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Deciphering Medicare Part D

Deciphering Medicare Part D. Susan Miller, Patient Education Douglas A. Magenheim, MD, MBA, FACP. Medicare D Is Important for Your Health Care. How many of you pay for most of your prescription medicines?. Will Seniors Enroll?. Cost of Prescriptions Will Go Up.

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Deciphering Medicare Part D

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  1. Deciphering Medicare Part D Susan Miller, Patient Education Douglas A. Magenheim, MD, MBA, FACP

  2. Medicare D Is Important for Your Health Care How many of you pay for most of your prescription medicines?

  3. Will Seniors Enroll?

  4. Cost of Prescriptions Will Go Up • The cost you pay today is much higher than what you paid just 5 years ago. • Medicare D insurance will help you with the cost of your medicine. • Yes, it is confusing to understand, but Medicare estimates the average senior will save a minimum of 30-40% on their drug costs

  5. Senior Spending on Prescription Medications Average annual out-of-pocket drug costs among the Medicare population: Projected:

  6. Percentage of Seniors Not Taking All Prescribed Medication SOURCE: Kaiser/Commonwealth/New England Medical Center 2001 Survey of Seniors in Eight States.

  7. Understanding Medicare D How does the plan work?

  8. Overview of Plan • Medicare Part A and B – now Part D for prescription drug coverage • 16 insurance companies are selling 57 plans from which to choose • Snowbirds must choose national plan • You must enroll in a plan – you are not automatically going to get prescription drug coverage • You must pay a monthly premium for this ranging from $14 to $68 a month • It is optional – you don’t have to buy it

  9. Overview of Plan -- Enrollment • You must enroll by Dec. 31, 2005 to have coverage Jan. 1, 2006 • can change your mind before 12/31/05 • Must enroll by May 15, 2006 to avoid premium penalty • can change your mind 1 time before 5/15/06 • Each year, annual open enrollment will be held in November for a January 1 effective date • This will be the only time you can change your mind each year.

  10. Current Insurance Coverage* Medicare and Employer/Union Coverage, including the Military Original Medicare Plan with or without supplemental/ secondary plan Medicare Advantage and Other Medicare Health Plans Medicare and Medicaid or Other State/Federal Assistance Programs Which box describes the health insurance you have now? *Does NOT include doctor samples, discount cards, Medicare-approved drug discount cards with or without the $600 credit, free clinics, or drug discount websites

  11. Current Insurance Coverage* Medicare and Employer/Union Coverage, including the Military? Check your company’s plan – Most Employer Coverage is BETTER than Medicare D Plans Original Medicare Plan Medicare only – Enroll in Part D to save money on your medicine Medicare with supplemental plan – check your supplemental plan for drug coverage Medicare Advantage and Other Medicare Health Plans New plans will include drug coverage. If you like it – stay with it or evaluate other options from Anthem, United, etc. Medicare and Medicaid or Other State/Federal Assistance Programs No drugs through Ohio Medicaid effective 1/1/06. Must choose Medicare D Plan. Extra Help with benefits and costs

  12. How does Insurance Work? • Take your prescription to a Network pharmacy • You will get an immediate discount on prescriptions • If your plan has a deductible, you must pay for this out of your pocket • Deductibles are $0 -- $100 -- $250 • After deductible, you pay a percentage of the discounted price OR a flat dollar amount • Co-insurance percentage -- 25-75% • Flat dollar copayments -- $0 to $60 per prescription • Most plans have a coverage gap or “donut hole” • After spending $2,250 (you and insurance company), you pay 100% of the cost up to $5,100 – or $2,850 out of your pocket • Some plans offer limited coverage for generic drugs during this gap. • Catastrophic Coverage - You pay only 5% of the cost of your drugs

  13. What Else Should You Know? • Insurance companies are selling both drug plans and “Advantage Plans” – know the difference and what they are selling • You must use a network pharmacy – ask who is in the network • All plans have drug lists or formularies. If your drug is not on the list, it may not be covered. • What you pay for your medicine will depend on “where” it falls on the insurance company’s list • Some companies are partnering to sell their plans through specific organizations • AARP and Walgreens = United HealthCare • Walmart and State Farm = Humana

  14. Extra Help Is Available • Financial help is available if: • Your income is less than $11,500 (single) • Your income is less than $23,000 (married) • Apply for help with the Social Security office • If approved: • Little or no premium to pay • Little or no deductible • Copayments for drugs are $1 to $5 • No coverage gap • Still must enroll in a plan

  15. To Apply For Financial Help • For financial help: Social Security Office • Call 1-800-772-1213 to apply for help • www.socialsecurity.gov

  16. Premium Penalties • Insurance companies want you to enroll • They will try to talk you into the basic plan at $14 per mo. • What if you don’t enroll? • Cost to enroll for 1 year: $14.43/mo = $173.16/yr • Cost to enroll 1 year later – 1% per month penalty = 12% • $14.43 x 12% = $1.73 • $14.43 + $1.73 = $16.16/mo or = $193.92/per year • Will cost you $20.76 to wait versus paying $173.16 to pay for something you may not use. • No penalty if you are covered by employer or retiree plan that ends

  17. How do I Choose A Plan? • Medicare.gov is most comprehensive source of information • How to use this tool and enroll in the plan that is right for you! • Have friend/family member help you review the website • Or Call 1-800-MEDICARE

  18. Talking with Your Doctor

  19. Understand the Plan You Choose • Look at the list of your medications and their costs • Ask for a copy of the company’s formulary drug list • Bring your insurance formulary list to your doctor’s appointment • Will help the doctor understand the options you have and help make decisions about changing your medications

  20. Talking with Your Doctor • Don’t be afraid to ask the doctor what the medicine is for and what other alternatives there are (i.e. Can I safely switch to a less expensive medication?) • Ask your pharmacist and doctor about generic alternatives • Understand how often you must take your medication and when

  21. Talk with Your Doctor • Most insurance plans will only give you a 30 day supply of medicine at a time • Plan for this when you call the office for refills or follow-up appointments • Some offer 90 day mail in • If you have to change your pharmacy, let your doctor’s office know so your information can be updated.

  22. The Medicare Part D Plans Questions?

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