Prescription Drug Plans: What You Need to Know

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Prescription Drug PlansWhat You Need to Know

• Medicare Prescription Drug CoverageGet the
  Facts So You Can Help
• Health Assistance Partnership

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Types of Part D Plans

• Medicare drug coverage is available through two
  types of private plans
• Prescription drug plans (PDPs)
• Medicare Advantage (MedicareChoice) plans with a
  prescription drug benefit (MA-PDs)

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Types of Part D Plans (cont.)

• Prescription drug plans (PDPs)
• Stand-alone plans that provide only the drug
  benefit
• Beneficiaries receive their Medicare Part A and B
  benefits through original Medicare

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Types of Part D Plans (cont.)

• Medicare Advantage plans with a prescription drug
  benefit (MA-PDs)
• Prescription drug benefit and Part A and B
• Supplemental benefits not covered by Medicare may
  also be offered

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Plan Enrollment Rules

• Beneficiaries who want to enroll in a Part D plan
  must
• Decide what type of plan they want
• Prescription drug plan (PDP) or
• Medicare Advantage (MA-PD) plan.
• Choose a specific plan.
• Enroll in the selected plan during the
  appropriate enrollment period.

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Plan Selection

• Key factors may include
• Monthly premium
• Cost-sharing structure
• Level of coverage
• Basic vs. enhanced
• Pharmacy access
• In-network vs. out-of-network
• Formulary

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Plan Selection (cont.)

• Monthly premium
• Varies by plan
• Some plans may not charge a monthly premium
• Beneficiaries may have the premium withdrawn from
  their monthly Social Security check (similar to
  their Part B premiums)

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Plan Selection (cont.)

• Cost-sharing structure
• Plans have a lot of flexibility
• Out-of-pocket costs will likely include
• monthly premium
• annual deductible
• co-payments or co-insurance amounts
• Beneficiaries must spend 3,850 out-of-pocket in
  2007 for Part D-covered drugs before the
  catastrophic benefit begins

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Plan Selection (cont.)

• Level of drug coverage
• Standard plans certain categories of drugs are
  excluded from Medicare Part D coverage
• barbiturates
• benzodiazepines
• weight-loss drugs
• over-the-counter medications
• Enhanced plans may offer optional prescription
  coverage for excluded Part D drugs
• Will likely charge a higher monthly premium

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Plan Selection (cont.)

• Pharmacy access
• Each plan will have a network of preferred
  pharmacies (in-network)
• Each plan must also allow beneficiaries to obtain
  prescriptions at an out-of-network pharmacy on a
  non-routine basis, BUT
• beneficiaries will pay more out-of-pocket

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Plan Selection (cont.)

• Formularies
• Each Part D plan can create its own formulary,
  BUT
• must include at least two drugs in each of the
  therapeutic classes or disease categories the
  plan designs in a variety of dosages and strengths

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Plan Selection (cont.)

• Part D plans can
• have tiers of preferred drugs and co-payments
• use utilization management tools
• change their formularies within limits
• Must notify affected beneficiaries of a price
  change or removal of a drug

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Plan Selection (cont.)

• Beneficiaries must be able to access a plans
  formulary in 4 ways
• a plan description must provide a list of the
  drugs included on its formulary
• a toll-free customer call center
• an internet web site
• a written request by the beneficiary

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Plan Enrollment Rules

• Initial Enrollment Period (IEP)
• Generally the seven months surrounding the month
  of eligibility
• Annual Election Period (AEP)
• After initial enrollment, beneficiaries can
  generally enroll in or switch Part D plans each
  year only from Nov. 15 to Dec. 31, with coverage
  effective on Jan. 1.
• Special Enrollment Period (SEP)
• Exceptions for special circumstances
• Continuous SEP for full dual-eligibles, QMBs,
  SLMBs, and QIs

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Plan Marketing

• In October of each year plans may begin
  advertising to Medicare beneficiaries for the
  following plan year
• Direct Mail
• Television
• Radio
• Telephone

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Plan Information

• The Medicare website, www.medicare.gov, has
  specific plan information
• Medicare Prescription Drug Plan Finder Tool
• Medicare You handbook each fall
• Plan information must be disclosed to each
  enrollee annually and at the time of enrollment

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Questions?

• Health Assistance Partnership
• www.hapnetwork.org
• shiphelp_at_hapnetwork.org
• 202-737-6340