Background |
Who Can Get Medicare Part D? |
What is a PDP?
What's Covered? |
How Much Will Medicare Part D Cost? |
Which Pharmacies Are Participating?
What's the Impact on Pharmacy? |
When and How Can Patients Sign up? |
The Bottom Line
References
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Pharmacists are getting and will continue to get LOTS of questions from patients about Medicare. Should I sign up? Which plan is right for me? How do I sign up? The nation's seniors are confused, and rightly so. There are many rules and many options. As a pharmacist, America's seniors will be asking you about Medicare prescription drug coverage. Be ready for these questions with this continuing education review on the new Medicare law.
To help your patients, get a copy of, "Picking a Medicare Prescription Drug Plan," produced by Consumer Reports in conjunction with Pharmacist's Letter specifically for you to hand to patients who want help figuring out the new Medicare options.
We've also put together a handy worksheet for you to give to seniors to help them select a Medicare plan.
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| | | | Background |  | |
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The Medicare Modernization Act (MMA) of 2003 created a federal drug plan for seniors. This new Medicare-sponsored drug plan, called Medicare Part D, began on January 1, 2006. Medicare Part D is meant to help patients pay for prescription medications. Under this new plan, the government doesn't directly pay for prescription drugs. Patients will get drug coverage from a private Prescription Drug Plan (PDP), which covers only prescription drugs, or a Medicare Advantage Rx Drug Plan (MA-PD), which is associated with a healthcare plan (like an HMO or PPO). Available plans have been approved by the Centers for Medicare and Medicaid Services (CMS).
As part of this new plan, the Medicare "Drug Discount Cards" are going away. They will be gone by May 15, 2006…but other types of drug discount cards may still be around.
| Timeline for Changes |
- October 2005 - CMS mailed the informational booklet, "Medicare & You," to beneficiaries which describes prescription plan benefit and cost information
- October 2005 - CMS approved PDP providers began marketing their plans to beneficiaries
- October 2005 - CMS distributed information comparing available Part D coverage to beneficiaries through the mail, CMS website, and by phone
- November 2005 - Beneficiary open enrollment began for Medicare Part D
- December 31, 2005 - Medicaid drug coverage ended for Medicare patients (dual eligibles)
- December 31, 2005 - Medicare prescription drug discount card program ended (phase out period will extend until May 15, 2006)
- January 1, 2006 - New Medicare Part D prescription drug plan started6,7
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Question #1 | | Which of the following is TRUE about Medicare Part D? | | | | | | | | |
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| | Who Can Get Medicare Part D? | | |
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ALL Medicare patients are eligible, regardless of income. Persons over age 65 or those permanently disabled can generally qualify for Part D. Those currently entitled to Medicare Part A, which covers general hospitalization services; or enrolled in Medicare Part B, covering certain physician, outpatient hospital, home health, durable medical, or other services; or Medicare Part C (Medicare managed care plans) will generally qualify.
MediCARE patients receiving MediCAID (dual eligibility) will also have drug coverage under Medicare Part D. They will be required to enroll in a Medicare Part D Prescription Drug Plan (PDP) or Medicare Advantage Rx Drug Plan (MA-PD).
