61. How can I disenroll?

If you want to disenroll from a plan you can:

  • choose another Medicare private drug plan during the Annual Coordinated Election Period or your Special Enrollment Period, and you will be automatically disenrolled;
  • send a letter to your plan asking to be disenrolled. If you do this outside of the Annual Coordinated Election Period or a Special Enrollment Period, you will not be able to enroll in another Medicare private drug plan. Therefore, you would have a premium penalty if you later signed up for another Medicare private drug plan unless you have drug coverage at least as good as Medicare’s from another source (such as retiree insurance).
  • Call 800-Medicare. A Medicare representative can disenroll you over the phone.

Note: Keep a copy of all letters you send or receive.

62. Which drugs will Medicare private drug plans cover?

Each Medicare private drug plan will have its own formulary (list of covered drugs), which will include both brand-name and generic drugs. Plans will be allowed to change their formularies at any time as long as they give a 60-day notice of the change. Information about any formulary changes will be posted on the plan’s web site, and members affected by the change will also receive a written notice by mail. (60-day notice is not required if the drug is removed for safety reasons.)

Medicare private drug plans must offer at least two drugs under each drug class. In addition, plans must cover a majority of drugs in certain classes, including:

  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Antiretrovirals
  • Anticancer
  • Immunosuppressants

Medicare will give plans the breakdown of the types of drugs they must cover. While some drugs are explicitly excluded from Medicare coverage by law, some plans may cover them as an additional benefit.

63. Which drugs are excluded from Medicare coverage?

There are some drugs that are excluded from Medicare coverage by law. These include:

  • drugs for:
    – anorexia, weight loss or weight gain;
    – fertility;
    – cosmetic purposes or hair growth;
    – relief of the symptoms of colds, like a cough and stuffy nose;
  • prescription vitamins and minerals (except prenatal vitamins and fluoride preparations);
  • non-prescription drugs (over-the-counter drugs);
  • certain anti-anxiety and anti-seizure drugs (barbiturates and benzodiazepines).

Note: Some plans may offer enhanced coverage that includes these excluded drugs. However, payments for these drugs will not count towards meeting your out-of-pocket coverage limit (TrOOP) (see question 12).

64. What is a formulary?

A formulary is a list of prescription drugs that are covered by a plan. All plans must cover at least two drugs from each therapeutic class of drugs. A “therapeutic class” contains drugs that are similar based on the disease they treat or on the way they affect the body. Plans can change their formularies at any time but must give their members and the public 60-day notice of any changes on the plan’s website. Members who use the drug must be notified in writing.

65. What is a “tiered formulary”?

Some Medicare private drug plans will most likely structure their formulary to have different cost-sharing tiers. That means your out-of-pocket costs for each prescription you fill would depend on which “tier” the drug is in. Lower tiers have lower out-of-pocket costs and may include generic version of the drugs. Higher-tier drugs will cost you more. Plans can have multiple tiers.

Plans can put other restrictions on the use of certain drugs, such as requiring that you get permission from the plan before the drug is prescribed (prior-authorization), or allowing a drug to be covered only after you tried the plan’s preferred drugs and found they were not effective for you (“fail first requirements”).

66. How will I know if my Medicare private drug plan’s formulary changes its coverage of my drug?

Your plan must send you written notice at least 60 days before it changes its coverage of a drug you use. This might include ending coverage of a medication you take or changing how much you have to pay for it. Any formulary changes will also be posted on the plan’s web site prior to 60 days before the change. (Sixty-day-notice is not required if the drug is removed for safety reasons.)

The notice must include the reason for the change, the names of similar drugs that are covered and how much you have to pay for them, and information about filing an appeal.

Alternatively, the plan can provide you the written notice after the change has taken effect as long as they cover a 60-day supply of the drug when you refill it at the pharmacy.

67. Where can I find the list of drugs each plan covers?

You can call the Medicare private drug plan, visit its web site or go to www.medicare.gov (starting in October) to find out which plans in your area cover the medications you need.

