Medicare Part D Drug Program: Making the Most of the Benefit Book

Foreword     xiii
Introduction     xv
The Part D Program of Medicare     1
What is Medicare     1
Medicare Part A     1
Medicare Part B     2
New Program in Medicare     2
Caution About Scam Artists     3
Complaints About Medicare Part D     3
So How Can I Benefit from Medicare Part D?     4
When Did Medicare Part D Start?     4
What Pharmacies Can I Use to Obtain My Prescriptions?     5
Are Your Drugs Covered?     7
What About Other Assistance Programs?     7
Signing Up for Medicare Part D     8
So What Do I Need to Know to Get Started?     8
How Will This Program Work and How Can I Determine What Is Best for Me?     11
Private Prescription Drug Plans (PDPS)     11
The Name of the Organization     12
The Actual Plan Name     12
Cost     12
Coverage     12
Type of Additional Coverage Offered in Drug Coverage Gap (the "Donut Hole")     13
Most Commonly Used Drugs     14
Convenience     14
Network Pharmacy     14
Medicare Advantage Plans     15
Location by County     15
Organization Name     15
Plan Name: The Name of the Medicare Drug Plan     15
Type of Medicare Advantage Plan     16
Cost     17
Coverage     17
Number of Top 100 Drugs on Formulary     18
Convenience     18
Network Pharmacy     18
General Issues Across Both Prescription Drug Plans and Medicare Advantage Plans     18
Maintaining Drug Coverage for Major Diseases     18
Extra Help for Those with Extra Needs     18
What Do I Do Now?     20
Learning About Different Plans     20
Know When You Need to Sign Up for Coverage     20
Are You Eligible for Extra Help with the Medicare Part D Program?     23
Extra Help is Available for Many     23
You Will Need to Do Several Things to Make Sure You Get the Help You Deserve     23
The Social Security Administration Will Mail Applications to Many Eligible People     25
Extra Help in Addition to Regular Assistance     26
How to Find Out If I Qualify?     26
Persons with Medicaid Coverage     28
What If You Previously Were on Medicaid and Medicaid Paid for Your Medications?     28
Do You Have a Limited Income but Do Not Qualify for Medicaid Coverage for Your Prescription Drugs?     29
Pharmaceutical Assistance Programs     29
Chapter Figures     31
Choosing a Medicare Part D Insurance Drug Plan     43
Different Plans and Options     43
Decisions to Sign Up for Medicare Part D     43
The Medicare Prescription Drug Plans     45
Medicare Advantage Plans     45
New Members in Drug Plans and What They Can Expect with Their Drug Coverage     47
Starting Your Coverage, But You Do Not Have Your Prescription Drug Plan Card     47
Creditable Coverage     48
There Are Consequences If You Do Not Sign Up when You Are Eligible     49
Penalty Fees     49
Initial Enrollment Periods     49
What Happens When People First Become Eligible to Enroll in a Medicare Drug Plan?     50
What Happens If I Go into a Nursing Home?     50
Refunds for Overcharges     51
How Can I Pay for My Premiums?     52
Medicare Errors in Billing     53
Maintaining Coverage for Your Drugs     53
Challenging a Prescription Drug Plan Action     53
Appealing Plan Decisions that Are Not in Your Favor     54
Other Considerations      55
You Can Apply for Extra Help at Any Time     56
How Does CMS Know About All of This?     56
Special Enrollment Periods     57
Coordinated Election Period     57
Medicare Advantage Special Plans for Special Needs Individuals     59
Changes in the Standard Benefit for 2007 (6)     60
True Out Of Pocket (TrOOP) Costs     61
What Else Might I Do to See What Is Available for Me?     62
What Drugs Are Covered?     65
Drugs for All Diseases and Ailments-But Not All Drugs     65
Drugs Covered in the Model Formulary Guidelines     66
How to Find Out What Drugs the Prescription Drug Plans Will Pay For     68
Formulary Finder     68
Coverage for Drugs Under Medicare Part B     70
Non-Covered Drugs in Any Formulary     72
Over-the-Counter Drugs (OTC)     75
Barbiturates     75
Benzodiazepines     75
Vitamins     75
How to Choose a Pharmacist     77
The Importance of Your Pharmacist     77
Referrals from Friends     77
Is the Pharmacist Accessible?     78
Can I Call for More Information and Speak to the Pharmacist Every Time?      79
General Concerns About Drugs and Drug Use     79
Concerns About Certain Medications if You Are Caring for an Elderly Individual     79
Counseling when Obtaining New Prescriptions     80
Brand and Generic Drugs     81
Charging for Services     82
Refusal to Fill Your Prescription     82
Furnishing You the Best Price Available     83
Drugs and Expiration (Freshness) Dating     84
Transfer of Prescriptions from One Pharmacy to Another     84
Who Owns Your Prescription?     85
Privacy and Respect     85
Who Are Those People Back There (Filling Your Prescription)? 86 What to Do if You Suspect Something Is Not Right with How You Receive Your Prescriptions     87
What if You Cannot Choose Your Pharmacy?     87
Other Services     88
The Formularies In This Program, and How They Work     91
Formularies-Definitions and Considerations     91
Formulary Definition     91
Formulary Finder     92
Uncovered Drugs     92
Formularies Used to Lower Costs     96
Specific Other Formulary Issues     97
Step Therapy     97
Prior Authorization     97
Preferred Drug Lists      97
Tiered Co-payments     98
Pharmacy Networks     98
Dispensing Limits     99
Summary of Formulary Issues     99
