PHARMACYZONE.COM HOME            SITE INDEX

 

Medicare Part D Participant Information - The Medicare Prescription Drug Benefit

Resources, Questions and Answers, and Links for Medicare Part D Participants and Beneficiaries of the Medicare Modernization Act


FREQUENTLY ASKED QUESTIONS ABOUT THE MEDICARE MODERNIZATION ACT

  • What is the Medicare Modernization Act?
  • Who qualifies for the voluntary prescription drug program?
  • How much will it cost per month to participate in this program?
  • For patients who do not qualify as low-income beneficiaries, what will their benefit design look like?
  • What are out-of-pocket costs?
  • Who will qualify for the low-income subsidy?
  • Who will determine if beneficiaries qualify for the low-income subsidy?
  • Will beneficiaries need to join a managed care plan to receive prescription drug benefits from Medicare (similar to current Medicare + Choice plans)?
  • Will any medications not be covered by this new benefit?
  • Will Medicare eligible beneficiaries currently receiving Medicaid benefits still receive Medicaid coverage for prescription drugs?
  • When can beneficiaries begin enrolling in the new Medicare prescription drug plans?
  • Will beneficiaries be able to choose from multiple plans?
  • If a patient does not enroll in a plan before May 15, 2006, can they still receive benefits?
  • Can beneficiaries expect to see overly restrictive formularies (e.g. only one medication covered to treat a condition)?

  1. Q: What is the Medicare Modernization Act?
  2. A: The Medicare Modernization Act was passed on December 8, 2003. It established a voluntary drug benefit for Medicare beneficiaries. From June 1, 2004 until December 31, 2005 Medicare beneficiaries have the option to purchase an interim Medicare-approved Drug Discount Card. Starting January 1, 2006 Medicare beneficiaries will have the option to purchase a full prescription drug benefit. This program is completely voluntary.

    back to top

  3. Q: Who qualifies for the voluntary prescription drug program?
  4. A: Any person currently entitled to Medicare Part A or enrolled in Medicare Part B qualifies for the new prescription drug program. Generally, anyone over age 65 or permanently disabled will qualify for this program.

    back to top

  5. Q: How much will it cost per month to participate in this program?
  6. A: Medicare beneficiaries will fall into two categories: regular beneficiaries and low-income subsidized beneficiaries. Regular Medicare beneficiaries can expect to pay a monthly fee of approximately $37 per month but the fee varies by plan. In most cases, beneficiaries who qualify as low-income will have their monthly fee waived by Medicare.

    back to top

  7. Q: For patients who do not qualify as low-income beneficiaries, what will their benefit design look like?
  8. A: The program will include:
     

       
    • Monthly fee (approximately $37/month)
       
    • $250 annual deductible
       
    • After drug spending of $250, the beneficiary will be responsible
      for 25% of drug costs until they reach $2,250 in drug spending
       
    • After reaching $2,250, the beneficiary will be responsible for
      100% of drug costs until they reach $3,600 out-of-pocket costs (~$5,100
      of prescription drug spending) – this is the coverage gap
      or "donut hole"
       
    • After spending $3,600 out of pocket, the beneficiary is responsible
      for 5% of drug costs
       

    back to top

  9. Q: What are out-of-pocket costs?
  10. A: Out-of-pocket costs are any costs that beneficiaries are responsible for paying out of pocket on prescription drug spending. For example, the $250 deductible is an out-of-pocket cost. Likewise, the 25% copay up to $2,250 (or $ 500) is also an out-of-pocket cost. Many beneficiaries will reach their $3,600 out-of-pocket cost after spending $5,100 on drug costs annually ($250 deductible + $500 after paying 75% of costs + $2,850 in the coverage gap). Other beneficiaries will actually spend more or less depending on contributions from state pharmaceutical assistance plans (e.g. EPIC, PACE, PAAD) or employee retiree benefits. Monthly fees do not count towards out-of-pocket costs.

    back to top

  11. Q: Who will qualify for the low-income subsidy?
  12. A: Anyone under 150% of federal poverty level will receive some governmental assistance.

     
    Income Test Asset Test Premium/
    Deductible
    Copayments
    Under 100 % of Federal Poverty Level (FPL) $6,000 individual/
    $9,000 couple
    $0/$0 $1 for generic/ $3 other until $3,600 out of pocket - $0 for catastrophic coverage
    100 % – 135% of FPL $6,000 individual/
    $9,000 couple
    $0/$0 $2 for a generic/ $5 other until $3,600 out of pocket - $0 for catastrophic coverage
    135 % – 150 % of FPL $10,000 individual/
    $20,000 couple
    Sliding scale premium/$50 15 % of drug costs from $50-$3,600 - $2 for generic /$5 other for catastrophic coverage

    back to top

  13. Q: Who will determine if beneficiaries qualify for the low-income subsidy?
  14. A: The agency that runs Medicare, the Centers for Medicare and Medicaid Services (CMS), has enlisted the assistance of the Social Security Administration (SSA) and state Medicaid agencies to perform the reviews to determine if a beneficiary will receive the low-income subsidy. The beneficiary will be required to complete an eight-page application form to initiate the process. It is important to note that these applications are not enrollment applications to participate in any particular Medicare plan. Low-income beneficiaries will be randomly auto-enrolled into a qualified plan later this year. The SSA application form is only the first step in the enrollment process. Once a beneficiary is automatically assigned into a plan, they can switch out of that plan if desired.

