Prescription Drug Programs

Last Updated:

10/8/08

Do you Need Help With Prescription Drug Costs?

Hints to Lower the Cost of Prescription Drugs

· Let your providers know you are having difficulty paying for your prescriptions. They may be able to help by:

ü Prescribing generic medications instead of brand name.

ü Provide you with samples of the prescribed drugs.

ü Give you a prescription for a larger quantity, which may reduce the cost per pill.

· Do a cost comparison at several pharmacies.

· If you have a prescription plan, see if there is a mail order service option at reduced costs.

· Do keep a list of all the medicines you take. Include both prescriptions and over the counter medicines. Ask your doctor to review this list.

· Do take medications in the exact amount and precise schedule your doctor prescribes.

PRESCRIPTION DRUG PROGRAMS:

Medicare Prescription Drug Program in 2009

Maryland Pharmacy Assistance Program (MPAP)

State of Maryland Senior Prescription Drug Program

Maryland Medbank Program

Department of Veterans Affairs Uniform Benefits Package

Retired Military

Maryland AIDS Drug Assistance Program

Medicare Supplement Plans

The New Medicare Drug Benefit for 2009

Programs Open to All

Senior Health Insurance Program (SHIP)

(301) 590 2819 www.medicarehelp.org

Medicare Part D (Prescription Drug Program) for 2009

What is Medicare Part D ?

Medicare offers prescription drug coverage for all people with

Medicare. These plans are offered by insurance companies and other private companies approved by Medicare. To get Medicare prescription drug coverage,

you must choose and join a Medicare prescription drug plan. Prescription drug

plans vary in premiums, formulary (list of covered drugs), out of pocket costs

(copayments and deductibles), and which pharmacies accept the plan.

Do I have to enroll in a Part D Plan?

Joining a Medicare prescription drug plan (PDP) is optional. However, if a Medicare beneficiary does not enroll in a Medicare prescription drug plan (PDP) when they are first eligible and does not have a drug plan that covers as much or more than a Medicare prescription drug plan they will pay a penalty (higher premium) when they do enroll. The penalty is 12% per year forever. You do not have to join a Medicare Prescription Drug Plan if you have “creditable drug coverage” through a current or former employer, VA benefits, TriCare for Life. “Creditable coverage” means the drug coverage is as good as the Medicare Prescription Drug Coverage.

I already have a Medicare Part D Plan. Do I have to change?

If you currently have a Medicare prescription drug plan, you should review your coverage each year. Why? Plans may change their premiums, the list of drugs they cover, the copayments, deductibles and other features each year. There may be other plans in 2009 that may cost you less and provide better coverage for your list of medications.

When do I have to change?

Every year there is an annual enrollment period from

November 15 – December 31.

Information on Medicare Part D will be available after October 15, 2008.

Coverage under the new plan will begin January 1, 2009. This is the one chance each year most people with Medicare have to make a change in their drug coverage. The exceptions are people with Low Income Subsidy (LIS) and those enrolled in the State of Maryland Senior Prescription Drug Program (SPDAP) will have additional opportunities to change plans during 2009.

How does Medicare Part D work?

Medicare drug plans vary based on which drugs are covered, your out of pocket costs, and which pharmacies you can use.

· Coverage – Medicare prescription drug plans cover generic and brand name drugs. Each plan can choose what specific drugs are covered in each drug category.

· Cost – Monthly premiums and your share (copayment) of the cost of your prescription vary depending on which plan you choose.

· Restrictions – Does the plan limit the quantity (how many pills you can get at a time), require prior authorization (before the plan will pay for your prescriptions, your doctor must show the plan that the drug is medically necessary for it to be covered), step therapy (the plan may require a lower cost drug to be tried before the plan will pay for the prescribed drug)?

· Convenience – does your local pharmacy accept the plan; does the plan have a mail order option?

How much will my Drug Coverage Cost?

Your costs will vary depending on which drugs you use, which plan you join and whether you get extra help paying for your drug costs.

· Monthly premium – most drug plans charge a monthly fee to be in the plan. This fee (premium) does not cover the cost of any drugs.

· Yearly deductible – this is the amount you pay for your prescriptions before your plan begins to pay. (May be as high as $295)

· Copayments or coinsurance – amount you pay for each of your prescriptions.

· Coverage Gap – after you and your plan together have spent ($2,700) for covered drugs, you have to pay all costs for your drugs. This is the coverage gap or donut hole. This amount does not include your plan’s monthly premium.

· Catastrophic Coverage – once you have reached your plan’s out of pocket limit, you only pay a 5% coinsurance or copayment for the rest of the calendar year. The out of pocket limit for 2009 is $4,350.