The Medication Management Programs and How to Use Them to Your Advantage     101
Medication Therapy Management Services     101
The Goal Is to Help You with Your Medicine Taking     101
Who Is Eligible?     102
Your Rights     102
An Example to Show How it Would Work     103
How This Service Might Work for You     104
Specialized Contacts to You by Phone or in Person     107
Reducing the Number of Drugs That You Take     108
Use These Services if You Can     108
Coverage for Preventive Services in the Medicare Program     109
Disease Prevention and Health Promotion     109
Disease Prevention     109
Seniors Not Aware of Services Available     110
Medicare Will Pay for Screening Tests and Other Services for Beneficiaries     110
My.Medicare.Gov     111
Health Promotion Screenings and Tests     112
Physical Examination (Women and Men)     112
Cardiovascular Tests (Women and Men)     112
Diabetes Screening, Supplies, and Self-Management Training (Women and Men)     112
Breast Cancer Screenings-Mammograms (Women)     113
Bone Mass Measurement     114
Glaucoma Tests     114
Cervical and Vaginal Cancer Screening (Women)     114
Colorectal Cancer Screening (Women and Men)     115
Fecal Occult Blood Test     116
Flexible Sigmoidoscopy     116
Screening Colonoscopy     116
Barium Enema     116
Prostate Cancer Screening (Men)     116
Digital Rectal Examination     117
Prostate Specific Antigen (PSA) Test     117
Various Shots (Vaccinations) for Flu, Pneumococcal Pneumonia, Hepatitis B     117
Flu Shot     117
Pneumococcal Shot     117
Hepatitis B Shots     118
Smoking Cessation Counseling     118
Coverage of Smoking Cessation Counseling     119
Drugs Do Not Work as Well when You Smoke     120
What Specific Services Are Provided to Help You Stop Smoking     121
Counseling     121
Medicare Part D Coverage for Smoking Cessation Drug Therapies     121
New Health Promotion and Disease Prevention Services for 2007     121
Use These Services to Help Yourself to Better Health      122
Getting Your Drugs and Drug Taking in Order     123
Tips to Improve Your Drug Taking     123
Take as Few Drugs as Possible     123
Routine Check-Ups     124
What is Patient Compliance?     125
Various Forms of Patient Compliance     126
The Importance of Patient Compliance Being the Best it Can Be     126
Difficulties Seniors Face with Medication Compliance     121
Social Isolation     127
Chronic Disease     127
Severity of Disease     127
Multiple Drug Regimens     127
Complex Drug Regimens     127
Advice on Medication Taking     128
Answers to Know About Your Medications     129
Summary     131
Summary and Next Steps     133
So Where Do You Go from Here?     133
Several Changes for 2007 and Beyond     133
Premium and Deductible Increases     134
Pilot Programs for Persons with Chronic Diseases     135
Miscellaneous Medicare Provisions That Are New     136
Income-Related Increase in Part D Premium     136
Health Savings Accounts     137
Ombudsman     139
Proof of Citizenship      140
Qualifying for Extra Help     140
The Coverage Gap-"Donut Hole"     141
Best Price     142
Generic Drugs     142
State Assistance Plans and Medicare Part D     143
TrOOP     143
Changes in Formulary Coverage     144
Removing Drugs from the Market     145
Protection for You     145
Coverage Determination     145
Approvals by You or Your Authorized Representative     146
You or Your Doctor and the Forms Required     147
Yearly Notification     147
Plans Must Respond Promptly     147
Level of Appeals     148
Your Personal Health Information and Privacy     149
Initial Enrollment Periods     150
Where Else Might You Obtain Help in Enrolling?     150
Enrollment Materials     151
Annual Coordinated Election Period (AEP)     151
Extra Help     152
Automatic Enrolling     152
Notification     152
Changes Affecting Your Extra Help Situation     154
Special Enrollment Periods (SEPs)     154
Losing Coverage Through No Fault of Your Own     155
Special Enrollment Periods     156
Notice of Plan Change Requirements     157
Options During Enrollment Periods     158
Special Circumstances     159
Penalty or Not     159
Changes in the Prescription Plan Finder for 2007     160
Summary of Considerations and Next Steps     160
Cost     160
Formulary Coverage     160
Coverage Gap     161
Convenience     161
Peace of Mind     161
Creditable Coverage     161
What Happens if You Move During the Year to Another State?     161
What If I Am Not Happy with My Plan?     162
State Resources That Can Help You     162
Types of Problems That Have Occurred     162
Incorrect Premium Deduction     162
Overcharging at the Pharmacy     162
Prior Authorization Hassles     163
Doctors Not Being Willing to Fill Out the Prior Authorization Paperwork     163
Medicare Advantage Plans     163
Deceitful Marketing Practices     163
Spouses of Individuals in Nursing Homes     163
Nursing Home Residents     164
General Summary of the Issues Related to Medicare Part D Prescription Drug Benefit Information     165
Web Sites for Senior Citizen Information     173
Individual States With Medication Assistance Programs for Seniors with Certain Income Restrictions     177
Petition Process for Formulary Addition and Notification of Noncoverage     179
Web Sites for More Information About Drugs     183
Privacy and Health Information Pamphlet Provided by the U.S. Department of Health and Human Services Office of Civil Rights     187
Glossary     191
Index     203