Everything You Need to Know About the New Medicare Prescription Drug Benefit, Part 5

81. What happens to my TRICARE For Life (TFL) drug coverage when the Medicare drug benefit begins?

Your TRICARE coverage will remain the same and you will not have to join a Medicare drug benefit (Part D) to keep it. (Note: This is different from medical coverage under TRICARE which requires you to enroll in Medicare Parts A and B.)

Since TRICARE coverage is more comprehensive than Medicare’s drug coverage (so it is considered creditable) you may be better off keeping your TRICARE and not enrolling in the Medicare drug benefit. If you decide you want to enroll in the Medicare drug benefit later, you will not have to pay a penalty as long as you enroll within 63 days of dropping or losing TRICARE coverage. Contact TRICARE for more information.

If you do join a Medicare private drug plan and keep TRICARE, TRICARE will pay first and Medicare will pay second.

Note: If you qualify for full extra help your total costs for covered drugs may be less than if you kept TRICARE. However, TRICARE covers most medically necessary prescription drugs and thus may cover more drugs than Medicare private drug plans.

82. What happens to my VA benefits when the Medicare drug benefit begins?

Your Department of Veterans Affairs (VA) drug coverage will remain the same, and you probably do not want to enroll in a Medicare private drug plan. VA coverage is more comprehensive than Medicare drug coverage. Also, Medicare only wraps around VA benefits in limited instances (only when you have VA permission to get services in a non-VA facility). Since VA pays first and Medicare pays second, you will not need Medicare to supplement your VA drug coverage. In addition, if you ever do want to enroll in the Medicare drug benefit later, VA drug coverage is “creditable coverage,” so you will not have to pay a penalty as long as you enroll in the Medicare drug benefit within 63 days of losing VA benefits.

Note: With no premiums and minimal co-pays for prescriptions, VA coverage is comparable to Medicare drug coverage with extra help.

You may prefer to drop VA coverage and join a Medicare private drug plan if you live very far from a VA facility and the Medicare private drug plan includes nearby pharmacies in its network.

83. What happens to my coverage through a Program of All-Inclusive Care for the Elderly (PACE) when the Medicare drug benefit begins?

If you are enrolled in a PACE organization that offers drug coverage as of December 31, 2005, do not sign up for a Medicare private drug plan. (If you do enroll in a Medicare private drug plan, you will be disenrolled from all PACE coverage.) Beginning January 1, 2006, you will get Medicare drug coverage through PACE, and you will not have any premiums, deductibles, copayments, coinsurance or other out-of-pocket costs for your prescription drugs.

84. What happens to my Medicare-approved drug discount card when Medicare drug coverage begins?

If you have a Medicare-approved drug discount card, your card will expire when your Medicare drug coverage begins or on May 15, 2006, whichever comes first.

85. What happens to my ADAP coverage when Medicare drug coverage begins?

AIDS Drug Assistance Programs (ADAPs) vary among states, so how Medicare drug coverage affects your ADAP coverage will depend on your state. You should call your ADAP to determine how it coordinates with the Medicare drug benefit.

If you currently receive your drug coverage through and ADAP, you probably want to keep your ADAP benefits and enroll in the Medicare drug benefit. ADAPs can require you to enroll in a Medicare private drug plan to continue receiving ADAP benefits. Also, most ADAPs will be not considered as good as Medicare’s basic drug coverage, so if you decide to enroll in a Medicare private drug plan after your initial enrollment period, you will have to pay a premium penalty and wait until the annual coordinated election period (November 15 to December 31 of every year) to enroll. (Private insurance paid for by ADAPs will probably offer coverage that is, on average, at least as good as Medicare’s basic benefit).

It may very important continue receiving ADAP assistance. Some ADAPs will supplement the Medicare drug benefit, paying your out-of-pocket costs and covering drugs that your Medicare private drug plan does not. These payments do not count toward meeting your annual out-ofpocket maximum ($3,600 in 2006, also called TrOOP). Some states will allow you to use ADAP payments to spend down to Medicaid, If you qualify for Medicaid spend-down for more than one month, you will automatically qualify for extra help (see question 27).

86. What happens if I currently get my prescription drugs through my nursing home?

Medicare private drug plans must provide convenient access to long-term care facility pharmacies in their networks. If you are living in a nursing home or other medical institution and qualify for Medicaid for at least one full month, you will be automatically eligible for the extra help paying for Medicare drug coverage and you will not have any out-of-pocket expenses for your drug costs. If you join a Medicare private drug plan with a premium that is higher than the extra help premium amount, the difference is a medical expense that counts towards the monthly amount you must contribute toward the cost of your care (“share of cost”).

If you do not have Medicaid, you will have the same out-of-pocket costs as other plan members.

Note: federal law requires nursing homes to cover the costs of medications if they will not be covered by the plan or are excluded from Medicare coverage.

In addition, entering, residing in, or leaving a nursing home will entitle you to change your Medicare private drug plan. Nursing home residents can change plans every month. Persons who leave a nursing home can change plans within two months after leaving the institution. Details on this are still being worked out. Stay tuned.

