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I’m
sure you know by now that the Medicare Prescription drug
coverage plan began January 1st, 2006. As you can tell
from TV, radio and newspaper advertising, there are many
plans available. It’s up to you to decide whether to
join a Medicare drug plan and to choose the plan that is
right for you. The good news for people with diabetes
like you is that your current coverage for diabetes
testing supplies remains the same. This means you can
continue receiving your supplies from Diabetes
Management & Supplies with no interruption of service.
These items are covered under Medicare Part B. Your Part
B coverage will stay the same regardless of whether you
join a Medicare drug plan or not. Here are some things
to remember when selecting a Medicare Prescription drug
plan:
Medicare Prescription drug coverage is available now to
help people with Medicare pay for the prescriptions they
need.
Medicare coverage for prescription medications is
available to everyone with Medicare.
There
is also additional financial help available for those
who need it most.
The
Medicare Prescription drug coverage pays for brand-name
and generic drugs.
You
will be able to choose between at least two Medicare
drug plans, selecting the plan that best suits your
needs.
Frequently Asked Questions
Who is
eligible for Medicare Prescription drug coverage? All
people who have Medicare Part A and/or Part B are
eligible to enroll regardless of age, income or existing
health conditions.
Is
participation mandatory? No. You can choose whether to
join in a Medicare drug plan.
How
does Medicare Prescription drug coverage work? Private
insurance companies worked with Medicare to develop
prescription drug plans under Medicare's standard of
care guidelines. Each plan is different, so people will
have to consider what coverage they have, if any, to
determine if Medicare Prescription drug coverage will be
of greater benefit to them. For example, if you have
prescription drug coverage through your former employer
or union and the plan adequately covers prescription
expenses on average at least as good as Medicare
Prescription drug coverage, you may want to stay with
that plan; on the other hand, if a Medicare drug plan
can offer greater coverage than you currently have, you
may want to join a Medicare drug plan.
Can
Medicare Prescription drug coverage be purchased
directly from Medicare? No. All plans are available
through private insurance companies that have contracted
with Medicare to provide this benefit.
Will
people who receive prescription coverage through the VA
have to change plans? No. Medicare Prescription drug
coverage will have no impact on VA benefits.
Will
Medicare Prescription drug coverage be available in the
US territories? Yes.
Will
prescriptions be free? No. Just like other insurance
plans, you will pay a portion of the cost. Typically,
Medicare will pay 75% and you will pay the remaining 25%
co-payment after an initial deductible. In addition, you
will have to pay a monthly premium depending on the plan
you select. See questions below.
How
much will people have to pay for Medicare Prescription
drug coverage? Most plans have a yearly deductible of
$250. In addition, the typical premium is about $37 per
month (approximately $444 per year) in 2006. Plus,
participants pay a portion of the cost (a co-payment)
for each prescription based on the plan you select.
Once a
beneficiary has paid the entire $250 deductible, how
much will his or her prescription drug plan cover? In a
typical plan, after you have met the $250 deductible,
Medicare will pay up to 75% of prescription drug costs.
You pay the other 25% until total drug expenditures
reach $2,250. In other words, you pay $500 for the next
$2,000 of expense!
What
happens if my drugs cost more than $2,500 per year? If
your total drug costs reach above $2,500 in a year, you
become responsible for paying 100% of the prescription
cost until your annual out-of-pocket drug costs reach
$3,600 in that year. This is called the “gap” or the
“hole in the doughnut.” For costs exceeding $3,600 in a
year, the plan will pay most costs with no upper limit.
You will still pay a small amount, such as 5% or a flat
co-payment for each prescription.
When
does enrollment in Medicare Prescription drug coverage
begin? The initial enrollment period began November 15,
2005 and ends May 15, 2006.
When
did Medicare Prescription drug coverage take effect?
January 1, 2006.
What is
a late enrollment penalty? If you do not have creditable
coverage through a retirement plan or union, and you
delay joining a Medicare prescription drug plan when
first eligible, an additional penalty fee of at least 1%
of the premium for every month you are not enrolled will
apply. The higher premium will be in effect for the
entire time you participate in Medicare drug plan.
