Starting January 1, 2006 , the federal Medicare program will provide a new prescription drug benefit. This new drug program (called the Medicare prescription drug benefit) will allow many people to get medications and will help pay for some or all of the drug costs for people who join a drug plan. This new program has many dates and facts to remember. All people with Medicare – especially people who have both Medicare and Medicaid – need to learn about this new program, how to enroll, and about their rights and responsibilities.
Initial enrollment for the Medicare prescription drug program begins on November 15, 2005 and lasts until May 15, 2006. All people with Medicare will receive materials from CMS, including the Medicare & You handbook, and from plans approved by CMS in your area. CMS also will have an online tool to compare plans in your area at www.medicare.gov. You should compare plans and choose the one that best meets all of your medication needs. Talk with your doctor, pharmacist, case manager, or other support person to help you choose a plan and to find other sources of help.
If your new pharmacy tells you that a medication is not covered by your plan, or your plan requires a higher co-payment for your medication than for other similar medications, you have the right to have that decision reviewed and possibly changed. This decision process is known as the exception and appeals process. If you decide to file an exception to get your medication covered by your Medicare prescription drug plan, be sure to keep track of all contacts you make (name of the person, phone number, and date and time of the call).
What is the impact of enrollment in the Medicare prescription drug benefit on Food Stamps, Housing Assistance and Medicaid Spend Down?
The Medicare prescription drug benefit is designed so that consumers will not be worse off for receiving subsidy assistance to help defer their prescription drug costs. Consumers need to be aware that the reduction in medical expenses may change the eligibility of other programs in which they are currently participating. Each person’s situation will be unique, so it is important to be aware of how Medicare prescription drug coverage affects other benefits.
All Medicare Prescription Drug Plans must provide a formulary, which is a list of drugs covered by the plan, including both generic and brand name medicines. CMS requires that the plans include medications in a wide range of therapeutic categories. The process for filling your prescriptions might change under the new Medicare prescription drug program.
Extra Help is a program that helps eligible people with Medicare pay for some or most of their prescription drug costs. If you qualify for Extra Help, you will not receive money; instead, Medicare will pay for part, or in some cases, all of your drug costs.
Costs for Consumers
Most people in a prescription drug plan will pay a monthly premium, co-payments for each medication, an annual deductible and co-insurance. People with Medicare and Medicaid and some people with limited incomes will have lower costs. Your costs will include a monthly premium of about $32 and a $250 deductible, unless you have very little income (about $14,000/year for an individual and about $19,000/year for a couple). In addition, you will have to pay 25% of your prescription drug costs between $250 and $2,250. Once your drug costs reach $2,250, you will be responsible for paying the full cost for your medications until you pay a total of $3,600 out-of-pocket. Once you reach this amount, you will only have to pay a co-payment (generally 5% of the medication cost or co-pays of $2-$5 per drug).