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Health Care Coverage
Medications/Prescription Drugs

Medicare Part D

Overall/Quick Reference: Kaiser Family Foundation Medicare Consumer Guide Talking About Medicare: Your Guide to Understanding the Program, 2012   SECTIONS Medicare D Medicare D Transition Assistance and Advocacy Includes tips sheets, appeal rights, etc. Other Sections: I. Background and Basics II. Benefits III. Extra Help IV. Choosing a Plan & How to Join a Plan V. Rights and Responsibilities    VI. To Join or Not to Join? (Late enrollment penalty) VII. Special Situations Drug Company Programs ("Patient Assistance Programs") - free medications from Drug Companies Dual Eligibles (those with Medicare and Medicaid/MassHealth) Health Safety Net (Formerly "Free Care") Hospice Medicare Health Plans Illnesses & Health Conditions Medicare Assistance Programs (QMB, SLMB, QI) Medigap Plans Off-Label Use Prescription Advantage Members VII. More Information for Consumers and Providers VIII. More Information for Providers, Advocates and Policy Wonks Transition Assistance and Advocacy Handout/Fact Sheet: 2017 Transition Rights to Medications Under Medicare Part D, Justice in Aging (Formerly the National Senior Citizens Law Center) The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Part D prescription drug plans provide beneficiaries with access to transition supplies of needed medications to protect them from disruption and give adequate time to switch to a drug that is on a plan’s formulary, file a formulary exception request or, particularly for Low Income Subsidy (LIS) recipients, enroll in a different plan. In the early months of the year, transition rules will be particularly important for low income beneficiaries who were automatically reassigned to new plans, which may or may not cover their medications. All plans change their formularies each year, however, so even people who remain in the same plan may find that their plan no longer covers their medications or has newly imposed utilization management requirements. CMS Minimum Transition Requirements CMS requires Part D plans to establish transition policies that cover beneficiaries when they: first enroll in a Part D plan. are moving to a new plan that does not cover their current drug, including when that move is mid-year. experience a change in level of care (e.g., from hospital to a nursing facility, from a nursing facility to home, or out of hospice status to standard Medicare, etc.). Or When, at the start of a new plan year, the plan in which they currently are enrolled drops coverage of a drug they are taking or imposes new utilization management restrictions on that drug. For all enrollees: Plans must provide a one time fill–30 day supply (unless a lesser amount is prescribed) — of an ongoing medication within the first 90 days of plan membership. Applies both to drugs not on formulary and to those subject to utilization management controls. Applies to the first 90 days in the plan, even if not at the beginning of the plan year and even if the 90 day period extends over two plan years (e.g., a November enrollment). Applies both to new members and to continuing members when a plan has changed formulary. Does not cover non-Part D drugs. Does not cover multiple fills.  For example, if a doctor only prescribes a pain medicine in 14 day batches, the transition will only cover one batch. Plans must mail a written notice explaining that the transition supply is temporary, including instructions for identifying appropriate substitutes; notice of the right to request a formulary exception; and instructions on how to file an exception request.  The notice must be mailed within 3 business days of the temporary fill. Transition fills are temporary. Clients should take action immediately and have the doctor change the prescription to a covered drug or ask the plan for an exception. If, at the point of sale, a plan cannot determine whether a newly written prescription is for ongoing drug therapy or not, the plan must assume that the prescription is ongoing and apply transition policies. Note: The pharmacist may need to ask the plan for its override code to bill correctly. Residents in a long-term care (LTC) facility or other institution get further protections. For CMS Guidance on transition drug supplies, go to Medicare Prescription Drug Benefit Manual, Chapter 6 at 30.4 et seq. -See the Justice In Aging fact sheet: 2017 Transition Rights to