68. Will my Medicare private drug plan cover medications that I am currently getting covered by Medicare?

No. If Medicare is currently covering some of your outpatient drugs, they are being covered under Medicare Part B. Drugs currently covered under Part B (such as some oral cancer drugs, immunosuppressants, antivirals, antigens and anti-emetics) will continue to be covered under Part B and will not be covered by the new Medicare private drug plans. The cost of drugs covered by Part B in no way affects your out-of-pocket costs for your new Medicare drug coverage (Part D).

69. What happens if my new Medicare private drug plan does not cover the medications that I currently take?

Your plan must have a transition process for you. These processes will vary with each plan, but could include a one-time refill or attempts to explore substitutions with you and your doctor before the new coverage is effective. Plans must include their transition process on their website and provide it to individuals upon request. To obtain long-term coverage of your medication, you will probably need to file an exception. (See question 91.)

70. Where can I get my prescriptions filled?

You must use pharmacies in your Medicare private drug plan’s network to get Medicare coverage for your drug costs. You can get coverage of drugs from an out-of-network pharmacy only if you cannot reasonably be expected to obtain such drugs at a network pharmacy and you do not get the drugs at an out-of-network pharmacy on a regular basis. In those instances you may need to pay for the prescription at the pharmacy and then ask for reimbursement from the plan for it. The plan can charge you more for using an out-of-network pharmacy (the difference between the out-of-network pharmacy’s customary price and the plan’s allowance for the drug).

If you live in a nursing home the same rules will apply, so make sure the Medicare private drug plan you choose has the pharmacy your nursing home works with in its network.

If you move out of your plan’s service area, you will have a Special Enrollment Period to choose a new plan.

If you regularly spend a few months of the year in another state, you should consider enrolling in a national drug plan that partners with pharmacies all around the country.

71. What if I need an emergency prescription when traveling outside my Medicare private drug plan’s service area?

You can get the medication if you can show that you could not reasonably obtain the medication from a network pharmacy and you do not routinely use out-of-network pharmacies. You may need to pay for the prescription at the pharmacy and then seek reimbursement from the plan for it. The plan can charge you more for using an out-of-network pharmacy (the difference between the out-of-network pharmacy’s customary price and the plan’s allowance for the drug).

72. Can network pharmacies charge different prices for the same covered drug?

It depends. If you are getting the extra help paying for your Medicare drug costs (the low-income subsidy), you will pay no more than $5 for your drugs as long as you go to a pharmacy that is in the plan’s network. It does not matter what network pharmacy you go to.

If you are not getting the extra help, what you pay for drugs may vary, depending upon how the plan sets up its network. Medicare private drug plans can have preferred and non-preferred network pharmacies. You will pay less at preferred network pharmacies than you will at nonpreferred network pharmacies. Also, you may pay less if you use a mail-order pharmacy through your plan than if you get your drugs from a network retail pharmacy.

73. How will I know how much I have to pay for my drugs?

Your out-of-pocket costs will be detailed in your plan’s benefits outline, which you can get on the plan’s web site or by calling its toll-free customer service number. You can also find out on the www.medicare.gov web site. In addition, at the time you fill a prescription, your pharmacist can tell you how much you will have to pay.

74. Who will keep track of how much I spend on drugs?

The plan is required to do this. When you enroll in a Medicare private drug plan, you will get a card to use when you fill your prescriptions. This is how the plan keeps track of your out-ofpocket expenses. Your plan is required to send you a statement every month showing how much has been spent for the year and how close you are to reaching the out-of-pocket maximum for catastrophic coverage ($3,600 in 2006). You can also request this information from your plan at anytime. Some plans may make this information available on their web sites.

75. What will happen to my employer or retiree drug coverage when the Medicare drug benefit begins?

If you already have prescription drug coverage through your employer or union, check with your plan or benefits administrator to learn how your plan coordinates with Medicare drug coverage. How Medicare affects your current coverage will vary. It does not matter whether you are currently working or retired.

The company providing your employer or retiree drug coverage will notify you this fall about whether your drug coverage is at least as good as Medicare’s basic drug coverage (“creditable coverage”). The information could either come in a letter or in another mailing from the plan, such as a member bulletin. Be sure you have this information before deciding whether to enroll in the Medicare prescription drug benefit. Contact the company’s human resources department if you do not receive the notice by the end of the year.

