Medicare Part D Prescription Drug Plans

*What are four ways to get Medicare Rx drug coverage?

- "stand alone" Medicare Rx drug plans - Medicare Advantage plans - some employers and unions - military/veterans benefits

What does QI, SLMB, and QMB help to pay for?

- QI pays for the Medicare Part B premium (available in Oregon) - SLMB pays for the Medicare Part B premium - QMB pays for Part A & B premiums, and all deductibles and coinsurance

What are MSP qualifications?

- be a US citizen or qualified immigrant - be a resident of a state - have a SS number - be entitled to Medicare Part A

What can one do if drug needed is not on the plan's formulary?

- can request an exception (hard to get approval) - if plan denies exception request, then can appeal or use the transition refill during the appeal - consider changing to a plan the following year that does have the desired drug

What should you avoid doing when joining a Rx drug plan and paying for premiums?

- do NOT have premium payments deducted from Social Security payment

Relationship between Rx drug plans and pharmacies

- generally must use plan's pharmacies - some plans also offer mail order - some plans have exclusive marketing arrangements with pharmacies (e.g. Humana Walmart-preferred

When can a person enroll in Part D?

- initial enrollment period: 7-month period when one first gets Medicare - Fall/annual open enrollment period: Oct 15 - Dec 7 each year; can change plans at this time - special enrollment period (result of ACA): Jan 1 - Feb 14 if disenrolling from a Medicare Advantage plan (back to original Part A or B); 60 days enrollment period w/o penalty

Describe Part D Rx drug plan formularies

- must cover two drugs in each pharmacological categories - usually cover similar drugs that are safe and effective - may have different levels ("tiers") - choosing generic drugs can save money

Who is eligible for Part D

- must have Medicare Part A and/or Part B (BUT need Part A AND Part B to get Medicare Advantage Plan with drug coverage - reside in plan's service area (PDP is zip code specific) - enroll in Medicare drug plan to get coverage

What are the Part D Rx drug plans' coverage rules?

- prior authorization: prescriber must show the drug is medically necessary - quantity limits - step therapy: try similar, lower cost drugs before the plan will cover prescribed drug

What are the three kinds of Medicare Savings Program (MSP)?

- qualified medicare beneficiary (QMB) program - specified low-income medicare beneficiary (SLMB) program - qualifying individual (QI) program

What drugs are not covered by Part D?

- those prescribed for weight-loss or weight-gain - most Rx vitamins - OTC drugs (except insulin) - fertility drugs - cosmetic drugs - erectile dysfunction drugs

How do you calculate the Part D late enrollment penalty?

1% premium increase for every full month delayed, beginning 3 months after turning 65 (rounded to nearest $0.10); pay the penalty for as long as having Medicare drug coverage

*What are two ways to get drug coverage under Part D?

1. Original Medicare: stand-alone PDPs 2. Medicare Advantage Rx drug plans (MAPD): must enroll in MA plan's PD if it offers one, otherwise choose a stand-alone PD

Who regulates Part D?

CMS

Who administers MSP?

Medicaid, administered by the states

What is creditable Rx drug coverage?

Rx drug coverage (e.g. from employer or union-based) that's expected to pay at least as much as Medicare's standard Rx drug coverage; can keep it without paying penalty if they decide to enroll in Medicare Rx drug coverage later

Does a person who qualifies for MSP, also qualify for LIS? Describe.

Yes, because LIS's income & asset caps are higher than those for the MSP

What is creditable coverage notice?

a notice letting you know know whether or not your drug coverage is "creditable" if you have drug coverage from an employer/union or other group health plan

When and what does a client pay for QMBs?

catastrophic rates until maximum dollar amount is reached when there is no copay

Who submits the Medicare Part D appeals?

client's physician submits citing why a specific drug is needed

What is Part D income-related premium adjustment based on?

deducted from the monthly Social Security pension check, based on previous year's tax return

Which drugs are covered by Part D?

drugs only available by Rx (brand and generic); drugs, biologicals, insulin and medical supplies for injecting insulin

What kind of privilege does LIS give with regards to Part D?

have continuous open enrollment privilege

What are exceptions to Part D late enrollment penalty?

have dual eligibility to Medicare and Medicaid, or have creditable coverage (coverage at least as good as Medicare drug coverage)

What does Low/Limited Income Subsidy (LIS) help to pay for and who administers it?

helps with Medicare Part D Rx Drug plans (generally pays the entire Part D premium, person has copays at catastrophic coverage rates); administered by SS

A drug in lower tier will cost ______ than a drug in a higher tier

less

What is Medicare Part D coverage gap ("donut hole")?

lies between the initial coverage limit and the catastrophic-coverage threshold in the Medicare Part D PDP administered by the federal government; after a Medicare beneficiary exits the initial coverage of RPDP, the beneficiary is financially responsible for a higher cost of Rx drugs until he reaches the catastrophic-coverage threshold

What happens if your coverage is not creditable and you do not enroll in a Part D plan?

you may be charged a penalty to enroll in Part D later