Medications Under Medicare Part D or see summary/excerpts: Medicare D Plan Transition Coverage Rights Fact Sheet, MGH Community News, January 2016. Learn more: Transition Drug Refills   Dual Eligibles- "What If" for Pharmacists - detailed instructions from CMS Prescription Advantage - Secondary Payer and Transitional Drug Coverage Information for Pharmacies Advocacy Tips - request an exception, change plans, etc. How Do I Appeal a Medicare D Coverage Decision? Tip sheet- for Advocates: Getting Prescriptions Filled for Medicare Part D Enrollees - From Mass. Law Reform Institute To Lower Your Medicare Drug Costs, Ask Your Pharmacist for The Cash Price: under a little-known Medicare rule, consumers can pay a lower cash price for prescriptions instead of using their insurance if they ask the pharmacist for the price- MGH Community News, May 2018 Problems Getting Scripts Filled? Documenting "Extra Help" (LIS) - MGH Community News, January 2007 MassHealth Emergency Drug Coverage Update - MGH Community News, January 2007 I. Background and Basics Beginning in January 1, 2006, Medicare began covering most outpatient prescription drugs through Medicare Part D. Medicare contracts with private companies to provide this drug coverage. Medicare D is a voluntary program. The staff version - from PCOI Members will need to chose from a number of privately-managed programs in their area. Medicare encourages applicants to consider the three “Cs” in choosing a plan: Cost, Coverage, and Convenience. Cost- plans have to operate within certain limits, but will vary. Coverage- the drugs each plan covers is called the “formulary”. The companies or “plans” must offer two medications in each category, but plans will differ in the specific drugs they cover. More information is available on the Medicare website and from the specific plans. See www.medicare.gov for more information, including formulary guidance - an interactive program to help you choose the best plan for you. For more information about what is and isn't covered, see Medicare Reminder – Medicare Drug Coverage- MGH Community News, April 2019. Also see "Benefits" below. Convenience- does the applicant’s pharmacy participate in that plan? Medicare Part D Basics- MGH Community News, August 2018 Watch for Scams!  The Massachusetts Executive Office of Elder Affairs issued these scam prevention tips. Top of Page II. Benefits Medicare.gov- Medicare D Page "How new Medicare drug plans will provide you with high-quality, lower-cost drug coverage" - From CMS. Includes information on network pharmacies, lists of covered drugs (Formulary), prior authorization, and quantity limits. Cost Sharing - The Donut Hole The prescription drug coverage gap, or donut hole, starts when your total drug costs—including what you and your plan have paid—reach $3,820 in 2019. In the past, most people had to pay the full cost of their drugs in the coverage gap. However, because of the Affordable Care Act (ACA), the government now helps you pay for your drugs in the coverage gap: in 2018, you will receive a 75 percent discount on brand-name drugs and a 63 percent discount on generics. These discounts will increase each year until 2020, when the coverage gap will close, and you will pay no more than 25 percent of the cost of your drugs at any point during the year. You get out of the coverage gap in 2019 when you have paid $5,100 in out-of-pocket costs for covered drugs since the start of the year. Your Medicare prescription drug plan should keep track of how much money you have spent out-of-pocket on your medications. This information should be printed on your monthly statements. You should keep your pharmacy receipts so that you can confirm that this information is correct. For more information, see The Part D donut hole. If you have Extra Help, the federal program that helps people with limited incomes pay the costs of Medicare prescription drug coverage, you will not have a coverage gap. See Medicare Interactive for Extra Help eligibility details. Learn more about the prescription drug donut hole and how you get out of it or related topics at www.medicareinteractive.org. -From Medicare Watch, Medicare Rights Center, Volume 3, Issue 12, March 29, 2012. Note: Medicare B covers drug costs in certain situations. Medicare Drug Coverage: Part D vs. Part B, Medicare Rights Center (updated January 2019). NOTE: Dual-eligibles receiving Medicaid Home and Community Based Waivers should have no co-pay for Part D drugs. Justice