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Medicare & You
Understanding Medicare Enrollment Periods Published on Oct 2, 2014 3:04 minutes
Medicare Plan Finder Lesson 2
Entering Your Prescription Drugs
Published on Sep 26, 2012 5:08 minutes
Medicare Plan Finder Lesson 3
Published on Sep 26, 2012 1:46 minutes
Medicare Plan Finder Lesson 4
Refining and Sorting Your Plan Results
Published on Sep 26, 2012 5:18 minutes
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Medicare & You
How the Part D Penalty is Calculated
Published on Oct 2, 2014 2:36 minutes
Medicare Plan Finder Lesson 1
Published on Sep 28, 2012 4:51 minutes
Medicare Plan Finder Lesson 5
Published on Sep 26, 2012 6:04 minutes
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Medicare Part D, also called the Medicare prescription drug benefit,
is a United States federal-government program to subsidize the costs of prescription drugs
and prescription drug insurance premiums for Medicare beneficiaries in the United States.
It was enacted as part of the Medicare Modernization Act of 2003
(which also made changes to the public Part C Medicare health plan program)
and went into effect on January 1, 2006.................
Prescription Drug Benefits
The MMA's most touted feature is the introduction of an entitlement benefit for prescription drugs, through tax breaks and subsidies.
In the years since Medicare's creation in 1965, the role of prescription drugs in patient care has significantly increased. As new and expensive drugs have come into use, patients, particularly senior citizens at whom Medicare was targeted, have found prescriptions harder to afford.
The MMA was designed to address this problem.
The benefit is funded in a complex way, reflecting diverse priorities of lobbyists and constituencies.
It provides a subsidy for large employers to discourage them from eliminating private prescription coverage to retired workers;
It prohibits the federal government from negotiating discounts with drug companies;..............
It prevents the government from establishing a formulary, but does not prevent private providers such as HMOs from doing so.
Basic prescription drug coverage
Beginning in 2006, a prescription drug benefit called Medicare Part D was made available.
Coverage is available only through insurance companies and HMOs, and is voluntary.
Enrollees paid the following initial costs for the initial benefits: a minimum monthly premium of $24.80 (premiums may vary), a $180 to $265 annual
deductible, 25% (or approximate flat copay) of full drug costs up to $2,400.
After the initial coverage limit is met, a period commonly referred to as the "Donut Hole" begins when an enrollee may be responsible for the
insurance company's negotiated price of the drug, less than the retail price without insurance.
The Affordable Care Act, also commonly known as "Obamacare", modified this measure.
What drug plans cover
Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary).
Many Medicare drug plans place drugs into different "tiers" on their formularies.
Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception (see below) to get a lower copayment.
A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare.
If the change involves a drug you’re currently taking, your plan must do one of these:Provide written notice to you at least 60 days prior to the date the change becomes effective.
At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.
What is an Exception?
You have the right to ask your plan to provide or pay for a drug you think should be covered, provided, or continued.
This is called a Formulary Exception. To file a a formulary exception, you will need to contact your Part D Plan as each plans procedures is different as some plans we have seen will simple take the request over the phone and follow up with your Dr.'s office while others has a special form that has to be completed by the prescribing physician.
You have the right to request an appeal if you disagree with your plan's decision about whether to provide or pay for a drug your are requesting the exception on.
Your plan is required by law to send you information that explains your rights called an "Evidence of Coverage" (EOC).
Call your plan if you have questions about your EOC.
What if my plan won’t cover a drug I think I need?
You have the right to do all of these (even before you buy a certain drug:
Talk to your prescriber—your doctor or other health care provider who’s legally allowed to write prescriptions.
Ask whether the plan has special coverage rules. You can also ask your prescriber if there are generic, over-the-counter, or less expensive brand-name drugs that could work just as well as the ones you’re taking now.
Get a written explanation (called a coverage determination) from your Medicare drug plan.
A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your benefits, including whether a certain drug is covered, whether you have met the requirements to get a requested drug, how much you pay for a drug, and whether to make an exception to a plan rule when you request it.
Ask for an exception if you or your prescriber believes you need a drug that isn’t on your plan’s formulary.
Ask for an exception if you or your prescriber believes that a coverage rule (such as prior authorization) should be waived...................
Ask for an exception if you think you should pay less for a higher tier (more expensive) drug because you or your prescriber believes you can’t take any of the lower tier (less expensive) drugs for the same condition.
You or your prescriber must contact your plan to ask for a coverage determination or an exception. If your network pharmacy can’t fill a prescription, the pharmacist will show you a notice that explains how to contact your Medicare drug plan so you can make your request. If the pharmacist doesn’t show you this notice, ask to see it.
You or your prescriber may make a standard request by phone or in writing, if you’re asking for prescription drug benefits you haven’t gotten yet.
If you’re asking to get paid back for prescription drugs you already bought, you or your prescriber must make the standard request in writing.
You can call your plan, write them a letter, or send them a completed form to ask your plan for a coverage determination or exception.
Once your plan has gotten your standard request, it has 72 hours to notify you of its decision.
You or your prescriber can call or write your plan for an expedited (fast) request. Your request will be expedited if you haven’t received the prescription and your plan determines, or your prescriber tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
Once your plan has gotten your expedited request, it has 24 hours to notify you of its decision. If you’re requesting an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.
Your doctor or other prescriber can request this level of appeal for you, and you don’t need to appoint them as your representative.
Your Medicare drug plan will send you a written decision. If you disagree with this, you have the right to an appeal.
Appeals Process (Click on each level below and a new window will open with a defined explanation from Medicare)................
2 Ways to Get Drug Coverage
1. Medicare Prescription Drug Plan (Part D).
These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private
Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
WARNING: If you enroll in an HMO or PPO advantage plan that DOES NOT come with Part D, you CAN NOT enroll in a separate drug plan!
2. Medicare Advantage Plans (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through
these plans. WARNING: HMO & PPO advantage plans are offered in some areas thatDO NOTcome with Part D drugs. (read the warning above)
Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”
You must have Part A and Part B to join a Medicare Advantage Plan.
Please see some great videos from CMS below on how to use Medicares Prescription Drug Plan comparison tool.
This is THE BEST way to pick the best plan to cover your specific medications.
With over 6000 medications on the market and the fact that NO DRUG PLAN covers more than about 4000 in their formulary,
there is literally NO OTHER WAY to be sure that you have chosen the BEST plan that covers your specific medications at the lowest cost
AND no surprises on any restrictions either because those are listed with each plan in the Plan Compare as well.
We have used this great Medicare tool to evaluate our clients drug coverage every since it was created and the drug plans started in 2006.
Take the confusing guess work out of picking your drug plan and spend just a few minutes to watch the videos to learn how.
(The first two are videos concerning Part D Important Information then the five part Comparison Tool videos follows)