Module 3

Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her?

An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. Correct: Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan.

Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him?

He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Correct: Some pharmaceutical manufacturers operate programs that assist low-income individuals. In addition, some states have assistance programs specifically for their residents. Some of the state programs are "qualified" and count toward TrOOP and some do not.

Which of the following statements about Medicare Part D are correct?

I, II, and III only Correct: Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. Also, private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. Additionally, beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP.

Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her?

If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Correct: Mrs. Lopez is enrolled in a Cost plan. This provides her with options as to how she secures Part D benefits. Beneficiaries enrolled in a Cost plan may obtain Part D benefits through their plan (if offered) or through a stand-alone Prescription Drug Plan (PDP).

Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision?

If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. Correct: Most Individuals should sign up for Part D as soon as they are eligible to do so. Otherwise, they face a permanent premium penalty of 1% of the national average premium for each month the individual does not have Part D coverage. Beneficiaries who qualify for the low-income subsidy, however, are not subject to the late enrollment penalty.

Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?

If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. Correct: An individual may enroll in a stand-alone Medicare Part D prescription drug plan (PDP) if they are enrolled in a PFFS plan that does not include Part D drug coverage or a MSA plan.

Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him?

If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Correct: To avoid a late enrollment penalty, Mr. Hutchinson must have "creditable" coverage. If he does not, he must enroll in Medicare Part D during his initial eligibility period to avoid a late enrollment penalty.

Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?

In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Correct: Generally, a Part D beneficiary must stay with a premium payment option for the entire plan year.

Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?

Jose, a grandfather who was granted asylum and has worked in the United States for many years. Correct: Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility.

Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him?

Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Correct: Part D plans must cover at least the Part D standard benefits or its actuarial equivalent. Part D plans are permitted to offer supplemental benefits that cover certain drugs not covered under Part D. Some Part D plans may offer these supplemental benefits for an additional monthly premium.

Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?

Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn's could look into that possibility. Correct. The drugs the Vaughns are interested in may be covered as supplemental benefits.

Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?

Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct: Part D formularies must include at least two drugs in each therapeutic category whether or not generic versions are available. Mrs. Allen should be able to find a plan that covers the medications she needs.

Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him?

Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Correct: Mr. Carlini can stay in Original Medicare and obtain prescription drug benefits through a stand-alone Part D plan. He does not have to enroll in a MA plan.

Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him?

Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. Correct: Mr. Schultz should enroll in a Part D plan, or otherwise obtain creditable drug coverage, before he has a 63-day break in order to avoid a premium penalty.

Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What could you tell him to do?

Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Correct: Formulary exception requests can be used to request coverage of a drug not on a Part D plan's formulary or to cover a formulary drug at a lower cost formulary tier.

Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary he takes several other medications. These include a prescription drug not on his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say?

None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. Correct: None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. If he receives an exception under which the plan covers the drug, it could count toward TrOOP.

What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications?

Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. Correct: Part D plans are not required to cover all prescriptions on the market. But they have various methods to manage costs including formularies, cost-sharing tiers, step therapy, prior authorization and substitution.

Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?

She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct: There are some circumstances that allow for enrollees to utilize a non-network pharmacy. However, these prescriptions are typically filled at a higher cost to these enrollees.

All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage?

Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5%. Correct: Standard Part D coverage would require payment of an annual deductible, and once through the catastrophic coverage threshold, the beneficiary pays either co-pays for generic and brand name drugs or co-insurance of 5%, whichever is greater.

Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage?

Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct: If a Medicaid beneficiary does not choose a Part D plan once they become eligible for Medicare, then Medicare will select one for them.