in Aging created an FAQ, Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, to give advocates working with dual eligibles the tools they need to prevent these co-pays. (Also see MGH Community News, September 2019)  Background/Historical Reference Documents The Donut Hole reduced by the Affordable Care Act - MGH Community News, December 2010, Rev. December 2018 Donut Hole Discount Program to begin in 2011- MGH Community News, May 2010 Income-Related Part D Premiums - MGH Community News, December 2010 Top of Page III. “Extra Help” Extra Help, also called the Medicare Low-Income Subsidy (LIS), is offered to those with a low income and assets. This will cover some or all of the patient costs under the Medicare D. Individuals AUTOMATICALLY qualify for Extra Help if they Are eligible for both Medicare and Medicaid (full dual-eligibles), Get help from their State Medicaid Programs to pay their Medicare premiums, or Get Supplemental Security Income (SSI) benefits Others Can Apply Individuals with income up to 150% FPL ($1,517.50 for an individual, $2,057.50 for couples in 2018*) and have limited resources ($13,640 for individual; $27,250 for a couple*- more detail at Extra Help Program Income and Asset Limits), but who do not automatically qualify for “Extra Help” can apply through Social Security, by calling 1-800-772-1213 or by visiting https://secure.ssa.gov/i1020/start. *Note: those with income/assets above these limits may still qualify because certain types of income and assets may not be counted. For example, part of earned income and the value of the house will not be counted. The amount of extra help you get depends on your income and resources (The Medicare Rights Center's Extra Help Program Income and Asset Limits factsheet includes corresponding assistance level details.) You still need to join a Medicare prescription drug plan for Medicare to pay for your drug costs. See What help can I recieve?, or you can call the Social Security Administration toll-free, 1-800-772-1213 for a paper application or to make an appointment.  If you are deaf or hard of hearing, call the toll-free TTY number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.  Tell the representative that you want to apply for the Help with Medicare Prescription Drug Costs.  Mediare Interactive's Extra Help Page Extra Help Redeterminations If one receives a recertification letter, it must be returned, even if there are no significant changes or one will lose Extra Help. If this does happen, one can reapply. See an Extra Help Redetermination case example- MGH Community News, December 2008 For more information about Extra Help, see Are Your Clients Missing Out on Enrollment in the Medicare Low-Income Subsidy? from MGH Community News, January 2018 Special Enrollment Period As of 2019, those receiving Extra Help are limited to changing their Part D plan once per calendar quarter in the first three quarters of each year. Any changes made during this special enrollment period are effective on the first of the following month. People with LIS may use the Fall Open Enrollment period during fourth quarter to make changes to their coverage, with changes effective January 1. For more information, see the Medicare Rights Center Open Enrollment guide.  Co-Pays Those receiving Extra Help will pay either the Extra Help copayment or their plan’s copay for their prescription drugs. They always pay the lower cost between the two. Note that plan copays for prescriptions may change during the year, meaning at times the price for prescription drugs may differ. For more information, including catastrophic coverage, see Medicare Reminder: Copays if You Have Medicare D “Extra Help”- MGH Community News, September 2018. Top of Page IV. Choosing and Joining a Plan: Choosing - Medicare Drug Plan Finder Tips for Using the Drug Plan Finder 10 Factors to Consider When Choosing a Medicare Drug Plan - From Elder Law Answers Joining (how & when): Signing Up For A Plan- AARP Open Enrollment Period- runs annually between October 15 and December 7 for coverage beginning in January of the following year. Top of Page V. Rights and Responsibilities under the plans- (83 page booklet – overall overview) Your Guide to Medicare Prescription Drug Coverage Appealing a Drug Denial- MGH Community News, March 2016 How to appeal- from Medicare Interactive Request a "Tiering Exception" - Case Flash from Medicare Rights Center Mid-Year Formulary Changes- MGH Community News, February 2016 CMS Announces New Rules That Will Complicate Part D Drug Formularies- MGH Community News, August 2018 Changing Plans mid-year and True Out-of_Pocket Costs (TrOOP) - Case Flash from Medicare Rights Center, 4/09 Medicare Advantage plans- Must now resolve disputes between Parts A, B and D seamlessly, 2/15 Medicare- Appealing an Income-Related Higher Part B or Part D Premium - MGH Community News, October 2017 VI. To Join or Not to Join?   