News & Advocacy

Important Medicare Rx Drug Benefit Resources

Beginning on January 1, 2006, Medicare will for the first time provide coverage for prescription drugs, including many of the medications needed by people with ALS (PALS). Coverage and cost will vary by plan and by region, so it is important for PALS on Medicare to review the options available to them in their particular areas to determine which plans are most appropriate for their needs and whether enrolling in a plan is, in fact, the best choice for them. This new coverage may provide significant savings to Medicare beneficiaries, especially for those who currently do not have drug coverage. In addition, those with limited incomes may be eligible for additional assistance, which could enable them to receive their prescription drugs at a very low cost. Additional information about the low income subsidy is available here: http://www.ssa.gov/pubs/10128.html.

Regardless of a person’s income or whether they currently have drug coverage, all Medicare beneficiaries will be eligible for this coverage with enrollment beginning on November 15, 2005.

Enrollment Not Required

While the new benefit is available to everyone eligible for Medicare, people are not required to enroll. They may elect to keep their current coverage as it may already meet their needs in terms of coverage, cost and convenience. However, those who do not enroll during the initial enrollment period (November 15, 2005 to May 15, 2006) may have to pay a penalty (1% premium increase for each month a person waited to enroll), unless their current prescription coverage is deemed to be equal to or better than Medicare’s. If people currently have coverage, they will receive a notice from their insurer or employer by November 14 indicating whether their coverage is at least as good as Medicare, in which case there will not be a penalty if someone chooses not to enroll in a Medicare prescription drug plan.

Options – Stand-Alone PDPs or Medicare Advantage

People who do want to receive Medicare prescription drug coverage will have many different plans available to them in their area. However, there are two ways to receive coverage. First, people can add prescription drug coverage to the traditional Medicare plan by enrolling in a stand-alone prescription drug plan (PDP). Or they can receive drug coverage and the rest of their Medicare coverage by enrolling in a Medicare Advantage plan, like an HMO or PPO.

Drug Coverage Not Automatic

It is important to note that Medicare prescription drug coverage is not automatic. People must choose to enroll if they so desire. However, those who qualify for extra help, receive Supplemental Security Income (SSI), or who receive Medicare and Medicaid will be enrolled in a plan automatically if they do not select one before drug coverage takes effect on January 1, 2006. We strongly recommend that these individuals enroll in a plan before December 30, 2005.

Medicare Part B Reminder

We also would like to take this opportunity to remind PALS and Chapters that people who do not enroll in Medicare Part B when they first become eligible will face penalties if they enroll at a later date. Part B provides important coverage for durable medical equipment and supplies, physician services, outpatient services, and other services not covered by Medicare Part A (hospital insurance). If people do not enroll in Part B when they first become eligible, they will pay increased monthly premiums equal to 10% more for each 12 month period that a person was eligible for Part B, but did not enroll. This penalty will apply for as long as someone has Part B.

Prescription Drug Toolkits Available

The Centers for Medicare and Medicaid Services (CMS) has several toolkits available to assist ALSA Chapters and caregivers in educating PALS about the new Medicare drug benefit and help them to make the enrollment decisions that meet their needs. These include:

“Outreach Toolkit on Medicare Prescription Drug Coverage” The toolkit includes presentation materials and other information available from CMS that will help Chapters and others reach out to their communities and provide information about the Medicare prescription drug benefit. The Outreach Toolkit is available online.

“Help is Here Resource Kit: Understanding, Deciding, Choosing, Joining” This toolkit, which is designed to be included in the Outreach Toolkit, includes information ALSA Chapters and individuals can use to help PALS understand the Medicare prescription drug benefit and choose a plan that meets their needs. The Kit is available online..

We strongly recommend that family members and caregivers review and retain a copy of this toolkit as it will help you respond to questions and guide PALS in reviewing the prescription drug options available to them.

This Kit also is available via an online Webcast at http://cms.archivevideo.com/. The Webcast runs with Windows Media Player and Real Player, and a closed captioned version also is available.

If you would like to order hardcopies of the “Outreach Toolkit” or the “Help is Here Resource Kit,” please contact Pat Wildman at pwildman@alsa-national.org or 1-877-444-ALSA.