If your current or former employer chooses to continue to offer prescription drug coverage you have three choices:

  1. If your current or retiree drug coverage covers at least as much as Medicare’s basic coverage, you may want to keep it and not buy Medicare drug coverage (if your coverage is at least as good as Medicare’s drug coverage, you will not have to pay a premium penalty as long as you do not go for more than 63 days without creditable coverage). However, you may want to compare the cost and coverage of your current coverage (including premiums, copays and list of covered drugs) with the cost and coverage of your area’s Medicare private drug plans (including extra help if you qualify), to see which offers you the best coverage for the your money. (Keep in mind that if you drop your current drug coverage you may not be able to get it back in the future. Also, make sure you can drop your drug coverage without losing your hospital and doctor coverage as well.)
  2. If your current or retiree drug coverage covers less than Medicare’s basic drug coverage, you may want to drop it and buy Medicare drug coverage. If you do not join a drug plan by May 15, 2006, you may need to pay a premium penalty. Note: Before making a decision, ask your employer if you can drop your drug coverage without losing your other supplemental insurance for doctor and hospital services. Once you drop your existing coverage, you may not be able to get it back.
  3. If your current or retiree coverage will fill in the gaps in Medicare’s drug coverage, you may want to keep it and enroll in the Medicare drug benefit as well. (Keep in mind, however, that you will still have to eventually spend $3,600 dollars in out-of-pocket costs for Medicare covered drugs before your Medicare drug costs go down a lot—catastrophic coverage—because payments made by other insurance do not count toward your out-ofpocket costs, even for covered drugs—see question 12.)

76. What will happen to my Medicare private health plan when the Medicare drug benefit begins?

If you are enrolled in a Medicare HMO or PPO you can

  • get your prescription drug coverage through that company (if the company offers it);
  • choose another Medicare HMO or PPO with Medicare drug coverage; or
  • drop your plan and enroll in a stand-alone drug plan and get the rest of your Medicare benefits through Original Medicare.

If you are enrolled in a Medicare Private Fee-For-Service plan (PFFS) or Medicare cost plan, you can

  • get your drug coverage through that plan (if the company offers it);
  • choose another Medicare private health plan (HMO, PPO or PFFS) that does offer drug coverage;
  • keep the plan and get your drug coverage through a stand-alone drug plan; or
  • drop your plan and enroll in a stand-alone drug plan and get the rest of your Medicare benefits through Original Medicare.

77. What happens to my Medigap policy with drug coverage when the Medicare drug benefit begins?

If you enroll in the Medicare drug benefit you cannot also have a Medicare supplemental insurance policy (Medigap Plans H, I and J) that offers drug coverage. If you have Medigap H, I or J you can:

  • Cancel your existing Medigap policy and switch to another Medigap policy that does not offer drug coverage and enroll in a Medicare private drug plan. To avoid a premium penalty (see question 13) you must do so before May 15, 2006. In most cases, you can enroll in certain Medigap policies offered by the same Medigap insurer, regardless of your health as long as you apply within 63 days after your Medicare drug coverage starts. You cannot be charged more because of previous or current health problems, and a pre-existing condition exclusion cannot be applied to you. Some states offer better protections. Call your state Insurance Department for More information.
  • Keep your Medigap policy but without the drug coverage and enroll in the Medicare drug benefit. Keep in mind that premiums for these Medigap policies will probably increase faster than Medigap policies that never offered drug coverage. To avoid a premium penalty (see question 13) you must enroll in a Medicare private drug plan before May 15, 2006
  • Cancel your Medigap policy and join a Medicare private health plan that includes Medicare drug coverage. You will not need your Medigap policy because it cannot pay premiums or co-insurance for Medicare private health plans (keep in mind you may not have a right to buy a Medigap policy later); or
  • Keep the Medigap policy and choose not to enroll in the Medicare drug benefit. If later you want to drop the Medigap drug coverage and enroll in the Medicare drug benefit, you may have to pay a premium penalty. Since the premium for this type of Medigap plans is usually high (and are expected to increase even more after the Medicare drug benefit goes into effect) and the drug coverage is limited, you are probably better off enrolling in the new Medicare prescription drug coverage.

