Medicare Part D Flashcards
Medicare - What is it?
Medicare is available to:
– 65 and older
– Permanently disabled
Medicare has 4 parts – A: Hospital coverage – B: Outpatient coverage (except drugs) – C: Medicare Advantage (A and B coverage and often D) – D: Prescription Drug Coverage
Medicare Part A
• Pays for inpatient care in hospitals
- Critical access hospitals (patient pays)
- Skilled nursing facilities
- Hospice and home health
• No premium if you or your spouse paid Medicare taxes while working (40 quarters) ($426 if not)
Medicare Part B
• Part B is optional (must opt out)
• Covers outpatient medical services like provider
services and outpatient care
• Covers medically necessary services (some preventative services)
• Must pay a monthly Part B premium-$148.50
• Part B premium is based on income since 2008
Medicare Part C
• Part C is Medicare Advantage
• Parts A and B are turned over to a health plan to
manage on behalf of the patient
• Includes HMOs, PPOs, PrivateFee-for-Service, Special Needs Plans, Medical Savings Account Plans
• Plans often include prescription drug coverage
• Most plans have extra benefits and lower copayments than traditional Medicare
• Patients may have to use the plan’s providers and hospitals
• There may be an additional premium for these plans
Medicare Part D
Medicare Prescription Drug Benefit
• Started January 1, 2006
• Offers brand and generic drug coverage
• Voluntary, choose to enroll
– Penalty assessed if a patient does not enroll when
eligible and chooses to enroll later
• Subsidies available to those with income <150% of poverty and limited assets
Private Health Plans provide Part D coverage
Two ways to get this coverage
1. A stand-alone Prescription Drug Plan (PDP) added to traditional Medicare
2. Medicare Advantage/ Medicare Part C/ Medicare Health Plans (MA-PD)
• Wraps medical and prescription coverage together (Kaiser, Health Net, AARP Select PFFS, etc.)
– *A patient cannot add a stand alone PDP to an MA-PD plan
Medicare Supplements Medigap Policies
- Medigap policies are health insurance policies sold by private insurance companies to fill “gaps” in traditional Medicare plan coverage
– You get help paying for some of the health care costs that traditional Medicare doesn’t cover
– You also get benefits not covered by traditional Medicare, like emergency health care outside the United States
– You pay a monthly premium to the private health insurance company that sells you the policy. Medicare and the Medigap policy combine to pay their shares of covered health care costs
– Medigap policies are not a part of Medicare
Part D is an Insurance Program
- It is not an entitlement program
- It is an insurance program subsidized by the Federal government
- The healthy pay for the sick
The Penalty
- Assessed if eligible and not enrolled
- 1% per month of missed enrollment
- Penalty is based on the national average premium when patient enrolls
Creditable Coverage
• Drug coverage equal to or better than the Medicare Part D program. It is NOT part of the Medicare program
• No penalty for those with creditable coverage who later sign up for a Part D program. Creditable coverage is provided by:
– Employer benefit or Union program
– VA or TRICARE
• Those that are Medicare eligible but have other prescription coverage will get a letter explaining whether it is “creditable” or not
The “Basic” Part D Plan in 2022
Total Annual Drug Costs (w/o premiums)
- > 10,690 (pt pays 5%): Catastrophic Coverage
- 4,430-10,690: (pt pays 25%): Coverage Gap
- 480-4,430: (pt pays 25%): Co-insurance
- 0-480: (pt pays 100%): Deductible
What Drugs Does Medicare Part D Cover?
• Each plan has its own formulary
– Must cover at least 2 medications from each drug class
• Prescription medications, biologicals, insulin
• Not all medications will be covered
– Must have an authorization process for those medications not on the formulary
The Following Drugs are Not Covered
• Drugs for – Anorexia, weight loss, or weight gain – Fertility – Cosmetic purposes or hair growth – Symptomatic relief of cough and colds • Prescription vitamins and mineral products – Except prenatal vitamins and fluoride preparations • Non-prescription drugs
*Barbiturates NOW Covered (epilepsy, cancer, or
a chronic mental disorder)
• Benzodiazepines NOW Covered unrestricted
Seniors Need Help But…
• Pharmacists may NOT enroll patients in a particular program, nor may they recommend a specific program.
Open Enrollment
Open Enrollment
• October 15 - December 7
• Plan year begins January 1
• Can’t change plans until the next open- enrollment cycle
• EXCEPT a Special Enrollment Period (SEP) created by CMS – see attachment