Why is
there a late enrollment penalty? Congress made the rule
to encourage people to enroll in the beginning, or when
they first become eligible, instead of waiting to join
when they are ill and healthcare costs are higher.
What is
“creditable coverage?” Creditable coverage refers to
coverage from an employee or union plan that is on
average at least as good as Medicare's standard level of
coverage. If you are enrolled in a plan that has
creditable coverage, you can wait to enroll in a
Medicare drug plan without incurring a penalty for late
enrollment. Your current plan will notify you if your
retiree benefit provides you with creditable coverage.
Where
can people get more information? Call Medicare at
1-800-MEDICARE or visit Medicare's web site at
www.medicare.gov.
How do
Medicare beneficiaries get started? Most people will
need to evaluate the Medicare drug plans offered in
their area. The government’s Medicare and You 2006
Handbook lists the approved plans to choose from in your
area (or look at www.Medicare.gov for the most up to
date information). You can join the plan of your choice
between November 15, 2005 and May 15, 2006. But
remember, there is a penalty if you choose not to join a
plan when you are first eligible and you do not have
“creditable coverage” from a current or former employer
or union.
If you
have both Medicare and Medicaid, Medicare enrolled you
in a plan on January 1, 2006 to make sure you get help
paying for your prescription drug costs. For people with
limited income or resources, if you don’t join a plan by
May 15, 2006, Medicare will enroll you in a plan to make
sure you get help paying for your prescription drug
costs. In either case, if you find a Medicare plan that
better meets your needs, you can switch.
What is
a Medicare Advantage Plan? Medicare Advantage Plans and
other Medicare Health Plans are organizations such as
HMOs, PPOs and Managed Care Plans. These plans manage
all your healthcare needs by combining Medicare Part A
(Hospitalization), Part B (Doctors and Medical Supplies)
and, now, prescription drugs. In the past, you would
have known them by the name "Medicare +Choice".
What is
a Stand-Alone Medicare Prescription Drug Plan? A
stand-alone Medicare Prescription drug plan covers only
prescription drugs. If you join a Medicare Prescription
drug plan you will need to continue your Part A and Part
B coverage separately.
How
will the Medicare drug plans differ? Medicare drug plans
differ on which prescriptions are be covered. All the
plans meet Medicare's standard level of care criteria;
however, some plans offer more coverage and additional
drugs, but at a higher premium. Additionally, there may
be differences in pharmacies you can use to get your
medication.
Will
all drugs be covered? Each Medicare drug plan has a
Medicare-approved list of drugs that are covered. The
list is called a “formulary”. Formularies vary from plan
to plan, so it's important to compare each formulary to
find the plan that best meets your medication needs.
What is
a formulary? A formulary is a list of drugs that each
particular plan covers, and it differs from plan to
plan. Be sure to request a formulary from the plans you
wish to compare by calling each plan’s benefits
administrator. You will want to choose a plan that best
suits your prescription drug needs.
What
else should I know about comparing formularies? You
should know that the cost of medications varies from
plan to plan. You will want to determine if the
deductible and co-insurance fees are within your budget.
Note that some formularies may not cover one or more of
the medications you take. If one or more of your
medications isn't listed, you may want to consider
another plan. Alternatively, your doctor might be able
to write a new prescription for a medication that is
equal in therapeutic value and is covered by a
particular formulary.
Which
drugs are excluded from the formularies? Certain drugs
are excluded from Medicare Prescription drug coverage by
law, most notably:
Drugs
used for anorexia
Drugs
used for weight loss
Drugs
used for weight gain
Drugs
used to promote fertility
Drugs
used to promote hair growth
Cough
and cold remedies
Prescription vitamins and mineral supplements (except
prenatal vitamins and fluoride preparations)
Non-prescription drugs
Inpatient drugs
Barbituates (such as sleeping pills)
Benzodiazepines (such as Xanax® and Valium®)
Is
medication management available? Yes. Help is available
to ensure that your medications work well together to
help avoid negative drug interactions. It's called
“medication therapy management.”
Will
participating pharmacies buy drugs from Canada? No. Only
drugs approved by the FDA for sale in the United States
of America will be eligible for coverage.
