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Pharmacy Outreach Program The University of Rhode Island College of Pharmacy Updated October 2011

MEDICARE  Medicare provides health insurance for…  Aged 65 years or older  Aged 65 years or less with certain disabilities  All people with End-Stage Renal Disease (ESRD)  All people with Lou Gehrig’s Disease (ALS)

THE PARTS OF MEDICARE  Part A  Hospital insurance  Part B  Medical insurance  Medicare Advantage Plans

 Part D  Prescription drug coverage

Medicare Part A  Covers:  Inpatient hospital care  Skilled nursing facilities (Under

certain conditions)

 Typically doesn’t require a monthly

payment (Premium)  Does require out-of-pocket deductible for

hospital stays (in 2011):  $1,132 of 1-60 days  $283 per day co-pay for days 61-90  $566 per day co-pay for days 91-150  All costs beyond 150 days  For skilled nursing facilities:  $141.50 per day for days 21 through 100 for each benefit period

 Helps cover:

Medicare Part B

Physician services  Durable medical equipment  Physical therapists 

 Also covers other services and

supplies: Glucose monitors  Test strips  Lancets 

 There is a monthly premium to enroll  The standard Part B premium for 2011 is

$115.40 per month (income based)  In general, automatically deducted from social security checks  Once deductible is paid enrollee generally pays a 20% co-payment for each service 

2012 deductible $162

Medicare Advantage (Part C) ď‚— Health insurance

coverage, including preventative care PLUS prescription drug coverage in a single plan ď‚— In exchange, typically

must use a certain network of doctors, hospitals, and pharmacies (HMO, PPO)

Medicare Advantage  7 plans available in Rhode Island

 If you already have a Medicare

Advantage plan and you want to add drug coverage you MUST obtain it through your Medicare Advantage provider.  If you obtain an independent standalone

drug plan instead, your health coverage under the Medicare Advantage plan will stop.

Medicare Advantage  New Annual Enrollment Period in 2011  October 15-December 7, 2011  Can choose to leave current Medicare Advantage plan to

switch to an Original Medicare plan  Can add prescription coverage - Part D

 Will run from January 1, 2011 through February 14, 2012  Remember! Can only disenroll during this period!

MEDICARE PART D  Stand-alone prescription drug coverage  Open to all people eligible for Medicare  Open enrollment begins October 15, 2011  Enrollment for coverage of the year 2012

ends on December 7, 2011  Coverage Begins on January 1st, 2012

 Medicare Part D is VOLUNTARY!!

When Can I Enroll in a Part D Plan?  Re-enrollment begins October 15th, 2011!  Your new plan will take effect January 1st, 2012  If you are happy with your current part D plan, you

don’t need to do anything during the re-enrollment period!  Your Med D plan will automatically re-enroll you

your premiums, co-pays, formulary, or deductible may be changed for the new year!

 But be aware:::::

Enrollment Info  NEW Open enrollment is from

Oct 15 – Dec 7th 2011 of each year  Dates just changed

 Coverage begins on January 1, 2012  If you become eligible for Medicare

Part D after the enrollment period, you have a 7 month period to enroll without incurring a penalty  3 months before, the month of and 3 months after the month of your 65th birthday

Who Should Apply?  People who are enrolled in a Med D plan right now,

but thinking about switching to another plan next year  You didn’t sign up for a plan when eligible

last time around but you’re thinking of enrolling now  Penalty for every month without coverage

 Enrolled in a Medicare Advantage Plan or Medigap

Supplemental Insurance Plan but you want to add or change your drug coverage  People who have major changes in the medications

they take on a daily basis

Who Doesn’t Need To Apply  If you have CREDITABLE Coverage:  This means that you already are enrolled in a plan that provides a

prescription drug benefit that is EQUIVALENT or better than that being offered through Medicare Part D

 You would have already been made aware of

this by your insurance provider by mail  KEEP THIS LETTER IN A SAFE PLACE** **If you are unsure if your coverage is creditable or not, ask your employer or union for it!**

Penalty Info  If you did not enroll but were eligible to do so,

when you enroll now for coverage beginning on Jan.1, 2012 – you will incur a penalty of 1% per month of average premium  Will have to wait until 2012 enrollment period to

join a Medicare drug plan if don’t do so now!    

Average premium 2012 = $36.92 1% of $36.92 = $0.37 12 months penalty= $4.44 Therefore, $4.44 will be added unto your monthly premium every month forever!

Penalty Info You will not have this penalty enforced: ď‚—

If you were not previously eligible for Medicare Part D


If you previously had creditable coverage

Affordable Care Act Changes  Lower costs during donut hole:  Patients pay 50% of brand name drugs  Discount of generic drugs will raise from 7-14% this year  Better Quality care:  Bonus payments from the government will give incentives to Medicare Advantage plans with better quality care

HOW PART D WORKS  Remember::: this is just an explanation of the

template used as a general basis for the plans --there are options!  STANDARD PLAN (2012)  $36.92 per month premium ($443.04)  $320 deductible  75% coverage from $320 to $2,930  New limited coverage from $2,930 to $6657.50 

Patient pays 50% of Brand Drugs and up to 86% of generic drugs This is called the coverage gap or “Donut

 95% coverage beyond $6657.50


HOW PART D WORKS Catastrophic Coverage > $6657.50

Medicare Pays 95% 5%

Donut hole - $2930 – $6657.50


Co-Insurance : $320-2930


0 - $320 is your Deductible

You Pay 100%


New Change for Donut hole, will only spend 50% out of pocket for brand name and 86% maximum for generic drugs!!!

