Greetings,

Medicare Prescription Drug Coverage:
What Does It Mean for People with Seizures?

Beginning January 1, 2006, prescription drug coverage will be available to all people with Medicare insurance.  No matter how people with Medicare get their health care today or whether they have existing drug coverage – they will be eligible for drug coverage under a Medicare prescription drug plan.  The drug plans will be available in all parts of the country, and they will cover brand name and generic drugs.  Prescriptions can be obtained from neighborhood pharmacies and through mail order.

All Medicare beneficiaries will have a choice of plans, so they can get the coverage that meets their needs.  They will need to make a decision soon about signing up for Medicare' s new prescription drug coverage – and the federal government has launched a nationwide outreach effort to help them to make an informed decision.

Enrollment Has Begun!

Enrollment began on November 15, 2005.  Coverage begins January 1, 2006. People currently on Medicare or eligible for Medicare have until May 15, 2006, to sign up for their prescription drug plan without penalty. There will be penalties in the form of higher costs for the plans for beneficiaries who enroll after May 15, 2006.

People with Epilepsy on Medicare

Access to all the medications the doctor has prescribed is a critical issue for people who have seizures. There are more than twenty different kinds of seizure medications. These medications are NOT interchangeable, some are better for some seizures than for others, some cause different side effects than others; some are better tolerated in one person than in another. It is important to see how the individual's own medications will be covered under a plan before deciding to sign up for one plan or another.

The agency that implements the new Medicare drug benefit (the federal Centers for Medicare and Medicaid Services – CMS) has publicly stated that "all or substantially all" epilepsy medications will be available under the plans. Thus far, the Foundation has reviewed ten of the national plans for their coverage of anti-convulsants. Our review has shown that many of the national plans are covering the generic drugs at the lowest cost, and placing the newer and more costly drugs in tiers that require a higher co-payment for beneficiaries. In addition, the Foundation's review of the plans has shown that the newest epilepsy drug, Lyrica, is not available on any of the plans. It may only be available if you call the plan after you have failed first on another anti-convulsant, and have documentation from your physician stating that you have tried another anti-convulsant and "failed" on that drug. The Foundation is currently developing comments to CMS regarding the coverage of anti-convulsants by the plans.

If You Also Qualify For Medicaid

Individuals who qualify for both Medicare and Medicaid are known as "dual eligibles" and now receive prescription coverage from Medicaid. On January 1, when Medicare's new Prescription Drug Plan begins, their drug coverage switches from Medicaid to Medicare.

Medicare doesn't want any dual eligible beneficiaries to experience disruptions in coverage as a result of this change. For that reason, all dual eligibles who do not choose specific drug plans and enroll before December 31, 2005, will be automatically enrolled in plans chosen for them by Medicare. This is known as "auto-enrollment." Any dual eligible beneficiary who is auto-enrolled and is not satisfied, is entitled to switch to another plan.

All dual eligibles should have received a letter by now informing them of which plans they will be auto-enrolled into starting January 1, 2006, if they do not pick their own before then. All dual eligibles are strongly encouraged to decide before December 31 whether another plan would better meet their needs. After that, they will be able to switch plans about once a month, although there may be a few weeks waiting period before the change takes effect. Dual eligibles will not need to wait for the annual open enrollment period, like most other recipients.

Choosing the best plan for you includes carefully reviewing information about the availability and costs of the medications you need. Most people with epilepsy need to take their medications as prescribed and on a regular basis. Thus, it is especially important to avoid too many drug plan changes. Not every plan will cover every drug available, or cover all drugs within a therapeutic class (e.g., antiepileptic drugs) the same way. So changing plans may mean changing your medication(s) or the way your medication is available to you. To avoid this problem, it will be important for you to choose the right plan for you early on, rather than spend time in the wrong drug plan.

Certain classes of drugs, such as benzodiazepines or barbiturates, will not be covered by any Medicare drug plan, but may be covered by state programs. Dual eligibles are advised to check with their state Medicaid offices or their physicians about options.

Questions for people with epilepsy to think about before enrolling in a plan

• What will my monthly premium cost?
• Are my anti-convulsants covered under the plan?
• Are my particular dosages covered?
• How much will my anti-convulsants cost?
• Will I have to pay a higher co-pay for brand name drugs versus generics ("tiered cost-sharing")? How many tiers? What are the increased costs at the different tiers?
• Will a prior authorization from my doctor be required before I can get my medication?
• If not on the plan, is there a simple process to ask the plan to cover your medications? (What is the exception or appeal process?)
• Is my pharmacy covered by the plan?
• Can I order my prescriptions by mail?

All Medicare beneficiaries will have to make many choices in picking a drug benefit plan that is best for them. First, you should determine if your current prescription coverage plan – if any - will continue to be available to you after January 2006. If it is, you will need to decide if it is better for you to stay on that plan than to switch to any of the new plans that will be offered to Medicare users.

Another question will be whether you want to go with a prescription drug plan (PDP) that includes only prescription drug coverage (a stand alone PDP), or one that includes other Medicare services along with a prescription drug plan (a Medicare Advantage plan). The answer to this may depend upon how well your medications are covered under the different plans available in your region of the country.

A critical choice for everyone will be the overall cost of the plan (the premium) and the deductibles that you will have to pay out of your pocket. There are tools to help you find out the costs of each plan available through www.medicare.gov. Each plan can also provide you with this information.

Separate from the overall costs of the plan, people will need to review the plans to be sure that the medications he or she is currently on are in fact covered, and how. Other questions that must also be answered include whether your local pharmacy is part of the network of covered pharmacy services, so that you can get your medications filled either at the pharmacy you use, and/or through a mail order service.

In order to assist you with answering all of these questions, the Epilepsy Foundation has joined with other groups to develop tools especially designed for people who have serious chronic health conditions like epilepsy. The goal of these tools is to assist you as you review the available plans and find the answers to the questions you have. One of these tools is available through www.MapRX.info. The information can be copied or downloaded directly from that website for your use.

It is the Foundation's recommendation that no one sign up for a plan without contacting the plan first to see how your medications are covered. After you have those assurances, you may sign up for the plan of your choice at 1-800-MEDICARE or online at www.medicare.gov.

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