| Medicare Part D |
SELECTING A MEDICARE PRESCRIPTION DRUG PLANHow do I compare the different Drug Plans? You will need to consider each Drug Plan’s coverage, the cost to you, and convenience. Medicare Drug Plans will vary because each one will have its own formulary (discussed below), monthly premium, and network of pharmacies. Find out if your current pharmacy is included in the Drug Plan’s pharmacy network and how much the monthly premium will be if you join. The monthly premium will vary depending on the whether the Drug Plan offers supplemental benefits above Medicare’s minimum requirements. Each Drug Plan’s formulary must meet Medicare’s requirements. However, you should contact the Drug Plan to determine if your drugs are included in the Drug Plan’s formulary. What is a “Formulary”? The formulary is a list of drugs covered by the Drug Plan. Drug Plans must cover all of the types of drugs required by Medicare, but within each drug-type, Drug Plans can limit which specific drugs they will cover. They can also charge different cost-sharing amounts for different drugs within a drug-type. However, there are six categories of drugs – including antidepressants and HIV/AIDS categories – in which Medicare requires each Drug Plan to cover all of the prescription drugs in those drug categories, regardless of the Drug Plan’s formulary. You can get a list of the drugs covered by a Drug Plan by calling the Drug Plan, checking the Drug Plan’s website, or going to www.medicare.gov. What if my drugs are not included in my Drug Plan’s formulary? If the Drug Plan you join does not cover your exact prescriptions, the Drug Plan is required to have a transition period where your current drugs may be covered for a certain period of time while you and your doctor work to find an alternative prescription drug to take that is covered by the Drug Plan. However, if you are currently stabilized on certain specific prescription drugs, including drugs for depression and HIV/AIDS, you do not have to switch to a different prescription drug. If one or more of your drugs are not included in the formulary, and you feel it should be covered, you have the right to request an exception (or a “coverage determination”) from your Drug Plan. You or your doctor can call or write your Drug Plan to request coverage of a particular prescription(s). Once your Drug Plan receives the request, it has 72 hours (for a standard request) or 24 hours (for an expedited request) to notify you about its decision. Your request will be expedited if your doctor tells your Drug Plan that your life or your health will be seriously jeopardized if you have to wait for a standard decision. You can appeal the decision if your Drug Plan decides against you. Clotting Factor isn’t covered under Medicare Part D, so how will it be covered in the future? In general, outpatient prescription drugs that have been approved by the Food & Drug Administration (“FDA”) are included in the Part D Program. However, if a drug is otherwise available and/or payable under a different Medicare Program (e.g., Medicare Part A or Medicare Part B), it is excluded from coverage under Medicare Part D. Because clotting factor is covered under the Medicare Part B Program, it will not be covered by the Medicare Part D Program. You will continue to receive coverage of your clotting factor through your Medicare Part B coverage. Does Medicare Part D cover my HIV and antidepressant medications? Medicare requires that all Drug Plans cover all outpatient prescription drugs approved by the FDA for the management of HIV and antidepressants, regardless of the Drug Plan’s specific formulary. This broad coverage requirement includes single chemical entities as well as combination products. What if the prescription I take is not covered by my Drug Plan? Will Medicaid still pay for it? If Medicare covers a prescription drug, after January 1, 2006, Medicaid will not pay for it. Some state Medicaid programs may choose to cover some or all of the few remaining prescriptions that are not covered by the Medicare Part D Program. However, you should also note that the Drug Plans do not have to cover every drug, they just have to cover every drug-type. Before joining a Drug Plan available in your area, review what drugs each Drug Plan covers and try to join a Drug Plan that covers all or the majority of the same prescriptions that you take now. If you have further questions or need assistance, contact your Hemophilia Treatment Center Social Worker.
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