Prescription Drug Plans Available in Your Area

Landscape of Local Plans

A listing of the prescription drug plans available in your area can be found online at http://www.medicare.gov/medicarereform/map.asp. Select your state on the map, and you will be provided links to charts showing the Medicare Advantage Plans (HMOs, PPOs, etc. that offer other benefits in addition to drug coverage) and Stand-Alone Prescription Drug Plans (provide drug coverage only) available in your area. The charts include information on premiums, deductibles, tiered copays, generic/brand name coverage and whether or not mail order is available for prescription drugs.

Medicare & You 2006

Much of the plan information mentioned above also is included in the Medicare & You 2006 handbook, which has been mailed by CMS to Medicare beneficiaries and provides information about the Medicare program as well as the prescription drug benefit. Handbooks that include state-specific plan information are available online here.

Since the information about health and prescription drug plans differs by region, it is important that you select the handbook that covers your particular area.

NOTE: The Medicare & You 2006 handbooks that were mailed to beneficiaries earlier in October contain an error. It inaccurately states that low-income beneficiaries who enroll in any Medicare prescription drug plan available in their area will not be required to pay premiums. That is false. About 40% of plans will require no premiums. The error has been corrected in the versions available online. It is possible that new handbooks will be mailed by CMS. The “Notice of Errata” is available here: http://www.cms.hhs.gov/partnerships/tools/materials/publications/erratas/noe100305.pdf

The Formulary Finder

The Formulary Finder will allow PALS and Chapters to enter a typical combination of drugs used by PALS to determine which plans in your area have formularies that cover these drugs. The Formulary Finder is available at http://plancompare.medicare.gov/formularyfinder/selectstate.asp.

NOTE: Some of these tools may not yet be fully functional as health plan data and the tools themselves have only recently been released.

How to Select a Prescription Drug Plan

There are two main ways for Medicare beneficiaries to review their options and select a prescription drug plan, depending on whether an individual has access to the internet. However, as you use these tools you should also have some key information handy, such as a list of the medications you take, to help you make a decision. Additional information to have on hand is described in the section below on Information to Have and Questions to Ask.

Selecting a Plan via the Internet:

For those with access to the internet, we strongly recommend using the online resources that are available to you. Chapters, caregivers and family members also may use these internet tools to assist PALS in learning more about their prescription drug options. The internet tools will be the most efficient and easy way to review the options available and select the plan that meets the needs of individual PALS. There will be several online tools available. They include:

The Prescription Drug Plan Finder

Available on the CMS website, www.medicare.gov, is a Medicare Prescription Drug Plan Finder. This tool will help Medicare beneficiaries decide whether they want to enroll in a plan that offers Medicare prescription drug coverage. It is designed to allow individuals to compare the Medicare drug plans in specific geographic areas and select a plan that meets their individual needs. For example, the tool allows people to enter information about specific drugs they take, the range of monthly premiums and annual deductibles they are willing to pay, as well as their pharmacy preferences, and then it will locate available plans that meet the criteria entered and will provide coverage, cost and other important information about those plans. The tool also allows people to compare between plans that provide prescription drug coverage alone and those Medicare Advantage plans that provide prescription drug coverage as well as coverage for other Medicare services. Importantly, the tool takes into account how you currently receive your prescription drug coverage and will let you know your options based on your current coverage.

The link to the Medicare Prescription Drug Plan Finder is here: http://www.medicare.gov/MPDPF/Home.asp

NOTE: Since Medicare prescription drug plan information has only recently been made available and because the Medicare Prescription Drug Plan Finder has just been launched, some of the features may not be fully functioning. However, the Centers for Medicare and Medicaid Services has stated that the site will be fully functional during the enrollment period. Once the Plan Finder is fully operational, it will allow people to personalize their search for a drug plan, as noted above, and look at a side-by-side comparison of up to three plans at a time based on cost, coverage and convenience.

The Plan Finder also will help people if they are not sure whether they qualify for extra help, whether their employer or union is continuing their current coverage with a Medicare subsidy, or whether they are already enrolled in a Medicare Advantage Health Plan or in a Medicare prescription drug plan.

A Webcast describing how to use the Plan Finder Tool is available online at http://cms.archivevideo.com/. The Webcast runs with Windows Media Player and Real Player.

