October 18, 2005
The federal agency that administers this program is called the Center for Medicaid and Medicare Services (CMS).
Starting January 1, 2006, your primary prescription drug coverage will switch from Medi-Cal to Medicare.
PDPs will only provide prescription drug coverage.
MA-PDs will offer both primary care and prescription drug coverage. If you are currently in a Medicare Advantage Plan, it is likely that this will become an MA-PD, and you can continue to receive your primary care and prescription drugs from that plan.
You can choose from among many PDPs and MA-PDs that offer prescription drug coverage. Each plan will have a list of drugs (formulary) that they will cover. All formularies will include all currently available anti-HIV medications. However, they may not cover other drugs you may need. You should review plan formularies to decide which plan works best for you.
Each plan will also have specific pharmacies where you can pick up your prescription drugs. You should review the plans to see which one has the best pharmacy network for you.
In October, you will be automatically assigned to a plan with a fully subsidized premium. If this plan does not work for you, you can switch to a different plan beginning November 15, 2005.
Some plans will charge higher premiums than others. The more expensive plans may have more benefits.
If you choose a plan with a premium that is higher than average, you will have to pay the difference between the average and the more expensive premium.
No charge ($0) for your plan deductible.
No donut hole or gap in coverage.
Most people will pay a co-pay of $1 for a generic drug and $3 for a brand name drug. Some may pay a co-pay of $2 for a generic and $5 for a brand name drug.
If you are enrolled in ADAP, it can cover co-pays for those drugs that are also on the ADAP formulary.
To receive ADAP assistance, you will have to go to a pharmacy that is in your PDP or MA-PD and also in the ADAP network of pharmacies.
There is a small number of drugs that are excluded from Medicare Part D but will continue to be covered by Medi-Cal. They include over-the-counter drugs, benzodiazepines (Xanax, Atavan, etc.), drugs used for weight loss or weight gain, and vitamins and minerals.
Share of cost is the amount you pay before Medi-Cal covers your medical expenses.
As of January 1, 2006, ADAP will no longer be able to pay share of cost for people receiving Medi-Cal and Medicare.
This may have an impact on some of your healthcare expenses.
It is important that you discuss these changes with your benefits counselor, case manager or other provider.
In October, more information about plans and pharmacy networks will be available. At that time, ask your current pharmacist which PDPs and MA-PDs they are participating in.
If you plan to use ADAP assistance, make sure that the pharmacy you choose is also in the ADAP network.
This assistance is being called extra help or the Low Income Subsidy (LIS).
If you are eligible for both Medicare and Medi-Cal, you will automatically qualify for the full extra help (Low Income Subsidy).
If you have a Medi-Cal share of cost, you should qualify for the full extra help in year 2006. See your benefits counselor, case manager or advocate about qualifying for extra help in 2007 and later.
The full Low Income Subsidy means you will not have to pay your Medicare Part D premium (as long as you enroll in a fully subsidized plan) and deductible. You will have no donut hole or gap in coverage and it will reduce your co-payments for drugs.
|Additional Resources for Information About Medicare Part D|
(company that administers ADAP)
California Health Advocates
California Medicare Information
Disabilities Benefits 101
Health Insurance Counseling
Centers for Medicaid and Medicare Services
Medicare Rights Center
Henry J. Kaiser Family Foundation
Treatment Access Expansion Project (TAEP)
Plan information will be posted at www.medicare.gov. You will also receive the Medicare & You 2006 handbook in the mail. This handbook will have information about Medicare Part D's Prescription Drug Plans (PDPs) and Medicare Advantage Managed Care Health Plans with Prescription Drug Coverage (MA-PDs).
It is important that you keep this handbook. Discuss its contents with your case manager, advocate or benefits counselor and become informed about the various plans available to you. You can also call 1-800-MEDICARE (1-800-633-4227) to discuss plan options.
Look for information and workshops about Medicare Part D for clients.
If you have employer-based coverage, work with your employer to choose your best option.
Review the plan you are assigned to by CMS.
Carefully read the Medicare & You 2006 handbook when it arrives in October 2005.
If you can access the Internet, visit online at www.medicare.gov for Medicare Part D info. You can also call 1-800-MEDICARE (1-800-633-4227) and discuss the different drug plans with a Medicare representative. However, this line primarily helps seniors and may not have all the information you need to make a good plan decision.
Review and evaluate the plans that are available to you and choose the best option. If possible, talk with your case manager, benefits counselor or advocate about plan options.
Choose and join a Medicare Part D prescription drug plan. If you do not choose a plan, CMS will automatically enroll you in the same plan you were assigned to in October 2005.
Make sure to choose a plan with an easily accessible pharmacy that is also in the ADAP network.
If you are not currently enrolled in ADAP, you should apply. Talk to your case manager, advocate or medical provider about how to apply. Starting October 1, 2005 you can also visit online at www.ramsellcorp.com to review ADAP qualification requirements and find a convenient enrollment site, or call 1-888-311-7632.
In December, ask your doctor and Medi-Cal for a 100-day supply of any medications you will need after January 1, 2006. This will ensure that you have the medication during the transition from Medi-Cal to Medicare.
|Important Information About ADAP Coverage|
ADAP can help pay co-pays and deductibles only for those drugs that are also on the ADAP formulary.
To receive assistance from ADAP, you will have to go to a pharmacy that is in your Prescription Drug Plan (PDP) or Managed Health Care Plan with Prescription Drug Coverage (MA-PD) and in the ADAP pharmacy network.
|More information about plans, including pharmacy networks, formularies and other details, will be available in October. If you have any questions about Part D, talk to your case manager, benefits counselor or advocate; visit online at www.medicare.gov; or call 1-800-MEDICARE.|
Special thanks to Julie Cross, State HIV/AIDS Benefits Coordinator, California State Office of AIDS for her input.
This publication was produced as a joint project of these organizations:
205 13th Street, Suite 2001
San Francisco, CA 94103
415-558-8669 fax 415-558-0684
National HIV/AIDS Treatment Infoline
Web site: www.projectinform.org