Think of it as Steps!  Step #1 – The Deductible  You pay 100% and plan pays 0%  You receive $320 worth of medications

Medicare Pays 95% 5%

 Step #2 – Co-insurance  You pay 25% and plan pays 75%  You receive $2610 worth of medications (Total: Step 1 + Step 2 = $2930)



You Pay 100%


Think of it as Steps!  Step #3 – The Donut Hole  New changes let you pay  

50% of brand drugs Max of 86% generics

 You receive $1770 worth

of medications  Total: Step 1 + Step 2 + Step 3 = $6657.50  New discounts!

Medicare Pays 95% 5% 50%-86%

 Step #4 – Catastrophic

Coverage  You pay 5% and plan

pays 95%  You receive unlimited drugs for the remainder of calendar year


You Pay 100%


Remember! 

Even though you were enrolled in a program last year, you start from the Step #1 all over again on January 1, 2012

You will continue to pay the premium every month regardless of what step that you are on  Even when in the ―donut hole‖ a

person still pays the monthly premium!

Besides Standard Plan…  Must offer basic/standard drug benefit  May offer enhanced benefit 

 Some have no deductible  Some have help during ―donut hole‖

(coverage gap)

 The Premium depends on the enhancements  Mail order options may save costs on

maintenance medications (90 days)

Explaination of Benefits  A statement sent by your insurance company telling

you which medical services were paid for by them.  Includes:  The service: date/place service provided  Doctors fee and what was paid by them  Remainder that the patient is responsible for

 To show you what portion the insurance is paying for

and which portion you are.

How Do I Choose The Right Plan? Rx Enrollment Check-Up: Cost  Will your premium and costs change in 2012?

Coverage  Will you need more comprehensive coverage?  Will your current meds be covered by your plan?  Now that donut hole is partially covered, is switching a better option? Customer Service  Are you satisfied with your service from your current plan?

Side Note: ď‚— If you decide that your

current Med D plan will meet your needs in 2012 then you do not need to re-enroll ď‚— Coverage will continue

through 2012 starting from Step 1

Plans Available in RI for 2012  Total of 30 prescription plans offered  14 plans available with NO deductible!  23 Plans without gap coverage  Monthly premiums start at $15.10 (Humana Walmart Preferred plan)

 7 Plans with gap coverage  Monthly premiums start at $65.80 and go up to $110.20  Lowest premiums have only generic coverage  All Medicare patients are eligible for a Medicare

advantage plan

What is a Formulary?  Formulary system  Each plan selects certain drugs

from each drug class that they will cover  May have a tier system  May have up to 5 tiers  Generic drugs = cheapest (ex: $5)  Preferred brand names = more expensive (ex: $28)  Non-preferred brand names = most expensive (ex: $40)  Certain injectable and specialty drugs= highest tiers (ex: $58)

Drugs Not Covered Under Most Part D Formularies  Benzodiazepines

 Drugs for cosmetic

 Barbiturates

purposes or hair growth  Fertility drugs  Prescription vitamins, minerals

 Weight loss  Erectile dysfunction

 Cough & cold relief  Non prescription


 Except prenatal vitamins

and fluoride preparations

Definitions:  Generics: will be required to be covered by ALL plans  Chemically identical to brand-name drugs and meet the same rigorous standards put

forth by the FDA (US Food and Drug Administration) for: Safety, Purity, Effectiveness  Generic drugs can be legally produced in the US if a patent has expired, or for drugs which have never been patented

 Prior authorization: may be needed for some medications  Appeal process mandated by insurance company which includes paperwork

involving the MD

 Step Therapy: may be required before certain medications will be covered  ex: Prilosec before Nexium, or Motrin before Celebrex

 Quantity limits: may be enforced  30 day quantities retail vs. 90 day mail-order 

Some plans DO allow 90 day quantities of maintenance medicines at community pharmacies.

Frequently Asked Questions

Who pays for my vaccines?  Now Medicare part D must

cover all vaccines not covered by part B  Ex: Zostavax (Shingles vaccine)

 Vaccines covered by part B  Pneumococcal  Influenza  Hepatitis B  Vaccines necessary to treat a

disease or prevent one after direct exposure 

Ex: tetanus

WHAT ABOUT MY RIPAE?  You SHOULD keep your RIPAE!  It will provide coverage throughout the deductible & coverage gap  BUT, it is not creditable coverage  You need a Medicare Part D Plan too  RIPAE is only available for those enrolled in a Medicare

part D plan  Must send in copy of enrollment letter or card

 See your SHIP counselor or call The Point for RIPAE


RIPAE…  Provides extra benefit for those who don’t

qualify for extra help from Medicare  Applicable to all expenses that

person is 100% responsible for:  Deductible  Coverage gap (―Donut Hole‖)  Drugs not covered under your Part D Plan 

Only certain ones!