BenefitsCheckUpRx

Another helpful tool that is available to PALS, Chapters, caregivers and family members is BenefitsCheckUpRx. This web-based decision-making tool is provided by the Administration on Aging and the Department of Health and Human Services and can be accessed at www.benefitscheckup.org or through the Access to Benefits Coalition website at www.accesstobenefits.org. The tool links to the Medicare Prescription Drug Plan Finder and will help people assess current prescription drug coverage, determine whether they are eligible for additional assistance, inform them of their rights and options based on their situation, and help them take the next step, including enrolling in a Medicare Prescription Drug Plan. BenefitsCheckUpRx also will help people determine what prescription drug programs they qualify for including the Medicare Prescription Drug Benefit (and low income subsidy), State Pharmacy Assistance Programs, Medicare Savings Programs, and Supplemental Security Income (SSI). The tool also will provide state specific recommendations.

MAPRx

Medicare Access for Patients Rx, MAPRx, is a coalition of patient, family caregiver and health professional organizations committed to safeguarding the well-being of patients with chronic diseases and disabilities under the new Medicare prescription drug benefit. ALSA is a member of the coalition. The MAPRx website, www.maprx.info includes helpful information and answers to questions as well as links to tools that allow users to compare prescription drug plans. The site also is expected to include a step by step guide on how to choose a plan and will include a checklist and comparison chart to assist in the decision-making process.

Selecting a Plan over the Phone:

While we recommend that people utilize online resources whenever possible, we recognize that many people do not have access to the internet. However, those who do not have internet access do have several options available to turn to for assistance. They can call the Medicare hotline at 1-800-MEDICARE, their local State Health Insurance Assistance Program or the Area Agency on Aging (contact information is available in the Medicare Training and Assistance Section below). Representatives at these numbers are available to answer questions and guide PALS, family members and caregivers through the decision-making process, including helping to identify their options and the plans that best meet their needs, if they choose to enroll in the prescription drug benefit.

Chapters, family members and caregivers also can be vital resources for PALS to turn to for information about the Medicare prescription drug benefit. We strongly recommend that Chapters, family members and caregivers use internet resources, such as the Drug Plan Finder, the Landscape of Local Plans, the Formulary Finder and the “Help is Here Resource Kit” to assist PALS in making the choices most appropriate for them.

The “Medicare Rx Help is Here Resource Kit” in conjunction with the Drug Plan Finder are especially valuable tools to use when guiding PALS through the decision-making process. These tools will help people ask the questions they need to ask when choosing a plan or deciding to enroll in the benefit. Please note that some of these tools may not yet be fully functional as health plan data and the tools themselves have only recently been released.

Finally, the Medicare & You 2006 handbook also is an important resource to use for those who do not have internet access. As previously mentioned, the handbook includes information about Medicare and the prescription drug benefit as well as the plans available in your area. Please note that the Medicare & You 2006 handbooks that were mailed to beneficiaries earlier in October contain an error. They inaccurately state that low-income beneficiaries who enroll in any Medicare prescription drug plan available in their area will not be required to pay premiums. That is false. About 40% of plans will require no premiums. The error has been corrected in the versions available online. It is possible that new handbooks will be mailed by CMS.

NOTE: We again want to note that people are not required to enroll in a Medicare prescription drug plan. While the drug benefit may bring savings to many PALS, it is important to review the options that are available before deciding whether to enroll in a Medicare prescription drug plan, Medicare Advantage Plan or whether a person should keep their existing coverage. The tools included here will help PALS, families and caregivers make the choices that are most appropriate for them.

Information to Have and Questions to Ask

Regardless of whether people use the internet or more traditional means to identify a prescription drug plan, they should begin the process armed with important information and key questions to ask. CMS has available two helpful documents that provide suggestions on issues to think about when comparing plans (http://www.medicare.gov/Publications/Pubs/pdf/11163.pdf) as well as tips on how to compare plans (http://www.medicare.gov/Publications/Pubs/pdf/11110.pdf). In addition, we have included below other information to consider when people review their options. But please remember that people should compare their current coverage to the new options that are available.

ALSA Chapters may want to customize the information below to include any other questions PALS may want to consider as they go through the decision-making process.

