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Accessing the Medicare Prescription Drug Plan

April/May 2006

Learn More

FACT Sheet: Medicare and HIV/AIDS. Henry J. Kaiser Family Foundation (October 2004)

Policy and Politics: Medicare Prescription Drug Coverage. Article from the Bulletin of Experimental Treatments for AIDS (BETA), Summer 2005

Medicare Part D Drug Benefit: What You Need to Know. American Academy of HIV Medicine

The New Medicare Prescription Drug Law: Issues for Dual Eligibles With Disabilities and Serious Conditions. Kaiser Commission on Medicaid and the Uninsured, June 2004

Additional Resources

Medicare's official website allows you to learn more about Part D and the prescription plans available to you.

Medicare Rights Center (MRC) is the largest independent source of health care information and assistance in the United States for people with Medicare.

Social Security Administration is offering a low income subsidy to individuals on Medicare to help them pay for the additional costs of the prescription drug plans.

As the final days of the first enrollment period for the new Medicare prescription drug plan grow closer it is important to review the facts to understand what Medicare Part D is, understand how to choose the best plan for your health care needs, and be aware of the costs associated with this new coverage. The following questions and answers where developed as a tool to help individuals become informed about Medicare Part D.

The Basics

What is Medicare prescription drug coverage?
Medicare prescription drug coverage (Medicare Part D) is insurance that covers both brand-name and generic prescription drugs. Eligible individuals may choose the plan that meets their needs to help them access their medications.

Who can get Medicare prescription drug coverage?
Everyone with Medicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses. Medicare eligible individuals who do not have credible coverage, prescription drug coverage that is at least as good as a Medicare prescription drug plan, should enroll in a Medicare prescription drug plan.

When can I get Medicare prescription drug coverage?
The first enrollment period ends May 15, 2006. If you don't sign up by May 15, 2006, you may pay a penalty. After that, yearly enrollment is from November 15 to December 31.

How does Medicare prescription drug coverage work?
Like other insurance, if you join, you will pay a monthly premium, which varies by plan, and a yearly deductible (no more than $250 in 2006). You will also pay a part of the cost of your prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible.

Choosing a Medicare Part D Plan

Are your drugs covered -- or not covered?
Medicare Part D covers all FDA-approved drugs except the following: drugs covered under Medicare Part A and B and seven categories of what are called excluded drugs. Those drugs considered within the excluded category most relevant to HIV care are those used for weight gain or loss, over the counter drugs, vitamins and minerals, and benzodiazepines, which are drugs commonly used to treat anxiety, to produce sedation, or as a muscle relaxant.

The Medicare Part D drug plans have the flexibility to determine what drugs to cover and at what cost. A list of the plans covered drugs is called a formulary. Before choosing plan you will want to make a list of all the drugs you are currently taking and enter them in the formulary finder at By doing this, you will know if your drugs are covered and a general idea of cost sharing. Plans using formularies are required to include at least two drugs in each class however, all Medicare Part D drug plans are required to cover all drugs included in the antiretroviral class so that individuals who are HIV-positive will have access to every FDA approved antiretroviral.

What if a drug is not included on the formulary?
If a specific drug is not included on your formulary or it is included but the cost-sharing is at a high cost co-pay tier, then the patient may submit an appeal to the insurance company if you and your doctor determine the drug is medically necessary. Insurance companies must make a decision on appeal requests within 72 hours.

Medicare Part D Costs

What are the costs associated with Medicare Part D?

  • Monthly Premium: This is the cost of the prescription drug plan on a monthly basis. The 2006 average is $32.20, although plans can charge higher premiums for better coverage. (Those who enroll after May 15, 2006 will be charged a premium penalty, 1% for every month after the deadline)

  • Deductible: This is how much an individual must spend every year on prescription drugs before the plan starts providing coverage, meaning an individual will pay the full amount for prescriptions up to $250. For 2006 the deductible is $250 however, it will increase each year.

  • Co-pay: After an individual meets their deductible, this is the cost of the prescription drugs. The costs vary at tier levels for different insurance plans. An individual will pay from $251 to $2,250 in total drug cost co-pays.

  • Coverage Gap: From $2,251 to $5,100 in total drug costs Medicare Part D does not cover any of the costs and the individual pays 100% of the prescription drug costs.

  • Catastrophic Coverage: Any expenses for prescription drugs over $5,100, the individual pays 5% of total drug costs or $2/$5 per prescription, which ever is greater.

What if I have a limited income and resources?
There is extra help for people with limited income and resources. Almost 1 in 3 people with Medicare will qualify for extra help and Medicare will pay for almost all of their prescription drug costs. To apply for this additional help please contact the Social Security Administration at or call 1-800-772-1213.

Sarah Biel-Cunningham
Sarah Biel-Cunningham is the Director of Peer Services for AIDS Survival Project (

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This article was provided by AIDS Survival Project. It is a part of the publication Survival News.