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Things you should know about Medicare Part D, part 4


Last updated 12/13/2007 at Noon

Part four of a series on Medicare Part D Prescription Drug Program

Important considerations before December 31 deadline

I just went to the Medicare Web site,, to be sure to provide you with the most up-to-date information.

There is a 114-page booklet titled “Medicare & You.” Pages 52 through 66 have current, general information on Medicare Part D and there is a statement that the information is valid throughout 2008.

As was mentioned in the last article, stand-alone prescription drug plan costs have increased, so look very carefully at your insurance company renewal information.

Your plan premium may have increased; however, your choices may be limited. Although my mother’s plan had increased by more than 30 percent it is still the best choice.

The information that has been provided in this series is related to Medicare Part D stand-alone prescription drug plans. If you have an HMO or a PPO your prescription medications should be covered as a part of your plan.

If you have limited income you may be eligible for additional assistance. If you do not have access to a computer you can call the Health Insurance Counseling and Advocacy Program (HICAP) for assistance at (858) 565-8772.

HICAP is funded by the California Department of Aging and the San Diego County Aging and Independence Services Department.

There are two especially important considerations to review before choosing a Medicare Part D prescription drug plan.

First, the prescription drug formulary. The formulary provides information about which drugs are covered, under which plans and under which conditions.

The following are important issues to consider:

1. What tier number is a drug? The tier numbers will dictate the cost of the drugs.

2. Is prior authorization required? Is step therapy required? Are there quantity limits? These restrictions allow the drug company, not your doctor, to make the final decision, which could lead to a delay in receiving your medications.

When you have chosen a plan and receive your drug formulary booklet, familiarize yourself with it and always bring it with you to medical appointments. Your doctor can make appropriate choices based on your drug formulary.

Secondly, let’s review prescription drug plan costs.

1. What is the premium? This is the monthly cost that is taken out of your social security check or that you pay directly to your insurance company.

2. Does the plan have a deductible? This is a cost that you pay prior to receiving any insurance benefits.

3. What are the co-payments for each of the drugs by tier? For example, Tier 1 is a generic drug and will be less expensive then a Tier 2 (a name brand).

4. Does the insurance plan have gap coverage? This is the coverage, usually for generic drugs only, that exists after the total payment of about $2,510 until about $3,800. Different insurance companies have different rules but the information is generally accurate for all companies. Remember that the total cost of your drugs, including your deductible and co-payments, are added together to reach the gap.

Let’s summarize some general information. Some of the following is new information that didn’t fit in the topics of the previous three articles.

1. You can only change your insurance plan one time a year. The plan period begins on January 1 but you must enroll by December 31.

2. Your insurance company can change their formulary at any time during the year.

3. If you do not enroll when you turn 65 years old, three months before or three months after your birthday, you will receive a penalty. It does not matter if you do not take any prescription drugs. See the Medicare Web site for details.

4. Be sure that the plan you choose will allow you to use a pharmacy in your area.

5. If you choose to use a mail-in pharmacy, be sure to reorder early. If you have received a new medication, ask for two prescriptions: one for a month’s supply for a local pharmacy to fill promptly and the other one to send to the mail-in pharmacy.

I’ve attempted to present you with simplified information from a complicated set of rules and regulations.

If you would like clarification or further information, the following resources are available to you:

• HICAP: (858) 565-8772 or (800) 434-0222 in San Diego

• Medicare (24-hour assistance): (800) 633-4327

• Fallbrook Healthcare District office: (760) 731-9187. We will answer your questions or refer you to another resource that will assist you.

Madelyn Lewis is a Registered Nurse in the community working with the Fallbrook Healthcare District to educate the public about Medicare Part D.

If this series on Medicare Part D has been helpful to you, please call the Fallbrook Healthcare District at the phone number listed above to let them know.


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