Medicare: Choose or Lose

Airs on Channel 9 March 2 at 9:00 p.m. (repeated March 4 at 2:00 a.m., March 14 at 9:00 p.m. and March 16 at 2:00 a.m.), Medicare: Choose or Lose offers seniors and their families easy-to-follow assistance to navigate Medicare Part D (also known as Medicare Rx). Produced by Channel 9 and hosted by Patrick Murphy, the show will answer the most frequently asked questions about Medicare Part D and talk to pharmacists, health-care providers, insurance representatives, and others who know the most about how the plan will affect seniors in different circumstances.

Important Dates to Remember Ten FAQs and Answers Resources for More Information and to Enroll
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Important Dates to Remember:

November 15, 2005-May 15, 2006: Open Enrollment for Medicare Part D.

January 1, 2006: The Medicare Part D Prescription Drug Benefit goes into effect.

May 15, 2006: The existing Medicare approved drug discount card ends (or this card expires when new Medicare Part D coverage begins, whichever comes sooner).

May 16, 2006: Monthly premiums will increase 1% per month after the end of the Open Enrollment period.

November 15, 2006-December 31, 2006: The Annual Coordinated Election Period (new plans are effective January 1, 2007).

Ten Frequently Asked Questions and Answers:

1. Why couldn’t I get my prescriptions filled?

Common Reasons:
a. It wasn’t on your Medicare Prescription Drug Plan’s formulary.
b. You didn’t go through go through a “step therapy” protocol
i. Your physician didn’t get prior approval from your Medicare Prescription Drug Plan for you to take the medication prescribed for you.
ii. The specific medication dosage or route of administration (liquid vs. pill) or type (generic vs. brand name) wasn’t in your Medicare Prescription Drug Plan’s formulary.
c. You can’t afford the cost-sharing amounts that your Medicare Prescription Drug Plan imposes on the drug your doctor prescribed for you.
d. Your Medicare Prescription Drug Plan removed the drug your doctor prescribed for you form the plan formulary in the middle of the year, and you can’t change to another plan.
e. The pharmacy you went to wasn’t in your Medicare Prescription Drug Plan’s network
f. The drug your doctor prescribed isn’t a Medicare Prescription Drug Plan covered drug.

Step Therapy: Alternative measures taken by the plan to help reduce cost. This includes substitutions for preferred, generic or less costly drugs; dosage limitations (that is, you only get 30 pills a month when your doctor has prescribed 60 per month); and prior approval that the doctor must get from the Medicare Prescription Drug Plan before the prescription can be filled.

2. The medicine my doctor prescribed is not on my Medicare Prescription Drug Plan’s formulary. What should I do?

a. You can talk to the doctor to see if there is an equivalent medication in the plan’s formulary that your doctor believes would work as well for you and the doctor is willing to prescribe for you.
b. If your doctor believes that you must have the medication that is not in your Medicare Prescription Drug Plan’s formulary, you will need to request a Formulary Exception from your Medicare Prescription Drug Plan
Formulary Exception: A process used to determine whether or not a plan will agree to accept a medication that is not currently on the Plan’s preferred list of medications. Details on how to file an exception is in each Medicare Prescription Drug Plan’s enrollment packet.

3. What happens if my Medicare Prescription Drug Plan removed the drug my doctor prescribed from the plan formulary or increased the amount I must pay for my medication in the middle of the year and I can’t change plans?

a. Your Medicare Prescription Drug Plan must give you a written notice at least 60 days before the change becomes effective. Your doctor should also be notified. The notice will say:
i. What change is being made and reason for the change
ii. The names of other drugs in the same category, class and cost-sharing level as the drug plan that is changing.
b. You can talk with your physician to see if you can get an equivalent medication on the plan’s formulary.
c. If your physician believes you must stay on that prescription, you can request a Formulary Exception from the plan.

4. Are there any medications that are not on the covered by the Medicare Prescription Drug Program?

a. Yes, these are:
i. Drugs prescribed for weight loss or weight gain
ii. Drugs prescribed for symptomatic relief of coughs and colds
iii. Prescription vitamins, with the exception of prenatal and fluoride
iv. Over the counter drugs
v. Drugs prescribed to promote hair growth
vi. Fertility drugs
vii. Cosmetic drugs
viii. Drugs that must be monitored by testing services that only the manufacturer provides, such as certain anti-psychotic medications
ix. Barbiturates (drugs used to control seizers or used for sedation or anesthesia such as Phenobarbital or Nembutal, and
x. Benzodiazepines, often referred to as minor tranquilizers, used to treat anxiety or insomnia (such as Xanax, Valium, Ativan)

5. Should I join a Medicare drug plan even if I don’t take many prescription drugs?

Joining a Medicare Prescription Drug Plan is your option. You need to be aware that if you do not join a plan by May 15, 2006 and you currently do not have any other prescription drug coverage that is considered to be creditable, you could be penalized 1% of the premium for each month after May 2006 that you’re not enrolled. For example if you do not enroll until November 2006, you will always have to pay a 6% higher premium.

