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New Medicare Prescription Drug Coverage


For the first time in history, Medicare will help. pay for prescription drugs in various drug ... Limited Income Help (if eligible) SSA accepting applications ... – PowerPoint PPT presentation

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Title: New Medicare Prescription Drug Coverage

New Medicare Prescription Drug Coverage
  • Presented by Benefits Assistance Program of the
    Area Agency on Aging, Region One

  • For the first time in history, Medicare will help
  • pay for prescription drugs in various drug
  • categories
  • Coverage begins January 1, 2006
  • Will be delivered by Prescription Drug Plans
  • Available for all Medicare beneficiaries

Eligibility and Enrollment
  • Entitled to Part A and/or enrolled in Part B
  • Reside in plans service area
  • Must enroll in a Medicare prescription drug plan
    to get Medicare prescription drug coverage
  • Stand-alone Prescription Drug Plan (PDP)
  • Medicare Advantage Prescription Drug Plan (MA-PD)

What it CostsHow it Works
  • Average monthly premium for AZ is 28 per month
  • 250 deductible
  • Coinsurance of 25 of drug costs from 250 to
  • Medicare pays 75
  • 100 of drug costs from 2,250 to 5,100
  • Coinsurance of 5 of drug costs after true
    out-of-pocket drug costs reach 3,600

Prescription Drug Plans Available in AZ
  • AZ is an individual region for PDPs
  • 18 companies offering PDPs in AZ
  • 43 stand-alone plans available
  • 10 companies offer National plans

TROOP (2006)
  • The amount of money to reach catastrophic
    coverage. Consists of
  • Deductible 250
  • 25 coinsurance 500
  • Coverage Gap 2,850

  • 3,600
  • Medicare prescription drug plan premium
    wrap-around coverage are not part of
    out-of-pocket threshold

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Medicare Prescription Drug Plans
  • Must offer basic drug benefit
  • May offer supplemental benefits
  • Can be flexible in benefit design
  • Will have formulary
  • Must follow marketing guidelines

Initial Enrollment Period
  • Nov 15, 2005 to May 15, 2006
  • Are currently eligible or
  • Will become eligible in November, December 2005,
    and January 2006
  • Coverage will be effective January 1, 2006 or
  • First day of the month after PDP selection

Postponing Enrollment
  • Higher premiums for people who wait to enroll
  • Exception for those with creditable drug coverage
  • Assessed 1 of base premium for every month you
  • Eligible to enroll in a Medicare prescription
    drug plan but not enrolled
  • No creditable drug coverage for 63 consecutive
    days or longer

Possible Examples of Creditable Coverage
  • Some Group Health Plans (GHP)
  • Active employer GHP
  • Retirement GHP
  • VA coverage
  • Military coverage including TRICARE
  • Note The source of the current drug coverage
    will send a notice telling the person if it is at
    least as good as Medicare prescription drug

How it How it Works for Retirees
  • If current coverage is creditable, keep current
  • Can join a PDP but not necessary
  • Enrollment in PDP may end all retiree-health
  • If current coverage is not creditable
  • Join a Medicare PDP to replace current coverage
  • Former employers or unions must provide letter
    of creditable or non-creditable coverage prior to
    November 15

Options for Retiree Health Plans
  • Offer coverage in place of Medicare drug coverage
    and receive a tax-free subsidy for each member
  • Offer or contract with a Medicare PDP to provide
    drug coverage
  • Provide coverage that supplements the Medicare
    drug coverage
  • Pay all or part of Medicare drug premiums

I am enrolled in a Medicare Health plan.
  • Individuals will be passively enrolled in their
    Medicare Advantage plans drug plan
  • Drug benefits will be covered directly through
  • Not able to have a separate
  • prescription drug plan

What About Medigap Coverage?
  • Some Medigap plans have a drug benefit
  • Must decide to keep current plan with
    prescription coverage
  • or
  • enroll in Part D modify current plan
  • If the Medigap plan does not have drug benefits
  • The Medigap coverage will not change
  • Should enroll in a Prescription Drug Plan