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| | | | What is a PDP? | | |
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You've likely noticed or gotten questions from patients about prescription drug plans based on all the advertising. Private companies have submitted prescription drug plans to the Centers for Medicare and Medicaid Services (CMS). The plans had to be evaluated and approved by CMS before they could be offered to patients. Patients will have a choice of at least two qualifying PDPs in their area, of which at least one is a drug-only plan, not an integrated MA-PD managed care plan. In fact, patients in most states have about 15 options for plans.1
PDP and Medicare Advantage Rx Drug Plan (MA-PD) providers will compete for three-year contracts with CMS. The PDP sponsors will use a typical fee-for-service plan and share financial risk for the benefits offered under the plan. The PDP providers' drug coverage provisions are similar to those currently administered by pharmacy benefits managers (PBMs).2-5
They will have different formularies, pharmacy networks, beneficiary prescription fees, and pharmacy reimbursement provisions. Each PDP provider is required by CMS to have a pharmacy and therapeutics committee, a cost and quality management program, and include medication therapy management (MTM) programs (MTMPs). They are required to allow any pharmacy meeting their provider qualifications the ability to participate in their program.2-5
CMS has defined 34 national geographic regions including some single-state and multi-state regions. Plan providers can offer services in any of the regions but they are not allowed to divide states.8 Ten national PDP sponsors have been named by CMS as of September 23. These are: Aetna, Connecticut General, Coventry Health/First Health/Cambridge, Memberhealth, Pacificare, Silverscript, Wellpoint, United Health Care, and Wellcare.15
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| | | | What's Covered? | | |
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Formularies will cover many prescription drugs but they will vary by plan. CMS has defined Medicare Part D covered drugs as those that are dispensed only on prescription, biological products, certain vaccines, insulin, and insulin-associated medical supplies. Drugs restricted or excluded from Medicaid coverage are not included, with the exception of smoking cessation drugs. Each formulary must include all therapeutic categories and classes of drugs but not necessarily all drugs within a category or class. Plans will cover compounded prescription drugs if at least one of the compounded ingredients is a Medicare Part D covered drug. The U.S. Pharmacopeia developed the list of categories and classes to be used by drug plan sponsors.10-12
For some drug classes, "all or substantially all" meds will be covered. These are critical medications where any substitution might be harmful. These include antidepressants, antipsychotics, anticonvulsants, anticancer agents, immunosuppressants, and antiretrovirals for HIV.1
The following drugs are not covered under standard Part D plans: barbiturates; benzodiazepines; anorexia, weight loss, or weight gain products; fertility products; hair growth products; products for symptomatic relief of cough or cold; prescription vitamins or minerals; nonprescription drugs; and any drug covered by Medicare Part A or B.9-11 It should be noted that bipartisan legislation (H.R. 3151) was introduced that would remove the exclusion of benzodiazepines from the new Medicare Part D prescription drug benefit.13
Beneficiaries will be able to appeal non-formulary covered drugs when the drug is considered medically necessary for that individual.11
| Drugs That Are Not Covered Under Standard Medicare Part D Plans9-11 |
- Barbiturates
- Benzodiazepines
- Anorexia, weight loss, or weight gain products
- Fertility products
- Hair growth products
- Symptomatic treatments for cough or cold
- Prescription vitamins or minerals
- Nonprescription drugs
- Any drug covered by Medicare Part A or B
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For more on drugs NOT covered by Medicare including niacin, benzodiazepines, and cough and cold products, see "Medicare Part D Excluded Medications" Detail-Document #220401.
But Are My Patient's Drugs Covered?
The only way to tell if a certain drug is covered is to investigate a specific PDP. All plans will cover some drugs in each class, but formularies vary by plan. Fortunately, there's an excellent tool at www.medicare.gov that compares Medicare Drug Plans. Patients enter their Medicare number and get PERSONALIZED info about available plans...covered drugs...premiums...co-pays...deductibles. This website will even allow patients to sign up for a plan online. Warn patients that a plan can change its formulary with only a 60-day notice, so their plan may not always cover the same drugs.
There are new Medicare policies on formulary changes. Patients should now be able to get a medication for the rest of the year even if their plan's formulary changes. For more, see "Medicare Part D Formulary Changes During the Plan Year" Detail-Document #220615.
Click here to visit the Medicare Prescription Drug Plan Finder.
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Question #3 | | Which medications will be covered under Medicare Part D? | | | | | | | | |
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| | How Much Will Medicare Part D Cost? | | |
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Plan costs to patients have been established by CMS but will also depend on the costs dictated by the PDP provider.
The standard benefit for those covered under Medicare Part A or B (excludes Medicare Part C Medicare Advantage participants) will be:
- A monthly plan premium of $37 or less depending on the PDP. This premium may be deducted from a beneficiary's monthly social security check, if desired.5,10,11
- A $250 deductible.
- Part D drug expenses over $250 but less than $2,250 will require a 25% patient co-pay.
