The Center for Reintegration - Support Resources

Starting January 1 2006, the federal Medicare program instituted a new prescription drug benefit. Medicare Part D is insurance that covers both brand name and generic prescription drugs at participating pharmacies in your area. (Medicare Part A provides hospital insurance, Part B medical insurance, Part C includes Medicare Advantage and Other Medicare Health Plans option-HMOs, PPOs, PFFS, etc. and Part D, the new Medicare prescription drug benefit.)

Medicare prescription drug coverage (Part D) is available to everyone with Medicare and may help lower prescription drug costs and help protect against higher costs in the future. The coverage is now part of Medicare, the comprehensive federal health insurance program for people 65 years of age or older; certain younger people with disabilities, including people with mental illnesses.

We are now into the third month of the new Medicare Part D plan, but very little has improved. The plan's design continues to be unnecessarily complicated and confusing, not only to recipients, but also to pharmacists, doctors and anyone trying to make sense of it. Consequently, many individual states across the country are stepping up to assist the millions of Medicare recipients, Medicare/Medicaid dual recipients and Medicaid recipients who have now been switched to this new, complicated system. The Federal Government needs to step in and make some serious improvements to the plan, but until such time, here are a few tips to help you navigate the system:

- If you haven’t yet enrolled in the plan you should do so (as soon as possible). You should begin by consulting with your treatment team immediately for help in familiarizing yourself with the way the new program works; reviewing your current health insurance coverage, if any to determine if you already have drug coverage or not; look at the prescription drugs currently being taken, the dosage, how often and how much they cost; comparing and choosing a prescription drug plan that best meets your needs and completing the necessary forms. Keep in mind you have until May 15^th, 2006 to join the plan without penalty[1] unless you currently have drug coverage that is equal to or better than Medicare.

- You will want to ensure that the medication(s) prescribed by your physician is in your "Plan Formulary," that is, the list of drugs covered by the plan in which you are enrolled.

- Within the Formulary, you should inquire about "Tiers" of coverage, which is a hierarchy of drugs based on their costs. In a "Tier," generic medications are generally the least expensive (and therefore require the lowest co-pay) with the new, emerging medications the most expensive. Many new or emerging drugs may not be covered by the plan in which you are enrolled.

-You should also find out if any of the medications you take need "Prior Authorization" by a physician. With "Prior Authorization" your physician completes a form to submit to your plan to explain that it is medically necessary for you to take a particular medication.

-If a medication is not in the "Formulary," you and your physician may ask for an "Exception" or "Appeal" for coverage of the medication. You, your legal representative or prescribing physician must complete a ‘Coverage Determination’ form. A standard "Exception" or "Appeal" may take up to 72 hours for a reply, or 24 hours for an "Expedited" request.

-Like other insurance plans, if you join, your costs will vary and you may have to pay a monthly premium, which varies by plan (on average, about $32) and a yearly deductible (no more than $250 in 2006). You may also pay a part of the cost of your prescriptions (25 percent) in a co-payment or coinsurance up to $2,250. Keep in mind that after $2,250, you must pay 100 percent of your drugs’ cost.

-If you have limited income and resources and you qualify for extra assistance, you may not have to pay a premium, a deductible and no more than $5 for each prescription. You can apply or get more information about extra assistance by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.socialsecurity.gov.

May 15, 2006 - Last day to join a plan offering coverage for 2006 or make changes without penalties.

For more information on Medicare Part D, you can contact Medicare directly at 1-800-Medicare (1-800-633-4227) or get information and forms online at www.medicare.gov. You can also visit the Center for Medicare and Medicaid Services’ website at www.cms.hhs.gov.

If you want to write your state representative to let them know that Medicare Part D is not working as planned, a list of their names and addresses can be found at the following websites:

Read more information about Medicare Part D coverage here.

[1] The penalty for late enrollment will be 1 percent of your monthly premium for as long as you remain in the program.