Learning about Medicare Drug Benefit
Description
The Medicare Prescription Drug Plan (also known as “Medicare Part D”) was initiated on January 1, 2006 to help Medicare recipients pay for their prescription drugs. It is available to everyone with Medicare, regardless of income, health status, or how you currently pay for prescription drugs. It helps to pay for both brand-name and prescription drugs. The drug coverage is provided after your loved one enrolls in one of the Medicare drug plans. The available plans vary by the city and state in which your loved one lives. You can enroll online or by phone (1-800-MEDICARE, 1-800-633-4227).
The Medicare Prescription Drug Plan is a program in which you (or your loved one) enroll in a drug plan through a private insurance company, which has been approved by Medicare. The coverage of specific drugs varies with each insurance company, but Medicare will reimburse the insurance companies to help pay for your prescription drugs. People with Medicare and Medicaid (also known as “dual eligibles”) were automatically enrolled into the lowest cost plan in their area in the fall of 2005, but may choose another plan before January 1, 2006.
Type of Plans
The Medicare Prescription Drug coverage is an insurance program, with two types of participating insurance companies: (1) private insurance prescription drug plans (PDPs) and (2) Medicare Advantage prescription drug plans (MA-PDs), which are managed care companies offering other health services and prescription drugs (this is also known as Medicare Part C, or Medicare Plus Choice).
If your loved one is currently in a Medicare Advantage managed care plan, you will need to choose a plan linked to the managed care plan. If your loved one currently has private health insurance, you will choose a plan in the private insurance drug plan. If your loved one already has prescription drug coverage through a Medicare private health plan or an employer, please check with the current plan to see if this coverage is changing.
You will be able to choose one plan and enroll to get coverage from that plan. Plans will decide what drugs they will cover. The list of the covered drugs is called a “formulary”. Each plan has its own formulary. Formularies often divide drugs into tiers. First-tier drugs are the preferred drugs and will therefore have the lowest co-payment. Second-tier drugs will have a slightly higher co-payment, and third-tier drugs an even higher co-payment. It is best to select a plan whose formulary covers most or all of your drugs. If that is not possible, then consider talking with your doctor or pharmacist about switching drugs to the “covered” drugs of the selected plan.
If you loved one is receiving prescription drug coverage through Military retiree benefits (TRICARE), Veteran benefits (VA), or Federal employee retiree benefits (FEHBP), the Medicare Website says:
Enrollment Timeline
Enrollment began November 15, 2005 and continues until May 16, 2006. After this time, you can still enroll your loved one, but there will be a higher premium or penalty. The higher premium/penalty will apply for the rest of your loved one’s life. So, it is highly advantageous to enroll prior to May 16, 2006.
Once enrolled, if you wish to change plans, you can switch plans during a specific window of time each year: November 15 through December 31. Your new Medicare prescription drug plan will then begin January 1 of the following year. Medicare beneficiaries who qualify for the Extra Help program (described below, under Plan Costs) can change their prescription drug plan at any time. If your loved one does not qualify for Extra Help, he or she can change plans once between now and May 16, 2006.
You (as your loved one’s caregiver) can sign up your loved one for the Medicare Prescription Drug Plan if you have the legal right to make health care decisions on his/her behalf (such as through a Power of Attorney). This person is sometimes called an “authorized representative.” Even if your loved one does not have the intellectual ability to enroll herself/himself in the plan, she/he is still eligible, if she/he is a Medicare recipient. However, the person completing the form must be a legal representative. If your loved one does not yet have a legal representative, he or she can choose an individual to act as the representative to fill out the application (such as a spouse, child, or a caregiver).
Plan Costs
If your loved one joins the Medicare Prescription benefit, his or her costs will vary depending on which plan is chosen. In general, there is a monthly premium (generally around $37 in 2006) and a yearly deductible (up to the first $250 in 2006). Your loved one will also pay a share of the prescription drug costs, and the plan will also pay a share. Medicare helps pay for drugs up to a limit ($2,250 in total). Once the total out-of-pocket costs for drugs reach $3,600, your loved one pays 5% of the costs and Medicare pays 95% of the costs for the rest of the year.
For people with limited income and resources – including people with Medicare and Medicaid and those with income below 150% of the Federal Poverty Level (or about $14,000 in annual income) – the government will pay for many of the costs of the new drug coverage through its Extra Help program.
If your loved one did not receive information on this program, you can call Medicare or your local Social Security Administration (SSA) office to find out if your loved one will automatically get Extra Help or to fill out an application for this program. For those who are “dual eligible patients” (ie, currently receiving both Medicare and Medicaid), contact the Center for Medicare and Medicaid Services (CMS) if your loved one is having problems getting prescriptions filled.
