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| Medicare Part D: An Overview |
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This text is referenced from California Health Advocates. For any additional Information please visit cahealthadvocates.org
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (also known as the MMA) created voluntary prescription drug insurance through Medicare. It is commonly referred to as "Medicare Part D."
This drug coverage is available to everyone who has Medicare, regardless of income, health status, or how their prescriptions were previously covered. Private companies provide the insurance coverage. You choose the drug plan and pay a monthly premium. If you have limited income, you may get extra help to cover prescription drugs at little or no cost. See the fact sheet titled "Extra Help for Part D Costs" at cahealthadvocates.org.
The amount of the monthly premium you pay cannot cost more because of your health condition or the number of prescriptions you need. In addition to the premium, you may also have to pay a deductible and a portion of your drug costs.
Some companies offer more coverage and additional drugs for a higher monthly premium. In California, there are 33 stand alone prescription drug plans (PDPs) that are available throughout the state in 2012.
Depending upon where you live, there may be additional Medicare Advantage plans with prescription drug coverage (MA-PDs). The availability of Medicare Advantage plans varies by county. Some counties have many options and other counties have only a few. All plans have a formulary, which is a list of drugs covered by the plan. This list must always meet Medicare´s minimum requirements, but it does not have to include all prescription drugs.
In some circumstances with Medicare´s approval, plans can change their formulary during the year. Two such circumstances include: if a new generic version of a covered brand-name drug becomes available; or new FDA or clinical information show a drug to be unsafe. In general, however, plans cannot discontinue or reduce the coverage of a drug you are currently taking. If a formulary change is made that affects you, the plan must let you know at least 60 days before the change takes place.
If your doctor thinks you need a drug that is not on the list, or feels a formulary change will adversely affect you, you or your doctor can apply for an "exception" with your plan. If the plan denies you, you can appeal the decision. For information on Part D appeals, see the fact sheet "When My Part D Prescription is Denied" at cahealthadvocates.org.
Prescription drug plans must contract with pharmacies in your area, but not all pharmacies will contract with all plans. Check with the plan to make sure that the pharmacies in the plans network you choose are convenient for you. Many plans also have a mail order option; allowing you to get your prescriptions by mail order, often at a lower cost.
If you have not joined a plan AND if you do not have creditable coverage for your prescriptions, your next opportunity to enroll in a PDP is during the annual enrollment period. This period begins on October 15 each year and ends on December 7th. Coverage begins the following year on January 1st.
Note: you may have other limited opportunities to enroll in a Part D plan depending on your situation. Call your local Health Insurance Counseling and Advocacy Program (HICAP) for more information.
In addition, if you do not join a plan AND do not have creditable coverage for your drugs, you will incur a penalty of 1% of the average annual premium ($31.08 in 2012) for every month you were eligible and did not sign up. This amount is then added on to your drug plan premium.
For people who are new to Medicare, the initial enrollment period for Part D lasts for seven months; you will have three months prior to the month you become eligible, the month you become eligible, and three months after the month you become eligible to enroll in a plan.
To find and compare plans, your best local resource is HICAP, which offers free and unbiased information. You can call the statewide toll free number 1-800-434-0222 with your questions or to make an appointment at the HICAP office nearest you. You can also go to the website medicare.gov or call 1-800-Medicare and speak to a customer service representative. It is important to have your list of medications, your Medicare number and the name of your preferred pharmacy available when you call or go on the website.
Standard Part D Coverage for 2012
Part D: Prescription Drug Coverage
Monthly Premium
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You Pay
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Premium for individuals who have an annual income of $85,000 or less and $170,000 or less for couples.
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Your plan premium
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| For individuals with incomes above $85,000 up to $107,000, or couples with incomes above $170,000 up to $214,000 |
$11.60 + Your
Plan Premium
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| For individuals with incomes above $107,000 up to $160,000 or couples with incomes above $214,000 up to $320,000 |
$29.90 + Your
Plan Premium
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For individuals with incomes above $160,000 up to $214,000, or couples with incomes above $320,000 up to $428,000
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$48.10 + Your
Plan Premium |
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Toll free:1-877-255-6273
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