Prescription Drug Coverage Benefit
Medicare provides prescription drug benefits to Medicare beneficiaries and those currently covered under Medicaid. The Medicare Part D Prescription Drug Coverage Benefit began in January 2006 under the Medicare Modernization Act of 2003.
Here are some important points for you to know:
Everyone with Medicare (Medicare Part A, Part B, and Medicare Advantage Plans) is entitled to the new prescription drug benefit. Individuals currently receiving drug coverage through Medicaid have been automatically enrolled, but others must sign up.
Enroll by calling 1.800.MEDICARE (1.800.633.4227) or visiting www.medicare.gov.
The open season for enrollment in the Medicare Part D prescription drug program runs from October 15 to December 7 of each year and takes effect on January 1 of the following year. This applies to newly eligible Medicare beneficiaries and current beneficiaries who are considering changes to their Medicare Part D plan.
Coverage begins on the first day of the month following the month you join.
Medicare has approved a variety of drug plans so it is important to explore your options and choose a plan that best fits your needs. The plans differ in terms of:
- Brand name and generic drugs covered
- Pharmacies and/or mail order companies that can fill prescriptions under the plan
- Costs, including premiums, deductibles and co-payments (see section on cost)
In addition, you can join a Medicare prescription drug plan, which covers only prescription drugs, or you can enroll in a Medicare Advantage Plan, which provides coverage for hospitals and doctors in addition to prescription drugs.
The number of available plans varies by state. In some states, a large number of plans have been approved; in other states, there are only a few options. In every state, each person will be offered a choice of at least two plans.
Enrollees pay a monthly premium, and the cost varies by plan. The average premium is $37 per month per person.
In addition, beneficiaries are responsible for:
- A co-payment—a dollar amount you pay to the pharmacy when you pick up your medication.
- A deductible —a portion of the cost of medications that are not covered by the prescription plan provider. Beneficiaries typically pay the deductible at the start of the year. Once you have paid the deductible, the benefits of the policy apply.
- Other cost sharing amounts—depending on the plan, some beneficiaries will be responsible for a portion of their medication costs when payments by the insurer reach a specific amount.
All of these amounts vary depending on the plan you chose. For instance, some plans cover more drugs, but have a higher premium.
Medicare will subsidize low-income beneficiaries. If you meet specific income and other requirements, you may qualify for a reduced premium or no premium at all, and you may not be responsible for any deductible.
Formularies are a list of approved medications that are covered by the drug plan. It is important to review a plan to be sure your current medications will be covered.
The formulary must include at least two drugs in the categories and classes of the most commonly prescribed drugs to people with Medicare.
Some formularies will not cover all medications prescribed for Alzheimer’s disease, although each plan will cover at least two types.
There are procedures in place to ensure access to prescription drugs that a physician deems medically necessary, even if they are not covered under your prescription drug plan. If your doctor believes you need to take your current prescription and should not switch to a drug covered under your plan, you or your doctor can contact your plan and ask it to give you an “exception,” which means the plan agrees to pay for your current drug. If the plan refuses to give you an exception, you can appeal the plan’s decision. Your Medicare drug plan will send you information about its appeal procedures when you enroll.
To find a plan in your area that matches your required drug list, visit the Medicare Formulary Finder Web site; this tool allows you to review formularies by state and specific medication:
Questions? Concerns? Ready to enroll? Here are some helpful links:
The Center for Medicare and Medicaid Services (CMS)
Medicare RX Education Network
U.S. Social Security Administration
Access to Benefits Coalition
Kaiser Family Foundation
For more information, connect with the Alzheimer’s Foundation of America’s licensed social workers. Click here or call 866.AFA.8484. Real People. Real Care.