October 18, 2005
The new Medicare program that will help you pay for prescription drugs is called Medicare Part D.
The federal agency that will administer this program is called the Center for Medicaid and Medicare Services (CMS).
If you have limited income, this program may offer "extra help," also known as the Low Income Subsidy, to help with some of your drug costs. If your annual income is about $15,000 for a single person or $20,000 for a married couple, you may qualify. (See the brochure, Your New Medicare Prescription Drug Benefit: Low-Income Beneficiaries.)
If you are currently on ADAP, you will be required to enroll in Medicare Part D to keep your ADAP coverage. After January 1, 2006, you will receive a portion of your drug coverage from both Medicare and ADAP.
|Important Information About ADAP Coverage|
ADAP will 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 (MA-PD) and also is used by ADAP.
Any of your Medicare Part D costs covered by ADAP will not count toward your out of pocket spending for Part D coverage.
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, and every formulary will include all currently available anti-HIV medications. However, they may not cover other drugs you need.
You should review formularies to see which one works best for you.
Each plan will also have specific pharmacies where you can pick up your prescription drugs. You should review all the plans to see which one has the best pharmacy network for you.
Some plans will charge higher premiums than others. The more expensive plans may have more benefits.
If you qualify for extra help, it can greatly reduce your out-of-pocket expense.
You can sign up for a plan starting November 15, 2005.
You will need to choose your plan carefully, because once you enroll you can only change plans once each year.
You will have to pay your premium before you can access Medicare Part D or ADAP coverage.
ADAP can cover costs associated with your yearly $250 deductible for medications also on the ADAP formulary.
Once your deductible is paid, you pay 25% of your drug costs between $251 - $2,250. ADAP can cover this 25%, but the drugs have to be on the ADAP formulary.
At $2,251 of drug costs, you reach the coverage gap in Medicare. ADAP can continue coverage for drugs on its formulary.
If you spend more than $3,600 out of your own pocket for prescription drugs during the plan year, you will receive Medicare catastrophic coverage. At that point, you will pay 5% of the cost of the medication. If ADAP covers any part of the $3,600, you will not get more Medicare coverage; but ADAP can continue to cover the drugs on its formulary.
ADAP can continue to assist with co-pays for drugs also on the ADAP formulary.
Costs paid by ADAP do not count toward your true out-of-pocket expenses (TrOOP) to help you achieve Medicare catastrophic coverage. In general, only the money you spend out of your own pocket will count toward TrOOP.
|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 online at www.medicare.gov.
You will receive the Medicare & You 2006 handbook in the mail. This handbook will have information about the Medicare Prescription Drug Plans and Medicare Advantage Managed Care Health Plans in your area.
It is important that you keep this handbook. Discuss its contents with your case manager, advocate or benefits counselor and begin to evaluate the various plans available to you.
Because ADAP cannot offer assistance unless you have enrolled in Medicare Part D, you should enroll before January 1, 2006 so that your prescription drug coverage continues.
After May, your premium will increase 1% each month until you enroll, unless you have other prescription drug coverage that is considered by CMS to be the same or better than the Medicare coverage.
Apply to SSA for extra help. This is the low-income subsidy that may help cover some of your drug costs, if you qualify. If possible, bring your application to your Medi-Cal eligibility office so you can also be screened for Medi-Cal services.
Determine if you are eligible for Medi-Cal services.
If you have employer-based health coverage, work with your employer to choose the best coverage for you.
Carefully read the Medicare & You 2006 handbook when it arrives in October 2005.
If you have access to the Internet, visit www.medicare.gov for drug plan information or call 1-800-MEDICARE (1-800-633-4227) to discuss the plans with a Medicare representative. Be aware that this line deals primarily with seniors and may not have all the information you need to make a good plan decision.
Choose a plan that best covers the prescription drugs you need and will allow you to use a pharmacy that is easily accessible to you. To receive assistance from ADAP, your pharmacy must also be in the ADAP network.
It is important that you carefully choose a PDP or MA-PD because you will NOT be able to change plans for ONE YEAR!
If you are not currently enrolled in ADAP, you should apply. Talk to your case manager, advocate or medical provider about how to apply. You can visit online at www.ramsellcorp.com to review qualification requirements and locate the most convenient eligibility site, or call 1-888-311-7632.
Pay the premium for your Medicare Part D plan in order to continue receiving prescription drug benefits. ADAP will not pay your Medicare Part D premiums, but it can help with some co-pays and deductibles. You should keep your ADAP coverage (see "How Will ADAP Work With Your Medicare Part D Coverage?," above).
|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