Additional help to pay for Medicare Part D

· Low Income Subsidy (LIS) Medicare Beneficiaries who qualify based on low income and limited assets will receive a subsidy to pay for Medicare Part D premiums, copayments, deductible, and coverage gap (donut hole). Medicare beneficiaries with full LIS will be able to change Prescription Drug Plans every month.

· Senior Prescription Drug Assistance Program (SPDAP) The State of Maryland will pay up to $25 each month toward the Medicare Prescription Drug plan premium. SPDAP may also pay up to $1,200 for the cost of drugs for people in the “gap” or “donut hole”. Enrollment in SPDAP also allows for one additional change in Medicare Part D plan during 2009.

What do I need to know to compare Prescription Drug Plans?

1. List of medication you are currently taking, the dosage and the quantity.

2. What is the premium of each plan?

3. Is there a yearly deductible?

4. Does the plan have mail order option?

5. Are there quantity limits on my drugs, do I need prior authorization for the plan to pay for my drugs.

How can I get help selecting a Medicare Prescription Plan for 2008?

· Call the Senior Health Insurance Program (SHIP)

(301) 590 2819

· Call 1 800 Medicare (1 800 633 4227)

· www.medicare.gov

Medicare Prescription Drug Plan (Medicare Part D) Definitions

Annual Deductible – The amount you must pay each year for your prescriptions,

before you Medicare drug plan coverage begins. The deductible amount cannot

be more than $295 for 2009.

Brand Name Drug – A patented drug that has a trade name and is produced

and sold only by the company holding the patent.

Catastrophic Coverage – Once you have reached your drug plan’s out of pocket limit, you will have “catastrophic coverage”. This means you only pay 5% of the drug cost after you have spent ($4350) for covered drugs, you have to pay all costs for your drugs while you are in the coverage gap or donut hole. This amount

does not include your plan’s monthly premium.

Coinsurance - A percentage amount that you pay for each prescription,

this will vary by the Prescription Drug plan.

Copayment – A set dollar amount you pay for each prescription

determined by the plan.

Creditable Coverage – Prescription drug coverage that is at least equal to,

or better than a Medicare Part D basic plan.

Deductible – The amount you pay out of pocket each year before the plan benefits begin.

Formulary – A list of drugs covered by a prescription drug plan.

Gap (Donut Hole) – A break in prescription drug coverage where the Medicare beneficiary is responsible for the full cost of the drug. In 2009 after you and your plan have spent ($2,700) for covered drugs, you have to pay all costs for your drugs while you are in the coverage gap or donut hole. This amount does not include your plan’s monthly premium. The GAP ends when you have spent $4350 on copayments and coinsurance (not premiums) and are in the Catastrophic Level.

Generic Drug – A prescription drug that has the same active ingredient

formula as a brand name drug and usually cost less than brand name drugs.

Low Income Subsidy (LIS) – Medicare beneficiaries who have low income

and limited assets will receive substantial assistance in paying the Part D premiums, deductibles, copayments, and gap prescription drug costs.

Medicare Advantage Plan (MA-PD) - Medicare insurance under which a

private insurance company arranges for all Medicare Part A and B covered services,

including physicians, hospitals, and labs. Some Medicare Advantage Plans

may also offer prescription drug benefits.

Non Formulary Drug – A drug that is not on a plan’s approved drug list. Unless an

appeal is granted, a non formulary drug will not be paid for by a prescription

drug plan and cost of the drug will not count toward out of pocket expenses.

Out of Pocket Costs – The payments made by the beneficiary that count toward

the total cost of covered prescription, including the deductible, coinsurances,

copayments and the cost of prescriptions during the “donut hole”.

Preferred Drug – A particular drug which is deemed by the prescription

drug company to be the drug of first choice for treatment of a particular condition.

Preferred Pharmacy – A network pharmacy that offers covered drugs to

plan members at lower out of pocket costs than a member would pay

in a non preferred network pharmacy.

Premium – The payment made to cover the cost of being in a prescription

drug program. This does not cover the cost of any drugs.

Prior Authorization - Approval by the prescription drug plan before prescription

drug cost is paid by the plan. Your doctor must contact the plan and show

it is medically necessary for you to use the particular drug.

Step Therapy – Plans may require you to first try one drug before they

will pay for the drug prescribed by your doctor.

Senior Health Insurance Program (SHIP)– A national program that

offers one on one counseling and assistance to people with Medicare,

family members, and care givers. Through federal and county grants,

SHIPs provide free counseling and assistance via telephone and face to face

sessions, public education presentations, printed material, and media activity.

The SHIP Program educates the public about Medicare, Medicaid,

managed care, Medicare Advantage Plans, Prescription Drug Plans

and Long Term Care Insurance. (301) 590 2819

Other programs available in Maryland if you do not qualify for Medicare's Part D prescription drug coverage:

Maryland Pharmacy Assistance Program (MPAP)

Under this program all MPAP participants currently pay $5.00 for each prescription and each refill, and the State pays the rest. As of June 15, 2005 the co-pay for all generic and some brand drugs will be $2.50. Certain brand name drugs will be $7.50. Proof of income and assets is required. Eligibility is established for a 12-month period.