6. When and how often can I switch my Medicare drug plan?

a. Generally you can only change plans under certain circumstances. You can choose to switch your current plan from November 15 through December 31 of every year. Any change made during that time period will take effect on January 1 of the next year.
b. In certain cases, such as if you move or enter a nursing home, you can switch you plan at other times.
c. If you have both Medicare and Medicaid, you can change plans at any time and that change will take effect the beginning of the next month.

7. If I qualify for extra help, will my drug plan premium always be $0

No. The amount of extra help you qualify for will be based on your income and resources, and your total premium will depend on the plan you join. Some people who qualify for extra help, there will be plans available in which you would pay no premium. There are other plans where you may have to pay a discounted premium. This means if you qualify to pay a discounted premium, you will have to pay a percentage of the drug plan premium, no matter which drug plan you join.

8. I’m turning 65 in August. When should I enroll in a Medicare Prescription Drug Plan?

Your initial enrollment period into a Medicare Prescription Drug Plan is the same as your initial enrollment period into Medicare. It is seven months surrounding your 65th birth month; three months before your 65th birth month, the month of your 65th birth month, and three months following your 65th birth month.

9. Should my spouse and I join the same plan?

The plan you join should be based on your individual prescription needs and not on the needs of another person. You and your spouse should only join the same plan if that plan meets both of your individual needs.

10. I’ve heard that I may have a gap in my Medicare Prescription Drug coverage. What does that mean?

The gap in coverage refers to a period when you are responsible for 100% of your drug cost. Typically this occurs when you and your plan have reached $2,250 in drug costs. The amount you pay during the gap can very between plans. It is important to check with your plan to find out what your cost will be during your coverage gap.

Resources:

For Comparing Plans:

1. www.medicare.gov
2. Medicare and You handbook
3. 800-MEDICAR(e)

For enrolling in a plan:

1. www.medicare.gov
2. Call 800-MEDICAR(e)
3. By phone, mail or fax through chosen provider

Missouri: Helpful State Contacts:

Area agency on Aging Offices for Missouri Residents:

St. Louis City:
St. Louis Area Agency on Aging
634 N. Grand, 7th Floor, St. Louis, MO, 63103
Phone: 314-612-5918; Fax: 314-612-5915

Missouri Counties of St. Louis, St. Charles, Franklin and Jefferson:
Mid-East Area Agency on Aging
14535 Manchester Road, Manchester, MO, 63011
Phone: 1-800-243-6066; Fax: 636-207-1329

Area Agency on Aging Offices for Illinois Residents:

For Illinois Counties of Bond, Clinton, Madison, Monroe, Randolph, St. Clair, Washington:
Area Agency on Aging of Southwestern Illinois
2365 Country Road, Belleville, IL, 62221
Phone: 618-222-2561; Fax: 618-222-2567

Website: www.answersonaging.com

Other Resources:

Missouri Department of Health and Senior Services:
www.dhss.mo.gov/seniorservices/
800-835-5465
Local Area Aging Agencies can be found at the contacts above, or by visiting www.eldercare.gov or calling 800-677-1116

State Health Insurance Assistance Program (SHIP):
SHIP offers free, one-on-one, local counseling to people with Medicare and their families.

Community Leaders Assisting the Insured of Missouri (CLAIM):
www.missouriclaim.org
800-390-3330
Local SHIP counselors can be found at the contact above, or by calling 800-677-1116, or by visiting www.shiptalk.org or www.eldercare.gov

State Insurance Commissioner
This office has information about insurance plans and costs. They often have special resources for seniors.

Missouri Department of Insurance
www.insurance.mo.gov
800-726-7390

State Medicaid Office
This office manages the state's Medicaid program. They also handle Medicaid enrollment.

Missouri Medicaid Program
dss.missouri.gov/dms/recipients.htm
800-735-2466

State Prescription Assistance Program
A program to help you reduce the cost of your prescription drugs.

Missouri Senor Rx Program
www.dhss.mo.gov/moseniorrx
800-375-1406

State Protection & Advocacy (P&A) Agency
This agency protects the legal rights of people with disabilities, including people on Medicaid.

Missouri Protection and Advocacy
www.moadvocacy.org
800-392-8667

Access to Benefits Coalition Members
Coalition members educate and enroll people in different prescription drug programs, including Medicare. These independent local groups belong to a national network. The agencies below serve only the areas listed:

The Kansas City Partnership for Caregivers
816-960-1083
Clay, Jackson, and Platte counties

Area Agency on Aging of Southwestern Illinois
800-326-3221

Centers for Medicare & Medicaid Services (CMS) Regional Office Outreach Campaign Manager
CMS Regional Offices play a key role in conducting outreach for the new Medicare Prescription Drug Benefit. Each office has a team dedicated to helping raise awareness and educate about the new coverage. Contact the regional campaign manager to learn more about local outreach events, schedule an event in your area, or request outreach materials

Region VII: Kansas City
Campaign Manager: Kathryn Coleman
816-426-6518