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What are the Basics of the Benefit?
The new Medicare drug benefit will offer insurance to help you
pay for your prescription drugs. It will be available to everyone who
is enrolled in Medicare. The new drug benefit begins January 1, 2006.
What Will the Basic Plan Look Like?
The new drug benefit will be offered through two types of insurance
plans:
There will be a choice of at least two plans in your area. Each plan
will have its own listing of drugs that will be covered under the plan
(known as a formulary). Since plans may cover different drugs, it is
important that you compare plans in your area before choosing a plan.
You must fill your prescriptions at a pharmacy that is in your plan’s
network. Each plan will provide a list of pharmacies where you will
be able to have your prescriptions filled.
A Plan Comparison Web Tool and Medicare Personal Plan Finder will
be available at http://www.medicare.gov in
late October 2005. These tools may help you in choosing a prescription
drug plan that is right for your needs. For help evaluating your plan
choices you may contact:
If you do not have Internet access and need help getting phone numbers
for these organizations, you can call the NMHA Resource Center at 1-800-969-6642.
What Will the Benefit Cost Me?
Unless you have very little income (about $14,000/year for an
individual and about $19,000/year for a couple.), your costs will include
a monthly premium of about $37 and a $250 deductible. 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 your drug costs reach
$5,100, or 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).
Extra Help with Costs For Medicare Participants With Limited
Incomes
“Extra Help” will be available to Medicare participants
who have low incomes and a small amount of assets. The amount of financial
help you receive from the federal government will depend on which of
the following two categories describes your financial situation.
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If your income is below $12,920 a year for individuals and
$17,321 a year for couples this year (in 2006, when the drug benefit
begins, these income limits will be higher reflecting inflation)
and you have assets below $6,000 for individuals and below $9,000
for couples (you do not count the value of the home you live in,
your furniture or your car but do count all of the following: bank
accounts including checking, savings, and certificates of deposit;
stocks; bonds, including U.S. Savings Bonds; mutual funds; individual
retirement accounts (IRAs); real estate (other than the house you
live in); and cash at home or anywhere else), you can apply for
the Extra Help.
Extra Help will cover both your premium for the lowest cost drug
plan or managed care plan in your area and will also cover your deductible.
If you choose a higher cost drug plan, you will have to pay the extra
premium amount yourself. You will have co-payments between $2 and
$5
until you pay $3,600 in out-of-pocket drug costs; then, your medications
will be covered in full with no co-pay.
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If your income is $14,355 a year for individuals and $19,245 a
year for couples (in 2006, when the drug benefit begins, these
income limits will be higher reflecting inflation) and you have
assets below $10,000 for individuals and below $20,000 for couples
(see description in Number 1 above for what assets are counted),
you can also apply for Extra Help.
"Extra Help" will cover your premium on a sliding scale (the exact
amount of help with your premium will be based on your income and assets information).
In addition, your deductible will be reduced to $50 and your co-pay will be 15%
on your out-of-pocket drug costs up to $3,600. Once your out-of-pocket drug costs
reach $3,600, you will only have to pay $2-$5 co-pays on each medication.
If you are unsure whether you qualify for “Extra Help” you
should apply. If you do not qualify for this financial assistance,
you can check with the following agencies to see if your state is providing
any additional assistance with medication costs for Medicare beneficiaries:
If you do not have Internet access and need help getting phone numbers
for these organizations, you can call the NMHA Resource Center at 1-800-969-6642.
How Do I Apply For the Extra Help?
If your income falls within the amounts described above, you should
receive an application from the Social Security Administration to apply
for the Extra Help. You will receive the application sometime between
May and August 2005. If you do not receive this application, call 1-800-
772-1213 to request an application or go to http://www.socialsecurity.gov.
You can complete this application on-line http://www.socialsecurity.gov or fill out a paper application and mail it to the Social Security
Administration or your state Medicaid office to apply for this help
with your prescription drug costs. The Social Security Administration
address should be on the paper application. Your state Medicaid office’s
address can be found at http://www.cms.gov/medicaid/statemap.asp.
For help completing this application, you can contact:
If you need help finding telephone numbers for these organizations,
please call the NMHA Resource Center at 1-800-969-6642.
Important Note: In addition to applying for this financial assistance,
you will also need to sign up for a prescription drug plan beginning
November 15, 2005.
How Do I Sign Up For A Medicare Prescription Drug Plan?