87. Could enrolling in a Medicare private drug plan disqualify me from drug assistance provided by certain pharmaceutical companies?

It is up to the companies. Some pharmaceutical assistance programs require that you do not have any other drug coverage to qualify for the program. Stay tuned to find out what these programs decide to do once the Medicare drug benefit is available.

88. What are my enrollment rights?

You have the right to enroll in any Medicare private drug plan available in your area during the Initial Enrollment Period (except if you have End-Stage Renal Disease and want to enroll in a Medicare private plan—HMO, PPO—with drug coverage). Plans are also required to provide you “prompt notice” of whether it has accepted or denied your enrollment. Medicare will provide more information about how this must be done. Stay tuned.

89. What is my Medicare private drug plan required to tell me?

Medicare private drug plans are required to provide information to their enrollees (and prospective enrollees) about their service areas, the benefits offered under the plan, the costsharing amounts, formularies, pharmacy network, and any other aspect of coverage. This information must be provided in writing at the time of enrollment and annually after that, and it must also be available on request and on the plan’s web site. The plan must also operate a tollfree number during business hours and be able to give you this information. In addition, plans and pharmacists are required to tell you if you could save money by using a generic drug.

90. Will my Medicare private drug plan help me manage what prescription drugs I am taking?

Medicare private drug plans are required to provide therapy management programs to members who

have multiple chronic conditions;
are taking multiple medications; and/or
have high drug expenses.

These programs will pay pharmacists to spend time counseling members who meet the above criteria to improve their overall health and reduce adverse drug interactions. Stay tuned for more information about these programs.

91. What if I am out of my Medicare private drug plan’s coverage area and I need to get a prescription filled?

Call your Medicare private drug plan. You can get coverage of drugs from an out-of-network pharmacy 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 (see questions 70 and 71).

92. What if the medication I need is not on my Medicare private drug plan’s formulary?

You have the right to request that your plan cover a medically necessary drug not on its formulary (list of covered drugs) when:

You are using a drug currently covered by your plan, but that drug is removed from your plan’s formulary for reasons other than safety.
Your doctor prescribes a drug not on your plan’s formulary because your doctor believes the drugs on the plan’s formulary will not work for you.

Once you realize the drug you need is not covered, you should contact your plan to request an exception. You will need an oral or written supporting statement from your doctor to demonstrate you need the drug. Generally, plans must grant these requests—called exceptions— when they determine that it is medically appropriate to do so. Plans must respond to your request within 72 hours. You can also ask for a faster response (an expedited request) when your “life, health or ability to regain maximum function” is in jeopardy. Plans must respond to expedited requests within 24 hours. If a plan denies an exception request, you can appeal the plan’s decision.

If a plan grants your request, it must continue to cover refills as long as the doctor continues to prescribe that drug, it continues to be safe, and the calendar year has not expired.

Note: You cannot ask for an exception for drugs specifically excluded from Medicare coverage (see question 63).

93. What if the medication I need is in a high cost-sharing tier?

You have the right to request that your Medicare private drug plan lower your drug copayment for a medically necessary drug (cost-sharing tier) when:

You are using a drug currently covered by your plan, but the plan raises your copayment for that drug.
Your doctor prescribes a drug on your plan’s formulary that requires a higher copayment because your doctor believes the drugs covered by the plan with a lower copayment will not work as well for you, would be harmful to you, or both. (Note: plans may exempt “high cost or unique drugs” from the exceptions process).

If a plan grants your request, it must continue to cover refills at that copayment as long as the doctor continues to prescribe that drug, it continues to be safe, and the calendar year has not expired.

If a plan denies an exception request, you can appeal the plan’s decision.

Note: You can also request an exception to other coverage restrictions, such as dose and dosage limitations and substitution requirements.

94. What can I do if my plan denies an exception to its formulary?

You can appeal. There are several levels in the appeals process.

Redetermination by your Medicare private drug plan. If your Medicare private drug plan denies your exception request for the drug you need (see questions 91 and 92), you can request a second review within 60 days of receiving notice of the plan’s decision. (Exceptions to the 60-day rule include sickness, death or illness of family member, incorrect information from the plan and destroyed records.) The plan must respond no later than seven calendar days from the date it receives the request (72 hours for an expedited appeal). If the plan fails to act within these timeframes, the plan must forward your appeal to the Independent Review Entity within 24 hours of the missed deadline (see below). Plans must expedite appeals if your doctor certifies that your health requires it.
Reconsideration by the Independent Review Entity (IRE). If your plan denies coverage after a redetermination request you can request a review by an IRE within 60 days of getting the notice of denial of your redetermination from your plan. That notice should also explain how to appeal to the IRE. An IRE is an independent agency that contracts with Medicare to handle these appeals and is not affiliated with any Medicare private drug plan. The IRE must get the input of your prescribing doctor either orally or in writing and respond no later than seven calendar days after receiving your request (72 hours for an expedited appeal).
Administrative Law Judge (ALJ) hearing. If you disagree with the IRE’s decision, or if the IRE fails to act, you can request an ALJ hearing within 60 days of the IRE decision if the amount in question meets the minimum amount that Medicare will announce annually ($100 in 2005). You can combine multiple appeals to meet this amount, meaning that you will project the cost of the drug to include all of the refills you will need for the calendar year. The timeframe for a decision is 90 days, but that period can be extended for several reasons.
Medicare Appeals Council (MAC). If you disagree with the ALJ’s decision, you can appeal within 60 days to the Medicare Appeals Council, which is the part of the Department of Health and Human Services that reviews ALJ decisions. The MAC can also review the ALJ decision on its own initiative.
Judicial Review. If you disagree with the MAC’s decision or if the MAC denied the request for appeal, and the amount in question meets the minimum amount that Medicare will announce annually ($1,050 in 2005), you can request Judicial Review in federal court.