    back to top

  15. Q: Will beneficiaries need to join a managed care plan to receive prescription drug benefits from Medicare (similar to current Medicare + Choice plans)?
  16. A: No, the MMA established two types of plans to administer the prescription drug benefit. They are prescription drug plans (PDPs) and Medicare Advantage (MA-PD) plans. The Medicare Advantage plans will take the place of existing Medicare + Choice plans. However, beneficiaries not wishing to join a managed care plan can enroll with a PDP. PDPs will be administered by pharmacy benefit management companies (PBMs) and other interested parties (such as Community Care Rx, AARP and other non-PBM entities)

    back to top

  17. Q: Will any medications not be covered by this new benefit?
  18. A: Yes, some medications are not covered by the new Medicare benefit. They include:
    • Immunosuppressants following kidney transplantation (can be covered under Medicare Part B)
    • Diabetic testing supplies such as strips, lancets, monitoring devices (can be covered under Medicare Part B)
    • Anorexia, weight loss, or weight gain medications
    • Fertility promotion medications
    • Hair growth medications
    • Cough and cold medications
    • Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparation)
    • Nonprescription drugs
    • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale
    • Barbiturates
    • Benzodiazepines

    back to top

  19. Q: Will Medicare eligible beneficiaries currently receiving Medicaid benefits still receive Medicaid coverage for prescription drugs?
  20. A: No, all Medicare-eligible beneficiaries currently receiving Medicaid assistance for prescription drugs will be disenrolled from Medicaid prescription plans effective January 1, 2006. These beneficiaries will continue to receive Medicaid benefits for other health services provided by their state.

    Before January 1, 2006, dual-eligibles (those beneficiaries qualifying for both Medicare and Medicaid) will be randomly assigned into participating PDPs and MA-PDs in their region. Dual-eligibles will have the option to switch from their auto-enrolled plan if they prefer a different plan or if their pharmacy does not accept their randomly chosen plan.

    back to top

  21. Q: When can beneficiaries begin enrolling in the new Medicare prescription drug plans?
  22. A: Starting November 15, 2005, beneficiaries can start enrolling in PDPs and MA-PDs. The initial enrollment period will last six (6) months until May 15, 2006

    back to top

  23. Q: Will beneficiaries be able to choose from multiple plans?
  24. A: The MMA requires that at least two plans be offered per region. Generally, plan regions are statewide. They vary based on PDP and MA-PD regions. A summary of the regions is below.

     
    PDP Region State(s) Included PDP Region State(s) Included
    1 New Hampshire
    Maine
    18 Missouri
    2 Connecticut
    Massachusetts
    Rhode Island
    Vermont
    19 Arkansas
    3 New York 20 Mississippi
    4 New Jersey 21 Louisiana
    5 Delaware
    District of Columbia
    Maryland
    22 Texas
    6 Pennsylvania
    West Virginia
    23 Oklahoma
    7 Virginia 24 Kansas
    8 North Carolina 25 Iowa
    Minnesota
    Montana
    Nebraska
    North Dakota
    South Dakota
    Wyoming
    9 South Carolina 26 New Mexico
    10 Georgia 27 Colorado
    11 Florida 28 Arizona
    12 Alabama
    Tennessee
    29 Nevada
    13 Michigan 30 Oregon
    Washington
    14 Ohio 31 Idaho
    Utah
    15 Indiana
    Kentucky
    32 California
    16 Wisconsin 33 Hawaii
    17 Illinois 34 Alaska

     

    MA-PD
    Region
    State(s) Included MA-PD
    Region
    State(s) Included
    1 New Hampshire
    Maine
    14 Illinois
    Wisconsin
    2 Connecticut Massachusetts
    Rhode Island
    Vermont
    15 Arkansas
    Missouri
    3 New York 16 Louisiana
    Mississippi
    4 New Jersey 17 Texas
    5 Delaware
    District of Columbia Maryland
    18 Kansas
    Oklahoma
    6 Pennsylvania
    West Virginia
    19 Iowa
    Minnesota
    Montana
    Nebraska
    North Dakota
    South Dakota Wyoming
    7 North Carolina
    Virginia
    20 Colorado
    New Mexico
    8 Georgia
    South Carolina
    21 Arizona
    9 Florida 22 Nevada
    10 Alabama
    Tennessee
    23 Idaho
    Oregon
    Utah
    Washington
    11 Michigan 24 California
    12 Ohio 25 Hawaii
    13 Indiana
    Kentucky
    26 Alaska

    back to top

  25. Q: If a patient does not enroll in a plan before May 15, 2006, can they still receive benefits?
  26. A: Yes, but they will be subject to a late enrollment fee of approximately 1% per month. This will be reflected in higher monthly fees for the beneficiary’s lifetime. It is important that if beneficiaries are considering the new Medicare prescription drug benefit that they factor the late fee into their decision whether or not to enroll prior to May 15, 2006.

    back to top

  27. Q: Can beneficiaries expect to see overly restrictive formularies (e.g. only one medication covered to treat a condition)?
  28. A: Plans will vary their benefit design in many ways to minimize drug spending. The United States Pharmacopeia (USP) has created model formulary categories and plan sponsors may choose to follow this design. USP created 146 unique therapeutic categories and pharmacologic classes. The MMA mandated that participating plans must cover at least two drugs per therapeutic category. Therefore, in most cases, there will be more than one drug covered to treat a condition. However, it is likely that formularies will have extensive tiering structures that will employ step therapy, prior authorization, and other methods to control drug spending.

    back to top

 

We are adding new pages to this site daily, so please check back for additional pharmacy information and updates.

 


PHARMACYZONE.COM HOME            SITE INDEX


 

PHARMACYZONE.COM HOME

We are adding new jobs to this site daily, so please check back for additional pharmacy jobs and updates.  Please see our main website - RxRecruiters.com for more detailed information on our services.