General Information to Have On Hand When Choosing a Medicare Drug Plan:

Your Medicare Card, including Medicare number and effective date for Part A or B.
General information on your current prescription drug coverage – whether you receive coverage through an employer, union, Medicare Supplemental, or other retiree drug coverage.
Information on annual income and resources (to determine if you qualify for extra help).
A list of medications you take, including dosage.
The name of pharmacies you use.

Information to Consider:

The amount of the monthly premium
Whether the plan formulary includes:

The particular drugs needed by PALS
The strengths and dosages of the drugs needed
The number of days covered in each prescription (Example: 30, 60, 90 days)

Whether the pharmacies in the plan’s network include:

The pharmacies used by the beneficiary
The pharmacy used by the long-term care facility in which the beneficiary resides

Whether there are price differentials among pharmacies in the network
Whether mail-order is allowed or required

The price differential for mail order
The number of days covered in each prescription (Example: 30, 60, 90 days)

The plan’s utilization management tools

The prior authorization requirements
Whether the plan requires step therapy (Requirement that certain medication(s) be tried before those prescribed by the PALS’ physician)
Whether the plan uses tiered cost sharing (Different co-pays for generics, brands, or for specific drugs)

The number of tiers
The co-payments/co-insurance per tier

Whether the plan offers therapeutic substitutions
Whether there are quantity limitations

On number of prescriptions in a month
On number of pills in a prescription

Whether the plan offers supplemental benefits
How the plan coordinates with the State Pharmaceutical Assistance Program
Who is the plan sponsor, has the entity been in the community for a while, is it reliable?
The “Transition” process used by the Prescription Drug Plan (Temporary use of a drug not covered by plan)
The “Exceptions” process used by the Prescription Drug Plan (Appeal if a person’s drug is not covered by the plan)
Whether a PALS has other insurance that covers prescription drugs:

Through a Medicare HMO or other Medicare Advantage plan. If so, the person must keep getting drug coverage through that plan if he wants to stay in that plan.
Through a retiree health plan. If so, has the former employer told the person whether the insurance is as good as or better than Medicare's coverage (i.e., "creditable coverage”)? If it is creditable coverage, the person may stay in that plan without getting a late penalty on the premium if he later decides to change to a Medicare drug plan.
Through a Medigap (Medicare supplemental) policy? If so, has the insurer told the person whether the insurance is creditable coverage? If it is not, the person will have to pay a late penalty on the premium if he keeps his Medigap drug coverage and later switches to a Medicare prescription drug plan.
Individuals with coverage through the Veteran's Administration, TRICARE, Federal Employee Health Benefit Plan, Railroad Retirement Board, Program of All-Inclusive Care for the Elderly (PACE), or Indian Health Service, may continue receiving prescription drug coverage through one of those plans if that coverage is as good as what is offered from Medicare prescription drug coverage.

Frequently Asked Question and Answers

CMS has a comprehensive list, which is updated regularly, of frequently asked questions and answers about the new drug benefit available here: http://www.cms.hhs.gov/partnerships/news/mma/qsandas.pdf

Questions and answers include:

Basic Information

What is Medicare Prescription Drug Coverage?
Is Medicare prescription drug coverage better than what I have now?
What if I already have prescription drug coverage?
How do I join a Medicare Prescription Drug Plan?
What happens if I choose not to join a Medicare drug plan by May 15, 2006?
Is there information and help available to compare Medicare drug plans?

Costs and Coverage

What are the out-of-pocket costs for Medicare prescription drug coverage?
What does a Medicare drug plan cover?
How can I be sure a Medicare drug plan will cover the prescriptions I might need?
What is a formulary?
What if I need a drug that isn’t on the formulary or is covered at a higher cost?

Affect on Current Drug Coverage

What do I need to know if I have prescription drug from a former or current employer or union?
What do I need to know if I have a Medicare Advantage Plan (like an HMO, PPO or PFFS Plan) or other Medicare Health Plan?
What do I need to know if I have a Medigap (Medicare Supplement Insurance) policy that covers prescription drugs and I have the Original Medicare Plan (Medicare Part A and Part B)?
What do I need to know if I have drug coverage from TRICARE, the Department of Veterans Affairs, or the Federal Employee Health Benefits Program?
What do I need to know if I have full coverage from my state Medicaid program?

