The "Part D" Prescription Drug Benefit from Medicare - What you need to do

On January 1, 2006, Medicare began sharing the cost of prescription medications with you, the consumer. The benefit, referred to as Pt. D of Medicare, is a component of the larger Medicare insurance plan but offered to consumers by Medicare approved private companies (stand-alones) and Medicare Health Plans. In 2008, at least 22 companies offering 55 plan options have been approved to offer Pt. D prescription drug plans to consumers in Colorado.

Like other insurance plans, Pt. D prescription drug plans will have co-pays, deductibles and monthly premiums. The dollar amounts of these co-pays, deductibles and monthly premiums will differ among the private companies and HMO's.

Because different Pt. D prescription drug plans cover some but not all formulary medications and offer formulary medications at different costs, always have a list of your medications available. This practice will enable you to select a Pt. D plan that covers all of your listed medications at the best prices.

General Costs

Among Pt. D plans in 2008, estimated monthly premiums will average $32 per month. After you pay the $275 deductible*, Medicare will share the cost of covered prescriptions from $276 to $2,510 by paying 75% of the prescription cost. Your co-pay is the remaining 25% of the prescription cost. *Note: Pt. D prescription drug plans offer different premium/deductible price mixes and offer medications at different costs, so be sure to compare plans.

The Coverage Gap (Donut Hole) and Catastophic Coverage

After $2,510, Medicare cost-sharing stops. You alone must pay 100% of the next $3216.25 in drug costs until you have spent $4,050 in out-of-pocket costs. After you reach $4,050 in out-of-pocket costs, you enter the catastrophic coverage level coverage and Medicare again shares the cost by paying 95% of the prescription cost. Your co-pay is the remaining 5% of the prescription cost.

Extra Help or (Low Income Subsidy)

Extra Help (or LIS) is a subsidy from Social Security that helps low income Medicare beneficiaries pay for their medications. Beneficiaries with gross monthly incomes below $1,300 monthly or below $1,750 for a married couple, living together and resources less than or equal to $11,990 for an individual or $23,970 for a married couple, living together, could be eligible for this benefit. Contact Seniors, Inc. for eligibility screening and application assistance.

Medicare Health Plans (HMOs, PPOs, PFFSs) or Pt. C

If you are currently enrolled in a Medicare Health Plan that provides your Pt A and Pt B benefits such as Kaiser or Secure Horizons, the MHP will enroll you in their Medicare-approved Pt. D prescription drug benefit plan and will inform you of the co-payments, deductibles, and premiums. Pt. D plan enrollment periods open in mid November of each year, so you should be hearing from various plans in early October.

If you wish to enroll in an HMO or if you wish to switch HMO's, you will need to choose the HMO that has the prescription drug plan with the drug formulary, co-payments, deductibles, and premiums that best meets your needs. Call the HMO for plan details and coverages before November.

Medicare Supplemental Plans (Medigap) and Employer Group Plans

If you have a Medicare Supplement (Medigap) policy (through AARP, Mutual of Omaha, Bankers Life, etc.) without Pt. D prescription drug coverage and if you are not part of an employer group plan, you will need to enroll in a Pt. D prescription drug Plan. Contact Seniors, Inc., and we will send you details on all stand-alone Pt. D plans offered in Colorado.

If you currently have a Medicare Supplement (Medigap) plan that includes Pt. D prescription drug coverage (such as Plan H, I or J) you can keep this coverage; however, enrolling in a Pt. D prescription drug plan could be less expensive.

If you have coverage from an employer group plan, contact that benefits coordinator at the plan and ask if your plan includes a Medicare approved Pt. D prescription drug plan. Some employer group plans offer Pt. D Prescription Drug Plans that Medicare has not approved.

Medicaid and Pt.D

If you are a full Medicaid beneficiary and in a long-term care facility, you will be deemed eligible for Pt. D low income prescription subsidy and should be automatically enrolled in a Pt. D prescription drug plan if you are not already enrolled in a plan. If you learn that you or a relative has yet to be automatically enrolled, call Seniors, Inc. at 303-300-6978. Our application assistance manager can help you submit an application for the benefit.

Enrollment Period

Pt. D Initial Enrollment Period: 7 months surrounding your 65th birthday. Begins 3 months prior to birth month, including the birth month, and three months after birth month. Coverage begins 1st day of month following month of enrollment (enrollment at some time in June, coverage begins August 1st).

The Annual Election Period opens on November 15, 2008 and ends on December 31, 2008. Pt. D coverage begins January 1, 2009.

Special Enrollment Periods exist for beneficiaries who are full dual eligibles (Medicare & Medicaid), partial dual eligibles (Medicare Savings Plan enrollees), and beneficiaries in long-term care facilities. These beneficiaries can switch among Pt. D prescription drug plans at any time. Call Seniors, Inc. to learn about special enrollment periods (SEPs).

TRICARE for Life

If you receive TRICARE as a military retiree or Veterans Administration benefits, you will not need to sign up for a Pt. D Prescription Drug Plan. You should contact TRICARE for advice.