Medicare Part D Prescription Drug Coverage

Medicare offers prescription drug coverage to its beneficiaries. This government-sponsored program, known as Part D, is a voluntary benefit provided by private insurance and managed care companies. Their prescription drug plans (called PDPs) help people eligible for Medicare with the cost of their prescriptions.

These PDPs cover part or all of the cost of most prescription drugs. Similar to the Medicare Part B benefit, Part D participants must enroll and pay a monthly premium (around $32 in 2009 for a standard plan), an annual deductible, and a share of the cost of prescriptions (through co-pays). Premiums, deductibles, co-pays, and drug choices vary among the PDPs.

Nursing facilities usually contract with one pharmacy, such as Forum Extended Care Services, that has special knowledge of the needs of their residents. Forum will provide to its facilities a list of its participating Part D plans. Facility staff or Forum’s reimbursement experts can provide information to help residents and families evaluate all PDPs. If you are a resident unable to enroll on your own, your authorized representative can enroll you in a plan that meets your needs

 

Important Resources

Other Useful Website Links

Medicare Part D Prescription Drug Plan (PDP) Information for Illinois and Wisconsin

AARP BULLETIN - Medicare Drug Coverage - The Basics (PDF)

Medicare D Quick Guide: What's a Beneficiary to DO" (PDF)

Facts at a Glance for Physicians Working in LTC (PDF)

SLF CILA Medicare Part D Copays (PDF)

Medicare Part D Excluded Drugs Covered by Illinois Medicaid.

 

The following contains answers to questions that residents in nursing facilities—or those responsible for them—should ask before enrolling in a Medicare Part D plan. For additional help, contact the resources listed below or speak with your facility representative.

Q: Will Part D cover all my costs on all my drugs?
A: This is a cost-sharing program. Those who do not qualify for Extra Help in paying for coverage will have monthly premiums, yearly deductibles, and medication co-pays. After fulfilling a deductible, if required, plans will pay at least 75% of covered drugs up to a total of $2,250. Depending on the plan, you may be responsible for 100% of prescription costs above that amount. Then, after you have spent a total of $3,600 in out-of-pocket drug expenses, the plan will pay 95% of all drug costs for the rest of the year.

Plans vary with regard to which drugs they cover. Some may cover only those drugs listed on their “formulary.” Some may cover most or all prescriptions, but co-pays may be higher for “non-preferred” or “non-formulary” drugs. It’s important to check a plan’s preferred or formulary drug list to see whether the medications you take regularly are covered. You’ll find plan information and links to drug lists on our website, www.forumextendedcare.com.

Q: What if I have Senior Care or Circuit Breaker?
A: You should enroll in a Part D plan. In 2006 Senior Care and Circuit Breaker will become Illinois Cares Rx, which will only help fill gaps in coverage. First, apply for Extra Help from Social Security (see next question) and enroll in a “state-coordinated” Medicare PDP as soon as possible. A designated representative can identify which PDPs qualify. You’ll have to re-apply to the state of Illinois between January and March of each year to obtain Illinois Cares Rx gap benefits for the next year.

Q: What if I can’t afford a Part D plan?
A: People with lower incomes, including those in state programs such as Senior Care or Circuit Breaker, may qualify for extra help to pay for a prescription plan. They will get continuous coverage for lower or no cost, depending on income and assets. The Social Security Administration has resources to help families evaluate need. For more information or to apply, visit www.ssa.gov or call 1-800-772-1213.

Q: What if I have drug coverage through Medicaid?
A: Responsibility for prescription drug coverage of Medicaid-Medicare dually eligible recipients switches to Medicare Part D as of January 1, 2006. Medicaid will no longer cover prescriptions except in special cases. There are no premiums, deductibles, or co-pays for beneficiaries in long-term care facilities.

There are a limited number of plans available at no cost to dually eligible recipients. You should enroll in a participating PDP of your choice as soon as possible—if you do not choose a plan by November 15, 2005, you will be randomly auto-enrolled into a PDP by the government. If you have been auto-enrolled in a plan, you may switch to another plan at any time.

 

Q: What if I have prescription insurance?
A: Whether you have private insurance, a Medicare Advantage plan, or Medigap, contact your current plan to learn what it covers and if coverage will change because of Part D. If your current plan is better or equal to what Part D plans can offer, you do not need Part D. Consider enrolling in a Part D PDP before May 15, 2006, if the coverage offered is better than what you now have or if you have a Medigap plan. Medicare Advantage plans will incorporate prescription drug coverage; you may stay with your current plan or switch to another during the enrollment period.

Q: When does coverage start?
A: Join by December 31, 2005, and coverage will begin January 1, 2006. Join after January 1 and
coverage will take effect the 1st day of the month after the month you join.

Q: Can I switch plans?
A: Beneficiaries can switch plans during the open enrollment period once a year. Residents in nursing
facilities may change PDPs during their stay. This allows them to participate in plans with allowances for special care. The facility has a list of plans that contract with Forum.

Q: Is this a limited-time offer?
A: If you are eligible and don’t join a plan by May 15, 2006, you will have to pay more for coverage when you do join. (If you have a prescription plan with equal or better coverage, you will not be charged more if you later choose to enroll in Part D.)

 

If you have Medigap or have no prescription insurance at all, consider joining a Part D plan before May 15, 2006 (even if you do not take many drugs), to avoid higher premiums later.

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Important Resources

Centers for Medicare & Medicaid Services:	1-312--886-6432	www.cms.gov
Elder Helpline:	1-800-677-1116
Illinois Senior Help Line:	1-800-252-8966
Medicare:	1-800-MEDICARE	www.medicare.gov
State Health Insurance Assistance Programs	Illinois: 1-800-548-9034 Wisconsin- 1-800-242-1060
Social Security: (Extra Help with plan sosts)	1-800-773-1213	www.ssa.gov/prescriptionhelp