How do I Choose a Plan?
  • Know what drugs are on the plans formulary
  • Know what pharmacy you can use to purchase drugs
  • Does plan have mail-order option

Are all drugs covered?
  • NO!
  • Must check PDPs formulary before choosing a

Excluded Drugs
  • Drugs for
  • Anorexia, weight loss, or weight gain
  • Fertility
  • Cosmetic purposes or hair growth
  • Symptomatic relief of cough and colds
  • Prescription vitamins and mineral products
  • Except prenatal vitamins and fluoride
  • Non-prescription drugs
  • Barbiturates
  • Benzodiazepines

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Can plans change their drug formularies?
  • Drug plan sponsors may change their list of
    covered drugs but must give 60 day notice to
    beneficiaries if using a drug that will be
  • dropped drug from formulary
  • moved to a to different tier level

My drug is not on the formulary What do I do?
  • Urgently needed drugs may be covered while a
    prompt exception process is completed
  • Appeal process if a physician determines that an
    alternate medication is not in the best interest
    of the patient

Is there a limit to the number of prescriptions?
  • Unlimited prescriptions can be filled
  • Plans will not limit number of prescriptions
    filled in a certain time period, for example, a

Can I fill my prescriptions at any pharmacy?
  • NO
  • Each plan will have their own pharmacy network
  • Must have prescription filled at a pharmacy in
    the plans network

Can I Change My Drug Plan?
  • Generally, a person is locked into their PDP for
    the calendar year. They may change their PDP
    only during
  • The Annual Coordinated Election Period, or
  • A Special Enrollment Period if applicable

Extra Help for Some People
  • Those with lowest incomes (
  • Pay no premiums or deductibles
  • Pay small or no copayments
  • Those with slightly higher incomes (2005) and resources
  • Pay reduced premium
  • Pay reduced deductible
  • Pay reduced coinsurance

Qualifying for Extra Help
  • Resources
  • Single less than 11,500
  • Couple less than 23,000
  • Income
  • Single less than 14,355
  • Couple less than 19,245

To Get This Help
  • Person does not have to do anything
  • If currently receiving benefits from both AHCCCS
    and Medicare
  • Receiving Supplemental Security Income benefits
    and Medicare

To Get This Help(if not on AHCCCS or receiving
  • Application should have come in the mail from SSA
  • Mail completed application to SSA or complete
    on-line at
  • Will need to enroll in a PDP starting November 15

How is Income Counted?
  • Includes income of applicant and spouse
  • Income is compared to family size standard
  • Family includes dependent relatives who reside
    with the applicant and who rely on them for at
    least half their support

How Are Resources Counted?
  • Includes resources of applicant and spouse
  • Will only consider
  • Liquid assets can be converted to cash within 20
  • Real estate Does not include applicants primary

Part Application Process
  • Separate application process for
  • Limited Income Help (if eligible)
  • SSA accepting applications now
  • Prescription Drug Plan
  • Enrollment begins 11-15-05

How To Enroll
  • Paper application through drug plan
  • On the Medicare website
  • On the drug plans website
  • 1-800-MEDICARE (1-800-633-4227)

Important Dates
  • If you have limited income and resources, watch
    your mail for information from Social Security
    about applying for extra help paying for
    prescription drugs

May-August 2005
Important Dates
  • If you receive AHCCCS, SSI, or are in a MSP,
    watch your mail for a letter from Medicare

May 2005
Important Dates
  • Watch your mail for the Medicare You handbook,
    which will have information about the plans in
    your area

October/ November 2005
Important Dates
  • You can begin to compare Medicare prescription
    drug plans
  • 1-800-MEDICARE
  • BAP (602-264-2255)

October 13 2005
Important Dates
  • You can begin to enroll in Medicare prescription
    drug plans

November 15 2005
Important Dates
  • Medicare prescription drug coverage begins for
    those who are enrolled

January 1 2006
Important Dates
  • Need to enroll in a Medicare prescription drug
    plan by

May 15 2006
Thank You for Watching!
  • If you have questions or want more information,
    please call
  • Benefits Assistance Program
  • at the Area Agency on Aging
  • 602-264-2255