Information for People with Limited Income and Resources

How do I know if I qualify for extra help?
How much will my prescriptions cost me if I qualify for extra help?

Medicare Training and Education

Included in the information that follows is local contact information for the regional CMS offices and State Health Insurance Assistance Program (SHIP) offices in your area. Local CMS offices can help provide training for ALSA Chapter staff about the prescription drug benefit and can answer questions Chapters may have. SHIPs are available to provide individual assistance to PALS receiving Medicare and can guide PALS through the decision-making process. The Medicare Hotline, 1-800-MEDICARE, also is available to provide answers to questions and personalized assistance identifying and reviewing the options available to PALS.

CMS Regional Offices, States & Territories Covered by Each Region

Region States & Territories

I – Boston ME, VT, NH, MA, CT, RI

II – New York NY, NJ, PR, VI

III – Philadelphia PA, MD, DE, WV, VA

IV – Atlanta FL, KY, TN, NC, SC, GA, AL, MS

V – Chicago MN, WI, IL, MI, IN, OH

VI – Dallas NM, TX, OK, AR, LA

VII – Kansas City MO, IA, KS, NE

VIII – Denver CO, UT, WY, MT, ND, SD

IX – San Francisco CA, NV, AZ, HI, Guam, Samoa

X – Seattle AK, ID, OR, WA

CMS MMA Education Campaign Regional Contacts

Region Contact Telephone Email

I – Boston Carol Maloof 617-565-1313 Carol.Maloof@cms.hhs.gov

II – New York Danielle Liss 212-616-2217 Danielle.Liss@cms.hhs.gov

III – Philadelphia Patti Lalor 215-861-4152 Patricia.Lalor@cms.hhs.gov

IV – Atlanta Wilma Cooper 404-562-7240 Wilma.Cooper@cms.hhs.gov

V – Chicago Greg Chesmore 312-353-1487 Gregory.Chesmore@cms.hhs.gov

VI – Dallas Julie Kennedy 214-767-6420 Julie.Kennedy@cms.hhs.gov

VII – Kansas City Kathryn Coleman 816-426-6518 Kathryn.Coleman@cms.hhs.gov

VIII – Denver Mark Levine 303-844-7070 Mark.Levine@cms.hhs.gov

IX – San Francisco Cate Kortzeborn 415-744-3661 Catherine.Kortzeborn@cms.hhs.gov

State Health Insurance Assistance Program Contacts

Contact information for local State Health Insurance Assistance Program offices is available below and online here: http://www.cms.hhs.gov/partnerships/communities/ship/default.asp

North Carolina

1-800-443-9354

South Carolina

1-800-868-9095

Publications and Fact Sheets

CMS has several publications and fact sheets available online, which you can download or order. Many of these publications come in the form of brochures which Chapters may want to make available at the Chapter office or distribute at support group meetings or other gatherings where PALS, caregivers and family members may be present. The publications can be accessed at http://www.cms.hhs.gov/medicarereform/factsheets.asp.

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As you can see, there is a great deal of information available about the new Medicare Prescription Drug benefit. We strongly encourage PALS, family members and caregivers to add this page of our website to your bookmarks or print this document. You will want to have this information handy to use as a resource during the enrollment decision-making process.

We understand that the amount of information available can be overwhelming. Therefore, please utilize the help that is available. Chapters, PALS, families and caregivers can contact 1-800-MEDICARE, local State Health Insurance Assistance Program offices or the CMS Regional Office. Of course, the Advocacy Department also is available as a resource, so please do not hesitate to contact Pat Wildman, Director of Federal Advocacy Outreach, at pwildman@alsa-national.org or toll free at 1-877-444-ALSA if you have any questions.

The implementation of the Medicare prescription drug benefit is one of the largest ever launches of a government program. As a result, problems may arise in both the tools that are available to assist Medicare beneficiaries as well as in the implementation of the drug benefit itself. If you or someone you know experiences problems or difficulties, either during the enrollment process, or after the benefit is implemented on January 1, please let us know. We want to communicate these concerns to both the Centers for Medicare and Medicaid Services (CMS) and Members of Congress as soon as possible to help ensure that they are addressed promptly.

Important Medicare Rx Drug Benefit Resources

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