- Part D drug expenses greater than $2,250 up to $5,100 will be paid entirely by the patient (so-called "doughnut hole").
- Part D drug expenses over $5,100 will require a $2 co-pay for generic or preferred multi-source drugs; for brand name drugs, the co-pay will be $5 or 5%, whichever is greater.
This standard benefit is the minimum required by the government. Standard plans have a $250 annual deductible...then pay 75% of the next $2,000 in Rx costs. From $2,250 to $5,100 there is no coverage...the infamous "doughnut hole." But after $5,100 in total Rx costs, these plans pay 95% of Rx costs. Because plans are trying to be competitive in order to attract patients to sign up, there is actually a wide range of prices and benefits. Plans can cost $2 to over $85 per month, with the average cost being $32.1 There are plans with monthly premiums of $20 or less in 49 states.1,15
Cheaper plans may have higher co-pays or deductibles. The cheaper plans may be right for patients with low prescription drug costs. Costlier plans often waive deductibles or cover the so called "doughnut hole." Medicare Advantage participants will have benefits established through the Medicare Advantage Rx Drug Plan (MA-PD) providers contract approved by CMS.
Special or low-income patients (annual income up to 150% of the Federal poverty line) will be provided subsidies for premiums and cost sharing to help cover the cost of prescriptions.5,10,11 This means low-income patients will pay much less...possibly just a co-pay. Patients currently with both Medicaid and Medicare benefits (dual eligibles) must enroll in a PDP or a MA-PD. These patients will pay from $1 to $2 for generic medications and $3 to $5 for brand-name drugs.10,16 If these patients don't sign up for a plan, a PDP will be randomly assigned to them.
For everyone else, it's very important to remember that they must enroll in order to get Medicare Part D drug coverage. Medicare Part D is an optional program, so if seniors don't sign up they don't get the benefit.
On the other hand, if seniors don't want to participate in Medicare part D, they don't have to. The decision to sign up depends upon each individual senior's current drug coverage and income. Seniors with prescription drug coverage through their employers retirement plan are often better off NOT trading it for a Medicare policy. The BenefitsCheckUpRx website, sponsored by the government, gives personal recommendations based on an individual's situation.
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Question #4 | | How much will the standard Medicare Part D benefit cost a patient? | | | | | | | | |
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| | Which Pharmacies Are Participating? | | |
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To assure patient access to pharmacies, CMS has adopted the Department of Defense TRICARE Retail Pharmacy access standards applied on a state basis. Medicare Part D Plans must provide access to pharmacies within two miles in urban areas, five miles in suburban areas for 90% of enrollees, and 15 miles in rural areas for 70% of enrollees. Advise patients to consider whether a plan allows them to use their preferred pharmacy. Mail-order pharmacies may be used by patients, but they cannot be the only pharmacy type accessible to the patient. Furthermore, beneficiaries must be allowed emergency prescription access in a pharmacy not necessarily associated with a plan or network.
Patients in long-term care facilities will be assured access to pharmacies because PDP providers must offer a standard contract to all long-term care pharmacies in the plan's service area. CMS has established certain standard service and performance provisions for long-term care pharmacies.5,10,11
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| | | | What's the Impact on Pharmacy? | | |
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Pharmacies are free to contract with any PDP or MA-PD provider as long as they meet certain provider standards. This qualified "at-will" contracting by the pharmacy ensures the ability to participate. In some cases this also means that if a pharmacy didn't opt OUT of plans offered to it, the fine print might say the pharmacy is automatically IN. Plans can qualify a pharmacy as "preferred" or "non-preferred" based on the pharmacy's service or other provisions. Long-term care pharmacies in a plan's service area must be offered a standard contract as long as they meet CMS mandated service and performance standards.9-11
CMS provides information on PDP provider agreements so that pharmacists and patients can determine which provider plans to join. CMS, through their Medicare Prescription Drug Plan Finder website, and others will provide web-based tools and other resources to guide in this determination.9-11,15
Just as with participation in a PBM or insurance drug plan, each pharmacy must carefully evaluate the benefits and economic impact (gross margin profitability) of participation. Each pharmacy must also consider their patients' current medication profiles and a matching PDP provider formulary. Without this match, the patient may need to choose another pharmacy for his or her services.