ELIGIBILTY

Individuals with incomes at or below:

$ 948 per month ($11,396 per year) with assets below $4,000

Couples with incomes at or below

$ 1,100 per month ($13,200 per year) with assets below $6,000

(Slightly higher income may be approved after review of your application)

For more information or to request a mail-in-application, call 800-226-2142

Maryland Pharmacy Program P.0. Box 386 Baltimore, MD 21203-0386

Note: you are not eligible if you have Medicare A or B.

State of Maryland Senior Prescription Drug Assistance Program (SPDAP)

This program began on January 1, 2006, and is available to anyone who has a yearly income at or below $28,710 per year ($2,393 per month) for an individual and $38,490 per year ($3,208 per month) for couples. There is no annual asset test (assets are not taken into consideration). SPDAP is available to anyone who is enrolled in Mediare Part D prescription drug plan and meets the income requirements. The SPDAP pays up to $25 per month towards the premium for the chosen Medicare D prescription drug plan. You must be enrolled in a Medicare Prescription Drug Plan to receive this benefit. Applications for SPDAP are available at 1-800-551-5995 or on the web at www.marylandspdap.com or SHIP at (301) 590-2819.

Maryland Medbank Program, Pharmaceutical manufacturers have programs that offer brand name drugs free of charge to qualified individuals. The Medbank Program is a state sponsored program that assists in obtaining free medications for the uninsured and underinsured. Medbank will help complete an application for you, contact your physician and the pharmaceutical company to arrange for the medications to be shipped to your provider – a 90 day supply is customary. Each pharmaceutical company has their own criteria for eligibility based on income, assets, and other expenses.

For more information and an applications contact Medbank at

(410) 821-9262 or www.medbankmd.org

Department of Veterans Affairs Uniform Benefits Package, honorably discharged veterans are eligible for prescription drug benefits through the Veterans Administration. You do not have to have a service-related disability to qualify for benefits. There is a means test for new enrollees. A 30-day supply of VA approved medications costs $8.00. Veterans must enroll with the VA and be seen by a VA physician. For more information or an application contact The Department of Veterans Affairs: 877-222-8387 www.va.gov/elig

Retired Military, if you are retired from the uniformed services (or a spouse) and a Medicare beneficiary you are eligible for pharmacy benefits through the Tricare for Life Senior Pharmacy Program. Prescriptions may be obtained from the National Mail Order Pharmacy and /or Tricare network pharmacies. One must be registered with the Defense Enrollment Eligibility Reporting System (DEERS). If you reached age 65 after April 1,2001 you must have Medicare Part B. Contact 1-877-363-6337 for information, or visit www.tricare.osd.mil.

Maryland AIDS Drug Assistance Program, helps low to moderate income residents pay for some drugs prescribed to treat HIV/Aids. There is no co-pay; there may be a monthly participation fee, based upon the person’s income. You can have Medicare and still be eligible for this program. Contact 1-800-205-6308

ELIGIBILITY

( based on income and household size )

Individuals at or below $49,000 /year income

Couples at or below $66,000 /year income

Medicare Supplement Plans H, I, and J Medigap Plans offered prescription drug benefits if purchased prior to December 31, 2005. H & I plans have a $250 deductible and cover 50% of the cost of prescriptions up to $2,500 /year. Plan J has a $250 per year deductible and will cover 50% of the costs up to $6,000. If you switch companies you will not be able to transfer Plans H, I or J. As of January 1, 2006, these plans will be affected by the Medicare Modernization Act of 2003.

Pharmaceutical Company Discount Cards - Several pharmaceutical companies are providing discount cards to people eligible who lack prescription coverage. Each pharmaceutical company has its own requirements for qualifying for their discount cards. The out-of-pocket cost for each program will vary. It is important to recognize that these discount cards will only apply to the medications manufactured by that particular pharmaceutical company. To determine the manufacturer of your medications, please look at the label on your prescription or ask your pharmacist. You may contact the pharmaceutical manufacturer to obtain the necessary application forms.

Several Pharmaceutical companies have patients assistance programs to help with the cost of medications. Contact the individual company that manufactures the medication you need help with.

The Montgomery County Senior Health Insurance Program (SHIP) is available for community educational programs and individual counseling on Medicare, Medigap Insurance, Supplements to Medicare, HMOs, Long Term Care Insurance, Pharmacy Programs, Veterans’ Benefits, and other health insurance issues. Please contact us at (301) 590 – 2819 or www. medicarehelp.org.

(301) 590 – 2819

www.medicarehelp.org