Note: Your prescribing doctor or a representative acting on your behalf can appeal for you. A representative is someone authorized under state law to act for you (such as a health care proxy) or someone you appoint in a written statement you send to Medicare.

95. I was told I won my appeal. How soon can I get my drugs covered?

Reversal of coverage determinations and redeterminations. Your Medicare private drug plan must process your request for benefits within seven calendar days (72 hours for an expedited appeal) from the date the plan received your request for redetermination. If you requested payment, the plan must authorize it within seven calendar days and pay within 30 calendar days from the date it received your request for redetermination.

Reversal of plan decision by IRE, ALJ, MAC or Judicial Review. Your plan must process your request for benefits within 72 hours (24 hours for an expedited appeal) from the date the plan received the decision. If you requested payment, the plan must authorize it within 72 hours and pay within 30 calendar days from the date it received your request.

96. Can private health or drug plans make unsolicited calls to me about their products (telemarket)?

Yes. In addition to marketing their Medicare private drug plans, insurance companies can market additional products and services to you by phone. However, plans cannot use information that they have obtained from you (such as your name and address) to market non-health-related products and services without your written consent. There are some restrictions:

Telemarketers cannot enroll you in their plan.
Plans must abide by the “Do Not Call” List, honor “Do Not Call Again” requests, and must comply with federal and state consumer protection laws for telemarketing.

97. What happens if my Medicare private drug plan leaves my area?

You will have a Special Enrollment Period to enroll in another Medicare private drug plan (see question 48). You can go to Medicare’s www.medicare.gov web site to look for Medicare private drug plans in your area and compare their costs, covered drugs and pharmacy networks. You can also call 800-MEDICARE for help finding a new private drug plan.

98. What happens if I lose my current drug coverage and want to enroll in the Medicare drug benefit?

It depends on whether your current drug coverage is at least as good as Medicare’s (“creditable coverage”) and why you lost your coverage.

If your coverage was at least as good as Medicare’s and

you lost your coverage through no fault of your own, you will get a Special Enrollment Period in which to enroll in a Medicare private drug plan. To avoid paying a premium penalty, you should enroll within 63 days of losing your drug coverage.
you decide to drop your drug coverage, if you decide to drop your drug coverage and it was at least as good as Medicare’s, you will not get a Special Enrollment Period. You can enroll in a Medicare private drug plan during the Annual Coordinated Election Period (see question 47). To avoid paying a premium penalty, make sure you are not without your drug coverage for more than 63 days.

If your drug coverage was not at least as good as Medicare’s, you can enroll in the Medicare drug benefit during the Annual Coordinated Election Period (see question 47), but you will have to pay a premium penalty for each month that you did not enroll after your Initial Enrollment Period (see questions 13 and 47).

99. If I move out of my Medicare private drug plan’s service area, can I change plans?

Yes. You will have a Special Enrollment Period in which to enroll in a new Medicare private drug plan (see question 47). If you are eligible for the extra help paying for your Medicare drug costs and enrolled through Social Security, you do not need to reapply when you move.

100. If my health condition significantly changes and my plan does not cover the drugs I need, can I switch plans?

Generally no. A change in your health condition does not entitle you to change your drug plan. You can request an exception to the plan’s formulary (see questions 91 and 92) and change plans during the Annual Coordinated Election Period (see question 47).

However, if you have Medicaid you can switch plans at any time, and if you enter or leave a long-term care facility, you will probably have the chance to change plans. Stay tuned for more information.

101. Can I get free help understanding my options?

Yes. For help comparing your Medicare private drug plan options you can call1-800-MEDICARE, visit the Medicare web site at www.medicare.gov, or call your State Health Insurance Information and Assistance Program (SHIP). For help filling out the application for extra help paying for your Medicare drug costs if your income is low, call Social Security at 800-772-1213 or your SHIP. You can get the telephone number of your local SHIP by calling 1-800-MEDICARE.

For regular updates on Medicare consumer issues, subscribe to the Medicare Rights Center’s free weekly e-newsletter, Dear Marci, at www.medicarerights.org/dearmarci.html.

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