Levels of pharmacy reimbursement will be set by the PDP provider. Pharmacy reimbursement will be for dispensing fees or costs associated with the prescription's provision to the patient. Supply items such as the drug, vial, and label; as well as pharmacist and staff time; including pharmacist prescription consultation with the patient, are included. Services such as medication therapy management programs (MTMP) are excluded from this reimbursement. These must be separately defined and billed by the pharmacy or pharmacist given the PDP providers' defined MTMP provisions and requirements.5,9-11
Community pharmacies will be able to offer an extended or 90-day supply of medications to beneficiaries. This will "level the playing field" as an alternative to patient use of a mail-order pharmacy.9-11
Plan beneficiaries will receive PDP sponsor identification cards as required by CMS. All PDP sponsor cards will contain the same standard, required information. Patient information card standardization is a long-awaited benefit.5,9-11
At this time, there is no requirement that prescriptions be transmitted electronically. PDP providers are, however, required to comply with CMS adopted National Council for Prescription Drug Program's (NCPDP) SCRIPT Standard version 5.0 for transmitting prescription information and the NCPDP Telecommunication Standard Guide version 5.1 for transmitting eligibility and benefit information.11
Pharmacists are an easily accessible source of information and help for Medicare in identifying "best fit" PDP provider programs. CMS and others will offer web-based tools and written information for helping with these decisions.5,7,9-11
As an essential and long-awaited part of Medicare Part D, MTMPs began on January 1, 2006. PDP providers will identify at-risk, high drug utilization patients, and others through their quality and cost management utilization reviews. These providers may seek the assistance of local network pharmacists within the pharmacy or independent consultant pharmacists for provision of these MTMPs. PDP sponsors will establish independent fees and provide negotiated reimbursement for these services.9 Through the efforts of the Pharmacist Services Technical Advisory Coalition (PSTAC) codes for pharmacist billing of these services have been established.14 The American Medical Association Current Procedural Terminology (CPT) Editorial Panel has approved three codes for this purpose. These codes became effective January 1, 2006.14 The CPT codes and their uses are:
- Code 0115T - a first-encounter face-to-face service performed with a patient in a time increment up to 15 minutes
- Code 0116T - for use with the same patient in a time increment up to 15 minutes for a subsequent or follow-up encounter
- Code +0117T - for billing additional 15 minute increments of time to either of the preceding codes
For more on MTM, see "Medication Therapy Management: An Opportunity for Pharmacists" Detail-Document #221001.
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Question #5 | | What impact will Medicare Part D have on pharmacies? | | | | | | | | |
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Question #6 | | Why are many pharmacists interested in medication therapy management programs (MTMP)? | | | | | | | | |
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| | When and How Can Patients Sign up? | | |
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The initial enrollment period is from November 2005 thru May 2006. Patients who are currently eligible but who enroll after May 2006 will be required to pay a late-enrollment penalty.2-5 The premium goes up 1% for every month they're late enrolling. For example, if a patient signs up ten months after their enrollment period, for a plan with a $50 monthly premium, the plan will actually cost $55 per month. This is to encourage healthy seniors to sign up. PDPs don't want only people who expect to need a lot of drugs.
Patients who turn 65 after the initial enrollment period will have 7 months to sign up...starting 3 months before their birthday. In the future, people who wait until AFTER their enrollment period will also pay the 1% per month late penalty.
Patients will be able to change plans if needed...but only from November 15th to December 31st each year…unless they go to a nursing home or an area that doesn't offer their plan.
"Dual eligible" patients on MediCARE and MediCAID will get their drug coverage only through MediCARE after January 1, 2006. These MediCAID recipients were randomly assigned a drug plan if they didn't choose one by the end of 2005. However, dual eligible patients may "opt out" of a plan and chose another plan at any time.
To actually sign up for a program, patients must complete an enrollment form. Patients can get enrollment forms from PDPs themselves or from a Social Security office. Patients can also request forms from Medicare at 1-800-MEDICARE or online at www.medicare.gov. The Medicare Prescription Drug Plan Finder even allows patients to sign up for a plan online.
