What You Need To Know About Medicare Part D Pharmacy Outreach Program The University of Rhode Island College of Pharmacy
Updated October 2021
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
○
Medical Insurance
○
Medicare Advantage Plans
○
Prescription Drug Coverage
● Part B ● Part C ● Part D
Medicare Part D ● Stand-alone prescription drug coverage ● Open to all people eligible for Medicare ● Open enrollment begins October 15, 2021 ○ ○
Enrollment for coverage of the year 2022 ends on December 7, 2021 Coverage begins on January 1st, 2022
● Medicare Part D is VOLUNTARY!! ○
But penalties may apply
Medicare Part D- What’s New? ● Part D Senior Savings Model ○ ○ ○
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You may be able to join a drug plan that gives supplemental benefits for insulin starting J anuary 1, 2022 (join during standard open enrollment). The Part D Senior Savings Model is available to all people with Medicare. Plans that participate in this model will offer coverage choices that include multiple types of insulin at a maximum copayment of $35 for a 30-day supply, even through deductible, initial coverage, and coverage gap phases. ○ Each plan must include at least one vial and one pen form of each type of insulin (rapid, short, intermediate, and long acting) People who enroll in a participating plan could save up to $446 a year in out-of-pocket costs. Visit Medicare.gov/plan-compare/ to find a participating plan in your state. This plan model becomes effective on January 1, 2022 and extends until December 31, 2025
What If I Like My Current Plan? ● If you are happy with your current part D plan, you do NOT have to change anything during the re-enrollment period! ○ ○ ○
Your Med D plan will automatically re-enroll you. But be aware….. your premiums, co-pays, formulary, or deductible may be changed for the new year! Always check to make sure!
Who Should Apply ● People who are enrolled in a Med D plan right now but are 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: 1% increase in premium for every month not enrolled ○ Longer you wait the higher the penalty when you do ● Enrolled in a Medicare Advantage Plan or Medigap Supplemental Insurance Plan but you want to add or change your drug coverage ● If you like your current plan, still good to check for any changes in premium, deductible, if it still exists!!
Who Does Not Need To Apply ● If you have CREDITABLE Coverage: ○
Creditable Coverage = a plan that provides a prescription drug benefit that is EQUIVALENT or better than Medicare Part D coverage
● 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 Information ● If you did not enroll but were eligible to do so ○ ○
When you enroll late for coverage beginning on Jan.1, 2021 – you will incur a penalty of a premium increase of 1% per month that you were eligible The national base beneficiary premium may change each year, so penalty amount may also change each year.
● Will have to wait until 2022 enrollment period to join a Medicare drug plan if don’t do so now! ○ ○ ○ ○
Projected Average premium 2021 = $33 per month 1% of $33 = $0.33 12 months penalty= $3.96 Therefore, $4.0 will be added on to your monthly premium every month forever if you wait until 2022 to enroll!
Penalty Information (Continued) ● You will NOT have this penalty enforced: ○ ○ ○
If you were not previously eligible for Medicare Part D If you previously had creditable coverage Qualify for an extra help program (Medicaid, SSI)
Initial Enrollment Period ● What if my 65th birthday does not fall within the enrollment window? ○
7 month penalty-free period when turning 65 ■ 3 months before turning 65 ■ Birthday month ■ 3 months after turning 65
● If not enrolling within these 7 months, will incur the late enrollment penalty
How Does Medicare Part D Work? ● Step #1: The Deductible ○ ○
You pay 100% and plan pays 0% You pay at most $480 and receive the same worth of medications
● Step #2: Initial Coverage ○ ○
You pay 25% and plan pays 75% Once total spending hits $4,430 you enter the coverage gap
How Does Medicare Part D Work? ● Step #3: Coverage Gap ○ ○
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Pay 25% of brand and generic medications Enter catastrophic coverage once total out of pocket spending hits $7,050. The cost of your meds can increase, decrease, or stay the same based on your plan's previous cost sharing and the drug's retail price
How Does Medicare Part D Work? ○ Step #4: Catastrophic Coverage ○ ○ ○
You pay $3.95 for generic medications with a retail price of <$79 or 5% with a retail price >$79 You pay $9.85 for brand name medications with a retail price of <$197 or 5% for those >$197 For low income individuals, maximum prices will be $3.95 for generics/preferred medications or $9.85 for all others
Coverage Gap Special Considerations ● If retail average of monthly medications exceeds $587.50, you will most likely enter the coverage gap at some point ● Hitting the $7,050.00 threshold varies per person ● You will receive a 70% discount from manufacturers for brandname medications ● Example: Using brand name inhaler with $100 retail value ○ You pay 25%= $25, but manufacturer has a 70% discount=$70 ○ Ends up with $95 contributing to $7,050.00 threshold
Remember! ● Even though you were enrolled in a program last year, you start from the Step #1 all over again on J anuary 1, 2022 ● You will continue to pay the premium every month regardless of what step that you are on
Plans Available in RI for 2021 ● Total of 21 stand-alone prescription plans offered ● 7 with Medicare prescription drug plans ● 14 with Medicare Advantage with prescription drug coverage that offer lower out-of-pocket insulin costs through the Part D Senior Savings Model
● Also 24 Medicare Advantage plans with prescription coverage ● All Medicare patients are eligible to enroll in a Medicare Advantage Plan ● Cheapest premium starts at $7.40
How to Find Plans ● Get a complete list of your medications ○
Include ALL prescriptions: eye drops, creams, inhalers, patches, etc.
● Go to Medicare.gov/plan-compare ○
Follow the prompts and enter your medications
● Can also call 1-800-MEDICARE (1-800-633-4227) ● Can enroll online—have your Medicare card ready ● CVS and Walgreens both have websites to condense your search of possible plans
What You Will See...
www.medicare.gov
How Do I Choose The Right Plan? Rx Enrollment Check-Up: ● Cost ○
Will your premium and costs change in 2022?
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Will you need more comprehensive coverage? Will your current meds be covered by your plan? Now that donut hole is essentially closed, is switching a better option?
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Are you satisfied with your service from your current plan?
● Coverage
● Customer Service
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 ● ● ● ● ● ● ● ●
Non-FDA approved drugs Weight loss or gain Erectile dysfunction Drugs for cosmetic purposes (hair growth) Non prescription drugs (over-the-counter medications) Cough & cold relief Fertility drugs Prescription vitamins, minerals ○
Except prenatal vitamins and fluoride preparations
Ways to Lower Your Drug Costs ●
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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 Use GoodRx internet coupons Walmart $4/$10 list Pharmaceutical Assistance Programs ○ Available from the pharmaceutical manufacturers ○ Contact the Partnership for Prescription Assistance ■ 1-888-477-2669 Apply for Extra Help ○ If you have limited income and resources, you may qualify for extra help ○ For more information go to www.socialsecurity.gov or call 1-800-772-1213
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 unless you are absolutely certain that they need it. Never share your Medicare information over the phone with someone else! ■ Especially if you did not call them.
Important Dates to Remember ● October 15, 2021: Open Enrollment Begins ● December 7, 2021: Open Enrollment Ends ● January 1, 2022: Coverage Begins
Summary ● No single plan is best for everyone ○ ○
You must pick the plan that’s right for YOU! Make sure to enroll between Oct 15 – Dec 7, 2021
● 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 email: reachrx@etal.uri.edu ■ www.uri.edu/pharmacy/outreach
Thank You! Pharmacy Outreach Program The University of Rhode Island College of Pharmacy email: reachrx@etal.uri.edu www.uri.edu/pharmacy/outreach