Can
beneficiaries have their premiums deducted from their
Social Security checks every month? For the most part,
yes. Just like your Part B premium, you can have your
Medicare drug plan premium deducted from your Social
Security check.
Is
help available for people with limited income and
resources? Yes. If you are single and your income is
below $14,355 and your savings, investments and real
estate (other than your home) are valued at no more than
$11,500, you may qualify for extra help from the
government. If you are married and living with your
spouse and your income is below $19,245 and your
savings, investments and real estate (other than your
home) are not worth more than $23,000, you may also
qualify. In some cases, people with limited income and
resources will not have to pay premiums or co-insurance
for a Medicare drug plan. Income amounts may be higher
in Alaska and Hawaii.
What
assets are counted to determine if one is eligible for
assistance? Assets, including cash or property that can
be converted to cash within 20 days, may be counted.
Property excluded from the count includes the primary
home, burial plots or burial agreements. Funds of up to
$1,500 that are set aside for burial arrangements are
also not counted.
When
should people start applying for assistance? You may get
an application in the mail from SSA for extra help
paying for a Medicare prescription drug plan. It is very
important that you fill out this application and return
it to SSA. If you don’t get an application in the mail
and think you may qualify for this help, call SSA at
1-800-772-1213. TTY users should call 1-800- 325-0778.
You can also visit www.socialsecurity.gov on the web.
SSA’s application process provides you with the quickest
decision. You can also go to your State Medical
Assistance office to apply.
Once
enrolled in a Medicare drug plan, can a participant
change plans? Yes. Each year there will be an annual
enrollment period from November 15 through December 31,
and participants can change plans then. Another
circumstance that may give a you the right to change
plans would be if you moved outside of your plan's
service area, you could then choose a plan that services
the new location.
Will
people who don't spend very much each year on
prescriptions benefit from having this? Yes. Those who
participate in a Medicare drug plan will have access to
discounts on the medications they purchase, as well as
peace of mind should they become ill in the future.
What
types of Medicare drug plans can I choose from? There
are three basic ways you can participate. They are:
Stand-Alone Medicare Prescription Drug Plans - If you
participate in a Stand-Alone Medicare Prescription Drug
Plan, nothing will change with your Medicare Part A or B
coverage. You will still have the freedom to choose
whatever participating doctor you prefer, and you may
fill your prescriptions through the participating mail
order or retail pharmacy of your choice.
Medicare Advantage Plan or other Medicare Health Plans
with Prescription Drug Coverage (HMO or PPO) - If you
choose to enroll in a Medicare Advantage Prescription
Drug Plan, all aspects of your healthcare - including
your Medicare Part A and Part B coverage - are managed
for you. You will choose a healthcare provider from a
list approved by your plan, and you must fill your
prescriptions through pharmacies that participate with
your plan.
Employee Retirement Plan - This is a plan provided to
you by your former employer or union. If your plan is
“creditable” (on average, at least as good as a standard
Medicare drug plan), you may want to stay in that plan.
All employee retirement plans are required by law to
inform you if the plan is considered “creditable.” If in
the future you wish to participate in a Medicare drug
plan, you won't be penalized for waiting to enroll.
What
does the typical Medicare drug plan look like,
dollar-wise? In addition to the premium you may pay, the
benefits design for a basic plan has the following
elements:
You
generally have a $250 deductible.
The
plan will pay 75% of your drug costs until you reach
$2,250 - you pay 25% of the cost (total of $500).
You
will then pay 100% of your drug costs until you reach a
total out of pocket costs of $3,600 per year (or $5,100
in total drug spending)
After
you have incurred $3,600 in out of pocket drug costs,
the plan will pay 95% and you will pay 5%.
Note:
The above numbers apply annually.There will be many
different plans, each offering different deductibles,
co-payments and pricing!
Should
I choose a regional or a national plan? It depends.
Let's say you live in Michigan but you spend your
winters in Florida. You would want to choose a national
plan. If, on the other hand, you live in Michigan
year-round, a regional plan would satisfy your needs as
well as a national plan. |