CHANGES IN THE LAW
MEDICARE PART D – THE DRUG PLAN
By Linnea J. Levine, J.D., CELA
As of November 15, 2005 , Medicare eligible individuals can enroll in one of many prescription insurance plans subsidized by the federal government. The plans offered come in two varieties:
- Stand alone prescription plan (PDP) to supplement existing health insurance – either Medicare or a private insurance.
- Comprehensive health plan such as a health maintenance organization (HMO) or a preferred provider organization (PPO).
The subsidized prescription plans must meet or exceed the basic guidelines below:
Enrollees may be charged:
- A monthly premium (the average premium appears to be $35.00);
- The first $250.00 for prescriptions;
- 25% of the annual cost from $251.00 to $2,250.00;
- 100% of the cost from $2,251.00 - $5,100.00;
- 5% or less of annual prescription costs above $5,100.00.
Medicaid recipients and low income enrollees may have their premiums and co-pays paid by the government depending upon the plans chosen. Some plans will cover the gap between $251.00 through $2,250.00, but likely with a higher monthly premium.
In addition to cost, there are serious pitfalls to avoid in selecting a plan:
- Each plan has its own “formulary” which is the list of drugs covered under the plan. A cost-savings plan may not cover the most expensive essential drug prescribed to an enrollee;
- Plans which are heavily subsidized by the government may require the enrollee to replace Medicare Part A and B Coverage with enrollment in an HMO. This is a serious issue because of the medical treatment pre-approval requirements of the HMO and the add-on costs of seeing medical specialists out of the HMO’s network;
- Plan enrollment after May 15, 2006 will result in a higher premium.
Some recommendation steps in choosing a plan:
- Ask your pharmacist for a printout of all of your prescriptions and the uninsured cost of each.
- Bring the prescription list to your treating physicians and ask which prescriptions are essential to your health and which prescriptions can be substituted with either the generic form of the drug, an over the counter substitution, or a less expensive brand.
- Carefully check the formularies offered by the drug plan under consideration to assure all of your prescriptions, or at least your most expensive prescriptions are covered.
- If Medicare is your primary insurance, consider the stand along drug plans first before the drug/HMO plans.
- In computing cost, consider the following:
- Plan premium amount;
- Plan deductible and co-pays;
- Gap coverage for the 100% cost of drugs between $2,251.00 and $5,100.00;
- Cost of prescriptions;
- Prescription coverage under your existing health insurer.
- If you have a Medigap policy with drug coverage, see if the drug benefit meets the government guidelines. If your Medigap plan does not meet the guidelines, you can keep the Medigap medical coverage, but drop the Medigap drug coverage and replace it with a Medicare Part D stand alone plan.
- If you have private health insurance through an employer or through union retiree benefits and are eligible for Medicare as a second insurance, compare your existing prescription plan to the new Medicare Part D plans to see if better drug coverage is available.
- If you are married and your monthly income is less than $1,604.00 or if you are single and your monthly income is less than $1,197.00, you qualify for a low-income subsidy.
- If you are an eligible recipient of state pharmaceutical programs such as EPIC in New York or ConnPace in Connecticut, your state should be notifying you of any change in your prescription benefits.
MEDICARE PART D – SELECTION WEB RESOURCES:
- medicareright.org - This is the website of the Medicare Rights Center which frequently posts updates on the Medicare Part D program.
- shiptalk.org – This website lists the contact information for each State Health Insurance Assistance Program which provides one-on-one counseling.
- eldercare.gov – Lists state and local community based organizations for the elderly.
Connecticut SHIP Provider:
The Choices Program
25 Sigourney Street
10th Floor
Hartford, CT
860-424-5322
New York SHIP Provider:
Contact: e-mail – rkitazawa@medicarerights.org
Telephone: 212/689-3850 or 800/333-4114
|
