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Table of Contents Chapter i. Introduction 1. The Part D Program of Medicare WHAT IS MEDICARE? Medicare Part A. Medicare Part B. New program in Medicare. What is this new program in Medicare? Caution about scam artists. Complaints about Medicare Part D. So how can I benefit from Medicare Part D? When did Medicare Part D start? What pharmacies can I use to obtain my prescriptions? Are your drugs covered? What about other assistance programs? Signing up for Medicare Part D. So what do I need to know to get started? 2. How will this program work and how can I determine what is best for me? PRIVATE PRESCRIPTION DRUG PLANS (PDPS). (THIS MATERIAL IS ADAPTED FROM THE www.cms.gov WEBSITE). The name of the organization. The actual plan name. Coverage. Type of Additional Coverage Offered in Drug Coverage Gap (the ¿donut hole¿). Most commonly used drugs.. Convenience. Network pharmacy. MEDICARE ADVANTAGE PLANS (THIS MATERIAL IS ADAPTED FROM THE www.cms.gov WEBSITE). Location ¿ County. Organization Name Plan Name: The name of the Medicare drug plan. Type of Medicare Advantage Plan Cost Number of Top 100 Drugs on Formulary. Convenience. Network pharmacy. GENERAL ISSUES ACROSS BOTH PRESCRIPTION DRUG PLANS AND MEDICARE ADVANTAGE PLANS. Maintaining drug coverage for major diseases. Extra help for those with extra needs What do I do now? Learning about different plans. Know when you need to sign up for coverage. 3. Are you eligible for extra help with the Medicare Part D program? EXTRA HELP IS AVAILABLE FOR MANY. You will need to do several things to make sure you get the help you deserve. The Social Security Administration will mail applications to many eligible Extra help in addition to regular assistance. How to find out if I qualify? PERSONS WITH MEDICAID COVERAGE What if you previously were on Medicaid and Medicaid paid for your medications? Do you have a limited income but do not qualify for Medicaid coverage for your prescription drugs? Pharmaceutical assistance programs. 4. Choosing a Medicare Part D insurance drug plan. DIFFERENT PLANS AND OPTIONS Decisions to sign up for Medicare Part D. The Medicare Prescription Drug Plans. Medicare Advantage Plans. New members in drug plans and what they can expect with their drug coverage. Starting your coverage, but you do not have your prescription drug plan card. Creditable coverage. There are consequences if you do not sign up when you are eligible. Penalty fees. Initial enrollment periods. What happens when people first become eligible to enroll in a Medicare drug plan? What happens if I go into a nursing home? Refunds for overcharges. How can I pay for my premiums? Medicare Errors in Billing. Maintaining coverage for your drugs. Challenging a prescription drug plan action. Appealing plan decisions that are not in your favor. Other considerations. You can apply for extra help at any time. How does CMS know about all of this? Special enrollment periods. Coordinated election period. Medicare Advantage special plans for special needs individuals. Changes in the standard benefit for 2007 (6). True out of pocket (TrOOP) costs. What else might I do to see what is available for me? 5. What drugs are covered? DRUGS FOR ALL DISEASES AND AILMENTS-BUT NOT ALL DRUGS Drugs covered in the model formulary guidelines. How to find out what drugs the prescription drug plans will pay for. Formulary finder. Coverage for drugs under Medicare Part B. Non-covered drugs in any formulary Over-the-counter drugs (OTC)(This is not a complete listing). Barbiturates. Benzodiazepines. Vitamins. 6. How to choose a pharmacist. The importance of your pharmacist. Referrals from friends Is the pharmacist accessible? Can I call for more information and speak to the pharmacist every time? General concerns about drugs and drug use Concerns about certain medications if you are caring for an elderly individual. Counseling when obtaining new prescriptions. Brand and generic drugs. Charging for services. Refusal to fill your prescription. Furnishing you the best price available. Drugs and expiration (freshness) dating. Transfer of prescriptions from one pharmacy to another. Who owns your prescription? Privacy and Respect. Who are those people back there (filling your prescription)? What to do if you suspect something is not right with how you receive your prescriptions. Other services 7 . The formularies in this program, and how they work. FORMULARIES ¿ DEFINITIONS AND CONSIDERATIONS Formulary definition. Formulary finder. Uncovered drugs. Formularies used to lower costs. Specific other formulary issues. Step therapy. Prior authorization. Preferred drug lists. Tiered co-payments. Pharmacy networks. Dispensing limits. Summary of formulary issues. 