Medicare D

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  • NOTICE:  Plan changes deadline now December 7!

2011 Fall Medicare D assistance service

The window during which you can change medicare plans has been changed.  Now you can review and choose a new Medicare D plan between October 15th & December 7th.  If you are one of our patients, we can prepare a list of plan options (using Medicare’s Plan Finder website & our records of your med history) for you and then sit down with you to make sure you understand all the details before you make your decision.  Simply let us know sometime in October and we’ll add you to the list.

Be sure to stop back or call to set up a time for us to sit down together and review all the details.  Any change of plans must be done BEFORE DECEMBER  7!

Creative Commons Licensephoto credit: vintagedept

2011 Donut Hole Help

Those Medicare D patients whose drug expenditure reaches a certain dollar level will enter the famous Donut Hole or Coverage Gap.  In #051/365
2011 anyone who reaches the Coverage Gap will get a discount on their medications! The discount will be 50% off of brand medications and about 7% off of generics.  (Note: even though you will pay less for these medications, the full value of each will be counted toward your yearly total so there will be no affect on how soon you reach the other side of the Coverage Gap, where you become eligible for Catastrophic Coverage.)

In other words: while your copay will go up dramatically if you reach the Coverage Gap, it will not be as dramatic as last year because a discount will have been automatically applied when we filled the medication.

This is part of the new Healthcare Bill that Congress enjoys arguing about and the goal of this part is to keep reducing what Medicare D patients pay for drugs during the Coverage Gap until it is just 25% of what they paid before.  Each year the discount applied will increase so that your Coverage Gap copays decrease . . . unless the law is appealed or altered.

Creative Commons Licensephoto credit: Kirstea

Some quick graphics showing the basics of Medicare D: More details are below the pictures.


And here’s one about the costs.  Remember:  these are just a sketch.  More details in the text that follows.


Medicare D Summary with more details

  • See above for a graphic summary of the basics of Medicare D & the costs involved.
  • Medicare D is for prescription drug coverage only: D for Drugs.  Health coverage is separate.
  • Each plan is operated by a private company under contract with the government medicare system.
  • There are dozens of different Med D plans available to people age 65 or more and to certain patients with permanent disabilities.  You must have Medicare before signing up for Med D.
  • Medicare Advantage plans are different:  they include extra health coverage benefits wrapped together with drug benefits.  They cost more.
  • Initial sign-up is between 3 months before the month you turn 65 to 3 months after: a 7 month window.  If you sign up later than that, there may be a penalty.  Usually small, the penalty is based on how many drugs you use and how long you waited to sign up after you were first eligible.
  • You may sign up by telephone or online or by paper forms from the company you choose.  A good starting point is the Medicare Plan Finder website: it will compare your costs for each plan and include links & phone numbers to sign up.
  • Which is the best plan?  It depends on where a person lives and on what their list of drugs is.  Medicare has an excellent website to help you compare plans: the Medicare Plan Finder.  This will show you details about the plan policies and also show comparative cost information.  However, to get the best results, you need to be certain that your medications have been entered into the website correctly, so be careful and methodical about it.  When we help our patients with this every fall, we have access to their medication history and we are certain to enter the data correctly.  Then our pharmacist sits down with the patient to make sure they (and/ or the responsible family member) very clearly understands the details of each plan and of the program as a whole.  It is up to the patient to select the plan: we have no role in choosing.  Only in making sure the choice is an educated one.
  • Every plan has a premium that must be paid monthly.  These usually range from $20 on up to over $100.  The premium may be paid by check like any other bill, or you can have it deducted from your bank account automatically or you can even have it removed from your social security check before it’s sent out.
  • Most plans have a deductible:  you pay “full price” (as determined by the insurance company) for each drug until the deductible is met.  Only then will the benefit kick in and your copays go down.  Deductibles may range from $0 to $100 to $310.
  • During your benefit period (after the deductible is paid off), your copay may be a flat dollar figure or it may be tied to the cost of the drug.  Some plans charge $5 for generics, some zero, some a percentage of the drug’s cost.  Some generics may cost a lot more than others.  Some generics may be place on higher tiers than others (see below).  Brand drugs typically have a much higher copay than generics.
  • Tiers.  Insurance plans rank drugs by placing them on different tiers.  The lowest (best) tier is 1 because the plan will usually charge you the lowest copay for tier 1 drugs and have few restrictions on these prescriptions: this is often the tier where you see low cost, well established generic drugs.  Tier 2 drugs will have a higher copay.  Tier 3 and tier 4 will be higher still.  Brand drugs will be found on the higher tiers.
  • Restrictions:  Plans may have limitations on your prescription.  There are several types of restrictions, similar to those found with other insurance plans.  Some drugs will need a Prior Authorization (the doc has to contact the plan and request approval) or may only be covered after other, lower cost, drugs have been tried first.  There are many different possible restrictions and limitations: our staff will explain it to you if such a thing affects any of your drugs.  Be aware that the plan can make changes to your coverage any time they wish.
  • The plan determines if we are allowed to fill your prescription for a 30 day supply or a 90 day supply.
  • Doughnut Hole
  • Catastrophic Coverage
  • Renewal:  If you do nothing, you will remain enrolled in whichever Medicare D plan you start with.  While the plan can make changes anytime, you are permitted to switch Med D plans only once a year, in the fall.  If you don’t check, the plan you are on may or may not be the best (most $ saving) for you in subsequent years.  It is best to check each Fall to see which plan will save you the most money overall.  This is a service we can help you with by entering the drugs into Medicare’s Plan Finder and discussing the results with you to be sure you fully understand all of the details before you make your choice.