Click here to visit the Medicare Prescription Drug Plan Finder.
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Question #7 | | What's TRUE about drug coverage for patients with "dual eligibility" for MediCARE and MediCAID? | | | | | | | | |
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| | The Bottom Line | | |
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There are many options available to patients under the new Medicare prescription drug plan. If they already have drug coverage, should they switch to Medicare Part D? If they don't have drug coverage, which plan is the right one? America's seniors will need your help sorting through the options and deciphering bureaucratic rules. Keep in mind, pharmacists can't PROMOTE any particular plan...you can't fill out forms for patients...but you can point out pros and cons.
Here are some important points to remember. Seniors with employment-based drug coverage are often better off NOT trading it for a Medicare Part D drug plan. Most patients with Medicare are NOT automatically enrolled in a Medicare Part D drug plan. They must still sign up for a plan. Lastly, there's an error in Medicare's own handbook that says ALL the plans listed for low-income seniors have zero premiums. This is not true, only about 40% are free for qualifying seniors.
| Glossary of Terms |
- CMS: Centers for Medicare and Medicaid Services
- CPT: Current Procedural Terminology
- MA-PD: Medicare Advantage Rx Drug Plan
- MMA: Medicare Modernization Act
- Medicare Part A: coverage for general hospitalization services
- Medicare Part B: coverage for certain physician, outpatient hospital, home health, durable medical, or other services
- Medicare Part C: Medicare managed care plan or Medicare Advantage
- Medicare Part D: Medicare-sponsored drug plan
- MTMP, MTM, or MTMS: medication therapy management programs or services
- PSTAC: Pharmacist Services Technical Advisory Coalition
- NCPDP: National Council for Prescription Drug Programs
- PBMs: pharmacy benefits managers
- PDP: prescription drug plan
- SCRIPT: standard created to facilitate the electronic transfer of prescription data between pharmacies and prescribers
- TRICARE: Department of Defense health care program for active duty and retired members of the uniformed services, their families, and survivors
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Here are additional resources for your pharmacy:
| Medicare Part D Resources for the Health
Professional |
| Patient Focused Resources
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| Pharmacist's Letter and Prescriber's Letter in conjunction with Consumer Reports
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Patient Handout: "Picking a Medicare
Prescription Drug Plan"
Produced by Consumer Reports in conjunction with Pharmacist's Letter and Prescriber's Letter specifically for you to hand to your patients who want your help on this topic.
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| Pharmacist's Letter and Prescriber's Letter
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Patient Handout: "A Stepwise Guide to
Selecting a Medicare Prescription Drug Plan"
Produced by Pharmacist's Letter and Prescriber's Letter for subscribers to hand to patients.
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| American Association of Retired Persons (AARP)
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Identifies information Medicare beneficiaries should know,
general costs, and what it means for the average couple.
http://www.aarp.org/health/medicare/
drug_coverage/a2004-03-30-
newdrugbenefit.html.
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| Center for Medicare Advocacy
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A Medicare advocacy organization offers information about
Medicare Part D and provides weekly alerts on current topics.
http://www.medicareadvocacy.org/.
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| Centers for Medicare and Medicaid Services
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Information is available for health care consumers, including
Medicare beneficiaries, Medicaid recipients, and others.
http://www.cms.hhs.gov/default.asp?
1=cons&2=.
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| Department of Health and Human Services - Eldercare
Locator
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Information about Medicare prescription drug coverage and
personalized help in choosing and joining a Medicare drug plan, by
ZIP code, city, or county.
http://www.eldercare.gov/Eldercare/Public/
medicare.asp.
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| Kaiser Foundation Medicare Drug Benefit Calculator
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This calculator allows users to enter their prescription drug
costs to determine what they will pay starting in 2006 under the
Medicare prescription drug law.
http://www.kaisernetwork.org/static/
kncalc.cfm.
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| Medicare Today
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Medicare Today is a partnership of organizations representing
seniors, patients, health care groups, employers, and others whose
mission is to inform beneficiaries about Medicare Part D.
http://www.medicaretoday.org/.