8. The medication management programs and how to use them to your advantage. MEDICATION THERAPY MANAGEMENT SERVICES Goal is to help you with your medicine taking. Who is eligible? Your rights. An example to show how it would work. Specialized contacts to you by phone or in person. Reducing the number of drugs that you take. Use these services if you can. 9. Coverage for preventive services in the Medicare Program DISEASE PREVENTIONAND HEALTH PROMOTION Disease prevention. Seniors not aware of services available. My.medicare.gov Health promotion screenings and tests Physical Examination (Women and Men). Cardiovascular tests (Women and Men). Diabetes screening, supplies, and self-management training (Women and Men). Breast Cancer Screenings ¿ Mammograms (Women). Bone Mass Measurement. Glaucoma tests. Cervical and Vaginal Cancer Screening (Women). Colorectal cancer screening (Women and Men). Fecal Occult Blood Test. Flexible Sigmoidoscopy. Screening Colonoscopy. Barium Enema. Prostate cancer screening (Men). Digital Rectal Examination. Prostate Specific Antigen (PSA) test. Various shots (Vaccinations) for Flu, Pneumococcal Pneumonia, Hepatitis B. Flu shot. Pneumococcal shot. Hepatitis B shots. Smoking Cessation Counseling. Smoking kills plain and simple. Smoking causes numerous health problems. Smoking causes many health problems including: Coverage of smoking cessation counseling. Drugs do not work as well when you smoke. What specific services are provide to help you stop smoking. Counseling. Medicare Part D coverage for stop smoking drug therapies. New health promotion and disease prevention services for 2007. Use these services to help yourself to better health. 10. Getting your drugs and drug taking in order. TIPS TO IMPROVE YOUR DRUG TAKING Take as few drugs as possible. Routine check-ups. WHAT IS PATIENT COMPLIANCE? Various forms of patient compliance. The importance of patient compliance being the best it can be. Difficulties seniors face with medication compliance. Social isolation Chronic disease Severity of disease Multiple drug regimens Complex drug regimens Advice on medication taking Answers to know about your medications. Please see the connect the dots diagram below. Summary 11. Summary and next steps. SO WHERE TO YOU GO FROM HERE? Several changes for 2007 and beyond. Premium and deductible increases. Pilot programs for persons with chronic diseases. Miscellaneous Medicare provisions that are new. Health Savings Accounts. Ombudsman. Proof of citizenship. Qualifying for extra help. The coverage gap ¿ ¿donut hole¿. Best price. Generic drugs. State assistance plans and Medicare Part D. TrOOP. Changes in formulary coverage. Removing drugs from the market. Protection for you. Coverage determination. Approvals by you or your authorized representative. You or your doctor and the forms required. Yearly notification. Plans must respond promptly. Level of appeals. Your personal health information and privacy. Initial enrollment periods. Where else might you obtain help in enrolling. Enrollment materials. Annual Coordinated Election Period (AEP). Extra help. Automatic enrolling. Notification. Changes affecting your extra help situation. Special enrollment periods (SEPs). Losing coverage through no fault of your own. Special ¿ Special enrollment periods. Notice of plan change requirements. Options during enrollment periods. Special circumstances. Penalty or not. Changes in the prescription plan finder for 2007. SUMMARY OF CONSIDERATIONS AND NEXT STEPS. Cost Formulary coverage Peace of mind Creditable coverage What happens if you move during the year to another state? What if I am not happy with my plan? State resources that can help you. Types of problems that have occurred. Incorrect premium deduction Overcharging at the pharmacy. Prior authorization hassles. Doctors not being willing to fill out the prior authorization paperwork. Medicare Advantage plans. Deceitful marketing practices. Spouses of individuals in nursing homes. Nursing home residents.
Library of Congress Subject Headings for this publication:
United States. Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Older people -- Pharmaceutical assistance -- United States.
Insurance, Pharmaceutical services -- United States.