Late enrollment penalty If you do not enroll in the Medicare drug benefit (Part D) when you first become eligible and you choose to enroll at a later date, you may have to pay a premium penalty. The late enrollment penalty does NOT apply to those with low-income (more). The premium penalty will be 1 percent for every month you delay enrollment (1 percent of the average national premium). For example, the average national premium in 2018 is $35.02 a month. If you delayed enrollment for 31 months, your monthly premium penalty would be 31% of $35.02, or $10.86, which will be added to your plan’s monthly premium. If you have to pay the premium penalty, and you do not qualify for full Extra Help, you will have to do so for as long as you are enrolled in the Medicare drug benefit. This penalty will increase every year, as the national average premium increases. In some specific circumstances you will not have to pay the premium penalty. You will NOT have to pay a premium penalty for late enrollment if: you already have prescription drug coverage at least as good as Medicare's ("creditable"). In order to avoid a premium penalty, you cannot have been without creditable drug coverage for more than 63 days. Speak with your insurer or your company's human resources department to find out if your current drug coverage is as good as Medicare's or better. For more information, see Medicare Reminder: Part D and Retiree Insurance Plans- MGH Community News, August 2018. you qualify for Extra Help and enroll in a Medicare private drug plan. you show that you received inadequate information about whether your drug coverage was creditable. -Above from Part D Late Enrollment Penalties Note: The late application penalty does not apply to those with low-income; it was eliminated as part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Every year, since Part D began in 2006, to encourage enrollment, Medicare has waived the late enrollment penalties for low-income beneficiaries. To ensure that this policy continues in the future, MIPPA permanently eliminates the Part D late enrollment penalty for low-income beneficiaries. Learn more about MIPPA Late Enrollment Penalty Tips When you become eligible for Medicare, you should enroll in a Part D plan unless you have other creditable prescription drug coverage. Creditable prescription drug coverage is coverage that is considered to be as good as or better than Part D. Your employer (or other entity providing prescription drug coverage) should inform you whether or not your coverage is creditable. If you do not receive this information, you should ask for it. Hold onto any notice of creditable coverage that you may receive. Keep this in a safe place just in case you have to prove your creditable coverage. If you have been without creditable drug coverage for more than 63 days while eligible for Medicare, you may face a lifetime Part D late enrollment penalty that must be paid or you will likely lose your coverage. Everyone has the right to appeal their penalty. A Medicare Rights Center “Ask Marci” column also addressed this topic and included this additional advice: If you drop or lose your creditable prescription drug coverage through no fault of your own, you will have a Special Enrollment Period (SEP) to sign up for Part D for up to 63 days after your coverage ends. If you drop or lose your current or former employer-based prescription drug coverage, regardless of whether it is creditable, you will also have an SEP to sign up for Part D for up to 63 days after coverage ends. In order to avoid a late enrollment penalty, this employer-based coverage must have been creditable. Those with Employer Plans- There may be consequences if you sign up for Part D in addition to your current drug coverage. You should ask your employer or retirement benefits administrator if you can keep their coverage and have Part D at the same time. You could lose your employer, retiree, or other benefits if you sign up for a Part D plan. It is important to keep this in mind if your