions filled and general incomprehension regarding all the complexities of the new system.

On a positive note, stories started appearing in March and April about notable successes in the program. The fact is that individuals over age 65 who have invested the time and effort to figure out their new benefit (or have had help doing so) will save hundreds or thousands of dollars by the end of the year, depending on their drug regimens. So the system, regardless of its glitches, has the potential to work.

What does it all mean for the sales representative? It could mean plenty. This is especially apparent when you consider the aging of the general population and the fact that the Medicare population consumes a significant percentage of the prescription drugs you promote every day.

This article provides an update on key Part D issues and then takes a look at a few steps you can take in the field to help boost prescription volume in the Medicare sector.

I covered details of the new Medicare Part D drug benefit in the September 2005 issue of Pharmaceutical Representative. Let's briefly review the basics:

The Medicare Part D prescription drug benefit is a voluntary program, and beginning last fall Medicare beneficiaries had the option of enrolling in one of two types of programs: a Medicare prescription drug plan (PDP) or a Medicare Advantage prescription drug plan (MA-PD).

Part D enrollment, spring 2006

PDPs are stand-alone plans that provide a prescription drug benefit for a separate premium; there are no integrated benefits with PDPs. An MA-PD is a prescription drug plan that is incorporated into a comprehensive managed care-type insurance plan. Medicare Advantage members who opt for Medicare Part D pay an extra premium to incorporate drug coverage into their plans.

PDPs and MA-PDs are private, risk-bearing plans that operate in the same manner as traditional pharmacy benefit management companies. Like PBMs, Medicare drug plans have their own drug benefit designs and formularies (many well-known PBMs operate their own Part D drug plans).

Filling in the "doughnut hole"

During the planning phase for the Part D launch, actuaries at the Centers for Medicare and Medicaid Services created a standard benefit design for PDPs and MA-PDs to follow. The design received a lot of negative publicity for the much-maligned "doughnut hole," a coverage gap that forces beneficiaries to pay for 100% of their prescription drug costs out of pocket if their costs exceed $2,251, up to a $5,100 limit, when catastrophic coverage kicks in.

In reality, when private PDPs and MA-PDs announced their Part D offerings in the fall of 2005, actual plan designs varied considerably from the CMS model. Most plans offer as many as three general plan designs, each with its own set of monthly premiums, copayments and variations on the coverage gap.

Regional Part D formulary coverage

Low-premium plans are typically designed for healthy seniors who anticipate the need for few prescription drugs during the year; mid-premium plans are tailored for seniors with average prescription drug requirements; and high-premium plans are targeted toward chronically ill individuals on multiple drug regimens.