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| Medicare: The Official U.S. Government Site for People with
Medicare
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The official U.S. government site for Medicare recipient
information spotlights updates and new developing topics.
http://www.medicare.gov/.
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Current information for patients in helping to make a decision
about Medicare coverage.
http://www.medicare.gov/medicarereform/
drugbenefit.asp. |
Identifies Medicare prescription drug plan approvals by
state.
http://www.medicare.gov/medicarereform/
map.asp. |
Helps patients find, compare, and enroll in prescription drug
plans that offer the drugs they are currently taking.
http://www.medicare.gov/MPDPF/Public/
Include/DataSection/Questions/
Questions.asp. |
| Social Security Online
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Social Security's site is to help the public understand how they
may qualify and apply for Medicare Part D.
http://www.ssa.gov/prescriptionhelp/.
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| Provider Focused Resources
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| American Pharmacists Association (APhA)
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The APhA Resources: Medicare website contains resources designed
to help pharmacists gain an understanding of this complex law and
provide tools to help them assist patients.
http://www.aphanet.org/Content/
NavigationMenu/AdvocacyONYourBehalf/
APhAResourcesMedicare/default.htm.
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| American Society of Consultant Pharmacists (ASCP)
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ASCP's government affairs resource center provides information
about Medicare Part D including information related to long-term
care provisions.
http://www.ascp.com/public/ga/.
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| American Society of Health-System Pharmacists (ASHP)
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ASHP's Medicare Modernization Act resource center provides
general information about Medicare Part D and special information
about medication therapy management aspects. The latest in policy,
breaking news, and CMS rules analysis are included.
http://www.ashp.org/medicare/.
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| Center for Medicare Advocacy
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A Medicare advocacy organization offers information about
Medicare Part D and frequently asked questions.
http://www.medicareadvocacy.org/
Page_FAQ/FAQ_MainPage.htm.
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| Centers for Medicare and Medicaid Services (CMS): Pharmacy
Information
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This site provides information specific to pharmacy on Medicare
Part D.
http://www.cms.hhs.gov/medicarereform/
pharmacy/.
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| CMS: Professional Information
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Information is available for a variety of professional audiences,
including the medical community.
http://www.cms.hhs.gov/?1=pros.
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| CMS: Provider Information
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Provides basic information for health care professionals through
the CMS Medicare Learning Network.
http://www.cms.hhs.gov/medlearn/
drugcoverage.asp.
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| National Association of Chain Drug Stores (NACDS)
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The government affairs Medicare resource center provides general
information on Medicare Part D and various briefings.
http://www.nacds.org/wmspage.cfm?
parm1=3407.
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| National Community Pharmacists Association (NCPA)
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NCPA's Medicare Resource Center provides a number of tools to
help assist community pharmacists in educating their patients about
Medicare Part D.
http://www.medicareresourcecenter.com/.
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| National Plan and Provider Enumeration System (NPPES)
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NPPES provides information about obtaining and applying for an
National Provider Identifier number for individual provider billing
for Medicare Part D medication therapy management services.
https://nppes.cms.hhs.gov/NPPES/
Welcome.do.
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| Also available as a handy print out, click here to get it.
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A Stepwise
Guide to Selecting a Medicare Prescription Drug Plan
The difficult part of the new Medicare Part D drug plan is knowing if
it will benefit you and what you should do. The information
in this handout will help you to begin to know what's best. You can use
this guide yourself or have someone help you. It requires that you or
someone you know have a computer with internet access.
Please complete each step to help you decide what's best for you. Also available as a patient handout, click here to get it.
- Are You Eligible for Medicare Part
D?
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Yes, if you're:
- over 65
- or permanently disabled and under 65
- or have end-stage kidney disease
- or already have Medicare Part A (Medicare hospital insurance)
coverage
- or already have Medicare Part B (Medicare medical insurance)
coverage.