RIPAE…  Eligible:  Single, income less than $45,991 per year  Married, income less than $52,561 per year 

The lower the financial category, the higher percentage RIPAE will pay

More information: 401-462-4444 The Point Wrong phone number on Medicare & You 2008 Booklet!

Talk to SHIP counselor

What About My Tricare, VA, Pension Benefits?  They are creditable coverage,

letters have been sent in mail!  Hold on to these letters!

 Contact your pension benefits

manager or union if you have any questions

Dual Eligibles (Medicare/Medicaid)  Will automatically be eligible for:    

No premium No deductible No donut hole Minimum co-payments ($1.10 generic & $3.30 brand)

 Have been automatically enrolled in a plan

& will be automatically re-enrolled in a plan  Part D plan for 2012 won’t necessarily

be the same plan as 2011

 Reassignment notices are being sent out  Enrollment confirmations will follow  If you are “dually eligible,” you can change your

plan at any time during the year! Once per month!

What is Extra Help? (Low Income Subsidy)  Federal poverty limits determined by government each year  Best to apply and be formally denied  Many deductions, so apply!

 In order to be eligible, a person’s resources

must be no greater than the limits established Single*


Yearly Income






*Includes $1,500 per person burial expenses

“Deemed” Population  Defined as those who had Low Income Subsidy

(LIS) for 2011 & are not automatically eligible for 2012  Notifications being sent out with applications to re-enroll

 Does not mean that you are not eligible  Reapply!!!  Check with your SHIP counselor or The Point

Ways to Lower Your Drug Costs During the Coverage Gap 

Ask your doctor about generic and less expensive brand name drugs (therapeutic substitutions)  

 

Cheaper in the gap Less likely to hit the gap if avoid brand name medications from the beginning!

Ask your doctor for samples Pharmaceutical Assistance Programs  Available from the pharmaceutical manufacturers  Contact the Partnership for Prescription Assistance 


Ways to Lower Your Drug Costs During the Coverage Gap 

State Pharmaceutical Assistance Programs 


Based on your income, RIPAE will pay 15%, 30%, or 60% of drug cost during coverage gap

Apply for Extra Help 

If you have limited income and resources, you may qualify for extra help For more information go to or call


New Medicare Changes  Cut in half the prescription drug

expenses of those who fall into the dreaded Part D donut hole!  This means you only pay 50% of the

cost of brand-name medications in the gap – instead of the 100% in previous years  14% discount for covered generic drugs  Earlier enrollment: Oct 15 – Dec 7 2011

What if I Like A Plan & One of My Drugs is Not Covered?  Options:  Ask your pharmacist about therapeutic substitution  Compare prescription vs. over-thecounter (OTC) options   

Nexium $158.00 Prilosec OTC $21.99 Omeprazole Rx- lowest cost or co-pay

 Always consult with your doctor

regarding changes to your medications

Drugs that are Not Covered by ANY Part D Plan  Can still get these drugs but must pay the retail

price (“cash”) and it does not count towards out of pocket expenses or total drug costs Examples:  Benzodiazepines 

alprazolam, lorazepam, diazepam

 Drugs for weight loss, hair loss, and fertility  Drugs covered under Medicare parts A and B 

Example: Drugs received while in the hospital, diabetic testing supplies

Medicare Fraud  The vast majority of your health care providers are

committed to providing you with high quality care…

 However, there are some individuals who cheat the

system out of millions of dollars, which results in higher premiums for its members.  Be very cautious when dealing with your Medicare information, &

never share it with a medical professional unless you are absolutely certain that they need it.  Never share your Medicare information over the phone with someone else!

Using the Internet  Get a complete list of your medications  Include all prescriptions-eye drops, creams, inhalers, patches, etc.

 Go to and click on “Formulary Finder”  Follow the prompts and enter your medications

 Can also call 1-800-MEDICARE (1-800-633-4227)  Can enroll on line—have your Medicare card ready  CVS and Walgreens both have websites to condense your

search of possible plans  Rite Aid has plan finding software, just call your Rite Aid pharmacist and schedule a time to choose a plan

Important Dates to Remember October 1- Compare and Prepare October 15- Open Enrollment Begins December 7- Open Enrollment Ends January 1, 2012- Coverage Begins

In summary….  No single plan is best for everyone  You must pick the plan that’s right for YOU!

 Yes, it is confusing! Don’t be afraid to ask for help:  The Point!!! (401) 462-4444  SHIP counselors at your local Senior Center  Dept. of Elderly affairs (401) 462-4000  Ask a relative or friend to help you navigate the Web

 Social Security Administration 1-800-772-1213  Pharmacy Outreach Program 1-800-215-9001 


Medicare Part D  

Overview of Medicare Part D for 2012