You can sign up for the new Medicare prescription drug benefit by
submitting an application to the plan you choose. You will receive
information from Medicare in October 2005 about the different plans
available in your area. Since plans may cover different drugs, it is
important that you compare available plans before choosing a plan.
A Plan Comparison Web Tool and Medicare Personal Plan Finder will be
available at http://www.medicare.gov in late October 2005. These tools
may help you in choosing a prescription drug plan that is right for
your needs.
For help evaluating your plan choices you may contact:
If you do not have Internet access and need help getting phone numbers
for these organizations, you can call the NMHA Resource Center at 1-800-969-6642.
The initial deadline for signing up is May 15, 2006. If you do not
have comparable drug coverage (coverage that is as good as the Medicare
prescription drug plan) through either an employer or past employer,
TRICARE, the Veterans’ Administration, or some other provider
of prescription drug coverage (such as a MediGap policy) you must sign
up by this deadline or you will have to pay a higher monthly premium
for your drug plan when you do enroll. Your employer or other organization
through which you have your drug coverage will provide you with written
information that tells you if your drug coverage is as good or better
than the Medicare drug coverage.
For more detailed information on enrolling into the new Medicare prescription
drug benefit, call the NMHA Resource Center at 1-800-969-6642 to request
a copy of NMHA’s “Medicare Prescription Drug Coverage Getting
Enrolled Consumer Workbook.”
What Medications Will Be Covered By Plans?
It is important to review the plans available in your region to see
which drugs they will pay for since plans can choose to cover different
medications. If possible, you should choose a plan that covers all
of your medications. You are only allowed to change plans once a year
during the open enrollment period between November 15th and December
31st unless you have both Medicaid and Medicare coverage.
A Plan Comparison Web Tool will be available in October 2005 at http://www.medicare.gov.
The tool will help you pick the drug plan that’s right for
you.
CMS requires that each plan cover at least two drugs in each drug
category. They are strongly encouraging plans to cover a majority of
medications in the following categories: anti-psychotics, anti-depressants,
and anti-convulsants.
Some drugs are not included in the new Medicare prescription drug
benefit. These include: benzodiazepines (e.g. Ativan, Klonopin, Valium,
Xanax), barbiturates, and drugs to treat eating disorders. If you take
these medications, you should:
- find other private manufacturer patient assistance programs
to see whether they might cover your prescription, by contacting
the Partnership
for Prescription Assistance at 1-888-477-2669 or http://www.pparx.org;
and
- talk with your doctor about other medications that might
work for you.
Plans are allowed to make changes to their approved drug list at any
time. However, they must give 60 days notice of these changes to enrollees
who are taking that medication or provide enrollees with a 60-day supply
of the medication they are removing from the approved drug list. The
plan must also notify prescribing physicians and the Centers for Medicare
and Medicaid Services.
What Do I Do If My Medication Isn’t Covered?
If your plan does not cover your medication or your plan requires
a higher co-payment for your medication than for other similar medications,
you may seek an exception to your plan’s approved drug list (formulary).
An exception is a formal decision by the plan to cover your medication
or reduce your co-payment. If an exception is granted, it will last
one year and will need to be requested again.
To file an exception, first call the plan to find out whether they
will cover your medication. If they say no, request that they send
you that decision in writing and follow the steps in your plan documents
to file an exception. Your doctor will have to give a statement in
writing or by phone (depending on the plan’s process) to the
plan that the medication you are seeking coverage for is medically
necessary and that other similar medications on your drug plan or managed
care plan’s list of covered drugs will not be effective or will
be harmful to you. Plans are required to make decisions on exception
requests within 72 hours or within 24 hours in emergency situations.
If your exception request is denied, you may appeal that decision.
Since this can take a long time, it is important to talk with your
doctor about other medications that you can take while you are going
through the appeals process. For more detailed information about appealing
a plan’s decision, call the NMHA Resource Center at 1-800-969-6642
to request a copy of NMHA’s "Medicare Part D: The New Prescription
Drug Benefit Getting Enrolled Consumer Workbook."
While your appeal is pending, you may also contact an organization that
helps consumers apply for state or pharmaceutical industry-sponsored
pharmacy assistance programs that provide medications or cost-sharing
assistance directly to consumers: Partnership for Prescription Assistance
http://www.pparx.org and 1-888-477-2669. You can also contact your local
Mental Health Association office http://www.nmha.org/affiliates/directory/index.cfm for information about pharmacy assistance programs available in your
state.
Need Further Help Understanding Your Benefit?
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