Yes No
If you answered yes to any of these questions you are most
likely eligible for the Standard Medicare Part D coverage described in
Section B. If you answered no to any of the questions above you
may qualify for extra help above what standard coverage provides. The
BenefitsCheckUpRx website, sponsored by the U.S. Department of
Health and Human Services and the Administration on Aging, will give you
personal recommendations about your situation and what steps you should
consider. This website provides a variety of fact sheets, forms, and
worksheets. It also links to plans available in your area described in
Section C and the Medicare Prescription Drug Plan Finder described in
Section D. Having the following information available before you go to
the website will make it easier to complete the online
questionnaire:
- State and ZIP code
- Date of birth
- Types of public benefits, insurance coverage, and prescription
drug savings programs you currently receive such as:
- state Medicaid
- Medicare Advantage (MA)
- Medigap (supplemental insurance) policy
- drug coverage from an employer, union, or
retiree plan
- drug coverage from the Department of Defense (TRICARE), The Department of Veterans Affairs, or the Federal Employee Health Benefits Program
- Current income and assets from all sources for self and spouse
- Number of prescription drugs taken
- Approximate out-of-pocket dollar amount paid for prescription
drugs
Once you have this information, go to the BenefitsCheckUpRx website
at:
https://ssl2.benefitscheckup.org/frmwelcome2.
cfm?cfid=2016238&cftoken=13919082&
source_id=1&prev_id=91660&org_id=0&
partner_id=12&subset_id=14&language_id=
EN&access_id=0&client_id=NULL&
user_id=NULL&test_id=0
- For Standard Medicare Part D
Coverage:
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Here's what you will generally pay for standard coverage:
- Yearly deductible of $250 (This may be lower depending on the
prescription drug plan you choose).
- Monthly plan premium averaging about $32. (This monthly premium also
varies by the plan chosen and the area you live in).
- 25% co-pay for plan covered drugs after the annual deductible of
$250 is paid up to the next $2,000 in covered drug expense (this can be
as much as $500 that you might pay and as much as $1,500 that Medicare
might pay).
- Once the drug expense, that you and Medicare pay, reaches $2,250,
then the next $2,850 in covered drug expense must be paid entirely by
you (you pay 100% of this next $2,850). You may hear this expense called
the "donut hole."
- After that amount is paid, your "out-of-pocket" threshold (called
TrOOP) has been met.
- Now, you pay only $5 for covered brand drugs, $2 for covered
generic drugs, or 5% of the covered drug cost, whichever is
more.
- What Medicare Prescription Plans Are Available Where You
Live?
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The answer to this question depends on which state or area of the
country you live in.
To help you determine which plan or plans are available for you, please
follow the stepwise directions below:
Step 1. On a computer, go to the Medicare website at: http://www.medicare.gov/medicarereform/map.asp
Step 2. Find your state shown on the list.
Step 3. Select either "Medicare Advantage Plans" or
"Stand-Alone Drug Plans."
Step 4. A landscape list of available plans is displayed that
includes information on premiums, deductible amounts, type of additional
coverage offered, tiered co-payment options, and availability of mail-order prescriptions.
- What Medicare Prescription Plans Meet Your Personal
Needs?
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You can answer this question by going to the new Medicare
Prescription Drug Plan Finder. This tool will help you find and
compare prescription drug plans that have the prescription drugs you
currently take and those that meet your personal needs. It will also allow
you to enroll in the plan you select.
Please follow the stepwise directions below:
Step 1. If you have a Medicare insurance card, have it ready,
and on a computer, go to the Medicare Plan Finder website at: http://www.medicare.gov/MPDPF/Public/Include/
DataSection/Questions/Questions.asp
Step 2. Follow the stepwise directions Medicare
shows.
- You can begin enrollment on November 15, 2005.
- You should enroll before May 15, 2006 to avoid paying a premium
penalty.
- Be sure to check if you have medical conditions that haven't been
treated. These can affect your prescription expenses and whether or not
to enroll in a Medicare Part D plan.
- Once you join a plan, you will be able to switch to another plan
after a year.
- For more information on Medicare Part D, call 1-800-MEDICARE or go
to: www.cms.hhs.gov/medlearn/drugcoverage.asp.
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