Note: Medicare prescription drug coverage will be better than most drug coverage provided by Medigap policies. However, some plans in Minnesota, Massachusetts and Wisconsin, as well as some older “pre-standardized” Medigap policies, may be considered to have coverage that is at least as good as Medicare basic drug coverage (“creditable coverage”), which means you will not have to pay a premium penalty for late enrollment.

If your Medigap policy covers drugs, sometime between September 15, 2005 and November 15, 2005, your Medigap insurer will send you a letter telling you how the new Medicare drug coverage will affect your Medigap policy.

78. Will Medigap Plans H, I and J be sold after December 31, 2005?

Perhaps. Insurance companies that sell Medigap policies can choose to continue to offer plans H, I and J (and other policies in Massachusetts, Minnesota, and Wisconsin that have included prescription drug coverage) but they will have to remove any drug coverage. Also, their premiums will probably increase faster than other Medigap policies that never had drug coverage. (Note: If you have a Medigap policy with prescription drug coverage it will not change unless you contact the company to change your policy).

Two new Medigap policies (Plans K and L) will be offered in 2005. These policies are designed to have lower premiums because they require you to pay a portion of your deductibles and coinsurance for most Medicare-covered services until you have spent a certain amount out of pocket each year. After you reach that limit ($4,000 for Plan K and $2,000 for Plan L), the policy will pay 100% of your costs.

79. What happens to my State Pharmacy Assistance Program (SPAP) when Medicare drug coverage begins?

It will depend on where you live. Some states are choosing to end their programs. If states are continuing their programs, they can choose to offer coverage as they always have or fill in the gaps in Medicare drug coverage for individuals enrolled in the state’s drug assistance plan. Each state will have to decide how its plan will coordinate with the Medicare private drug plans. Your state will send you information about how your SPAP drug coverage will be affected by the Medicare drug benefit. You should contact your state if you have questions before you get this information.

If you continue to have drug coverage from an SPAP when your Medicare drug coverage begins, Medicare will always be your primary coverage. That means when you get your prescriptions filled at the pharmacy, Medicare always pays first and the SPAP can choose to “wrap around” a Medicare private drug plan by paying your premium, deductible, coinsurance and other out-ofpocket costs. It can also choose to cover drugs not on your plan’s formulary and those explicitly excluded from Medicare coverage.

Payments made by an SPAP will count toward your out-of-pocket maximum ($3,600 in 2006) to get to catastrophic coverage (unless they are for drugs not on your plan’s list of covered drugs or are explicitly excluded from Medicare coverage).

80. What happens to my COBRA drug coverage when Medicare drug coverage begins?

If you have drug coverage through COBRA and you want to keep it, you should find out if that coverage is at least as good as Medicare’s basic drug coverage (“creditable”). You should receive notification this fall from the company providing your COBRA coverage letting you know whether your drug coverage is as good as Medicare’s. The information could either come in a letter or in another mailing from the plan, such as a member bulletin. Be sure you have this information before deciding whether to enroll in Medicare prescription drug coverage. If you do not receive it, contact your former employer. Especially if it is creditable, you may want to keep your COBRA coverage and delay enrolling in Medicare drug coverage. Many COBRA plans will not allow you to drop your drug coverage and keep your other medical coverage. Also, if you enroll in Medicare drug coverage after November 15, 2006, you will not have to pay a higher premium (premium penalty) as long as you join within 63 days of losing creditable coverage.

If your COBRA drug coverage is not creditable and you decide not to enroll in the Medicare drug benefit during your Initial Enrollment Period, you will have to pay a premium penalty if you want to enroll in Medicare drug coverage at a later date (see question 13). Also, you will need to wait until the next Annual Coordinated Election Period to enroll (November 15 through December 31)

Note: To have both COBRA and Medicare at the same time, you have to become eligible for COBRA after you already had Medicare. If you already have COBRA when you become entitled to Medicare, your COBRA coverage ends on the date you become entitled to Medicare (unless you are entitled to Medicare because of End-Stage Renal Disease (ESRD).

© 2005 Medicare Rights Center