Coverage of Current AD Drugs
Which drugs are covered?
In general, you and your loved one will have numerous drug plans from which to choose, but the exact number of plans will depend on your city and state. You can choose which plan is best for your loved one by simply completing a form online. This form will ask you which drugs your loved one is currently taking and what pharmacy he or she uses, and will show you all of the insurance plans that currently cover that drug. From those choices, you can then narrow down the choices of which plan would be best for your loved one.
So, for example, if your loved one is taking Aricept® (donepezil), you would indicate that on the form, along with all of the other drugs he or she may be taking for other conditions (eg, high cholesterol, high blood pressure, depression, etc.). If possible, you should choose a plan that covers all of your medications.
The CMS requires that each plan cover at least 2 drugs in each drug category. They are strongly encouraging plans to cover a majority of medications in the following categories: anti-psychotics, anti-depressants, and anticonvulsants. This is true for 2006, and may be re-evaluated in 2007. However, benzodiazepines (eg, Ativan®) are not currently covered.
A Plan Comparison Web Tool is available. The tool will help you pick the drug plan that’s right for your loved one. Otherwise, you can call Medicare directly and someone at Medicare will fill out the form for you to determine your options. There are also local Medicare-related events in which Medicare representatives are available to explain this drug plan and help you complete the form.
If your loved one currently does not have coverage for some of their drugs, they may now be able to get coverage, depending on what plans are available locally. You can quickly find that out by completing the form.
Can a Medicare drug plan change their formulary?
Plans are allowed to make changes to their approved drug list at any time. However, they must give 60 days’ notice of these changes to enrollees who are taking that medication or provide enrollees with a 60-day supply of the medication they are removing from the approved drug list. The plan must also notify prescribing physicians and the Centers for Medicare and Medicaid Services (CMS).
The CMS requires that the plans include medications in a wide range of therapeutic categories.
What if the doctor changes my medication(s)?
That will depend on the specific insurance plan. You can complete the online plan comparison tool (described above) or call Medicare to find out what other plans would cover the new medication. You can switch to a different plan between November 15 and December 31. Your new Medicare prescription drug plan will then begin January 1 of the following year. However, please remember to list all of your loved one’s drugs when using the plan comparison tool. So, even if the new drug is covered by another plan, another drug that he or she is currently taking may not be.
Which drugs are excluded?
Some drugs are currently not included in the new Medicare prescription drug benefit. These include: benzodiazepines (eg, Ativan® [lorazepam], Klonopin® [clonazepam], Valium® [diazepam], Xanax® [alprazolam]), barbiturates, and drugs to treat eating disorders. If your loved one takes these medications, you should either find another patient assist program, which are available from private organizations and drug manufacturers, or talk with your doctor about other possible medication options.
Selected Helpful Online Resources
While the new prescription drug plan can be confusing, many resources are available to provide information. These include:
The Alzheimer’s Association – Medicare Prescription Drug Coverage
This section of the AA Website contains fact sheets and links to Websites to help you make informed decisions about this new coverage for you or the person you care for.
The American Association for Retired People (AARP)
This site helps you prepare the drug plan search and protect yourself against fraud and scams. It also provides information on what to do if you don’t have computer access and other issues you may not have considered -- prior authorization, step therapy, quantity limits, co-payments [including “tiered co-payments”], and premiums and deductibles, as well as enrollment and changing plan information. The site also provides a list of medications for the plan finder tool.
Tel: 1-800-MEDICARE (1-800-633-4227)
This site offers all of the information on the prescription drug plan, including:
The Medicare Rx Education Network is a network of organizations that share a common interest in educating and informing seniors and persons with disabilities and chronic conditions about the new Medicare benefit. The mission of the Website is to provide information and assistance with outreach and enrollment for the new Medicare Part D prescription drug benefit to Medicare beneficiaries.
The member organizations of Medicare Rx Education Network include AARP, the American Academy of Managed Care Pharmacy, the Alzheimer’s Association, the American Geriatrics Society, National Alliance for the Mentally Ill, the National Council on Aging, and many, many others.
There is a lot of information on Medicare Prescription Drug Plan on this site, as well as links to all of the network organizations.
This site explains Medicare Part D (ie, the Medicare Prescription Drug Plan), enrollment and eligibility, costs, the Extra Help program, information on whether the new benefit will affect other assistance (eg, food stamps and housing assistance), and what can be done if a prescription drug isn’t on the formulary, is subject to prior authorization, or is subject to higher co-payments.
Partnership for Prescription Assistance
Tel: 1-888-477-2669
This organization can help you find other private assistance programs to pay for drugs that are not covered by Medicare Part D.
TRICARE, Military Health System
Tel: 1-888-363-5433
1-877-222-8387
1-888-767-6738