plan covers a spouse or dependents because if you lose coverage, they will too, and it is unlikely you will be able to get the coverage back. The Five-Star Special Enrollment Period: Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans. For more information, see 5-star special enrollment period. More Information on Medicare Interactive Part D Late Enrollment Penalty Appealing the Part D Late Enrollment Penalty -See the original Medicare Rights Center blog post (October 2016) Joining (how & when): Signing Up For A Plan- AARP Top of Page VII. Special Situations Drug Company Programs ("Patient Assistance Programs")- 2005 article from The Boston Globe “Dual Eligibles”- Those who are eligible for both Medicare and Medicaid (MassHealth). Dual eligibles who don't have insurance through an employer, and aren't enrolled in programs such as PACE, SCO, OneCare, Medicare Advantage or a Medigap plan are required to enroll in Medicare D. They are automatically eligible for Extra Help, and co-pays cannot exceed what they would pay under MassHealth. Enrollment Letters sent to dual eligibles from the state- explaining 2005 switch from MassHealth to Medicare coverage of prescriptions- Sample enrollment letter. Health Safety Net (Formerly "Free Care") - Written by Partners' HealthCare Staff (2005) Hospice: Hospice covers drugs related to terminal condition, Part D non-related drugs (More at CMS Guidance on Medicare Part D vs. Hospice Coverage - MGH Community News, June 2014) Immunosuppressants- Medicare Reminder- Immunosuppressant Coverage- MGH Community News, April 2019 Medicare Health Plan (Medicare Advantage and Medicare Cost Plans) -from CMS Medicare Advantage plans- Must now resolve disputes between Parts A, B and D seamlessly- MGH Community News, February 2015 Medicare Assistance Programs (QMB, SLMB, QI) - from GBLS Medicare Advocacy Project (2014) Medigap - If one enrolls in the Medicare drug benefit (Part D), they cannot also have a Medicare supplemental insurance policy (Medigap) that offers drug coverage. As of 2006. when the Medicare drug benefit began, Medigap plans H, I and J, which offered limited drug coverage, are no longer sold. Off-Label Use Editorial: shortcomings of the compendia, and call to allow individual coverage decisions - MGH Community News, February 2009 New Rules for Off-Label Use of CANCER Drugs - MGH Community News, January 2009 Part D Fails to Cover Off-Label Prescriptions - MGH Community News, September 2007 Prescription Advantage - Fact Sheet (2006) Top of Page VII. For more Information for consumers and providers: 2006 Fact Sheet:  “Introducing Medicare's New Coverage for Prescription Drugs” Source: CMS AARP: Medicare Part D (2019) The New Medicare Prescription Drug Coverage What You Need to Know (2005) “Medicare & You” – To get a free copy of a state-specific book, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Also see: Medicare Drug Coverage Medicare Plan Finder Medicare Interactive (from the Medicare Rights Center) Part D Coverage Overview “Your Guide to Medicare Prescription Drug Coverage”, from the Centers for Medicare and Medicaid Services (CMS)- 88 pages, best single source for detailed information. Medicare Advocacy Project (MAP) helps Massachusetts residents’ secure Medicare coverage. MAP provides free legal services to individuals in a Medicare plan or individuals having problems with Medicare enrollment. Contact MAP: Greater Boston Legal Services Essex, Middlesex, Norfolk, and Suffolk counties 197 Friend St. Boston, MA 02114 617-603-1700; 800-323-3205 South Coastal County Legal Services Bristol and Plymouth counties 231 Main St., Suite 201 Brockton, MA 02302 800-244-8393; 508-586-2110 Fall River 22 Bedford St., 1st Floor Fall River, MA 02720 800-287-3777; 508-676-3777 Barnstable, Dukes, Nantucket, and Plymouth counties 460 West Main St. Hyannis, MA 02601 800-742-4107; 508-776-7020 Community Legal Aid Berkshire, Franklin, Hampden, Plymouth, and Worcester counties 405 Main St., 4th Floor Worcester, MA 01608 1 Monarch Pl., Suite 400 Springfield, MA 01144 20 Hampton Ave., Suite 100 Northampton, MA 01060 152 North St., Suite E-155 Pittsfield, MA 01201 All offices: 855-252-5342 VIII. Detailed Information for providers: “Your Guide to Medicare Prescription Drug Coverage”, from the Centers for Medicare and Medicaid Services (CMS).  88 pages, best single source for detailed information. Medicare Access for Patients-Rx (MAPRx) Kaiser Family Foundation Also see:  Medicare D News Articles