2012 Medicare Part D Drug Coverage

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1 2012 Medicare Part D Drug Coverage Consumer Costs Under a Standard 2012 Part D Plan Premiums range from $15.10 to $ per month. The annual deductible is $0 to $320. The deductible is the amount you pay before your drug plan starts to pay anything. Initial Coverage Period After you pay your deductible, you pay 25% of the total retail cost of your prescription drugs until the total cost reaches $2,930 for the year. Coverage Gap When your total drug costs reach $2,930 for the year, you pay 50% of the cost for brand name prescriptions and 86% for generic drugs until the total cost reaches $6, Catastrophic Coverage Once your total drug costs are greater than $6, for the year, you pay $2.60 to $6.50, or 5% of the cost, for each prescription drug. Need help? Call the Center for Health Care Rights at The Center for Health Care Rights (CHCR) is a California non-profit organization that provides free information and help with Medicare. CHCR is funded by government and private foundation grants. Funding for this flyer is provided by Los Angeles City Department of Aging MIPPA grant. Copyright February 2012 by Center for Health Care Rights

2 Do I have to enroll in a Part D plan? Enrollment is voluntary. There is a penalty for late enrollment unless you have drug coverage that is equal to or better than the standard Medicare drug benefit. The penalty is 1% of the base premium for each uncovered month. Are there different kinds of Medicare drug plans? Yes, there are two kinds of Medicare drug plans: 1. Prescription Drug Plans (PDP) These plans provide Medicare Part D benefits only. You get your Part A and Part B benefits through Original Medicare. 2. Medicare Advantage Prescription Drug Plans (MA-PD) These are primarily HMO and PPO plans that cover Medicare Parts A, B and D benefits. If you are in an HMO, you must get all of your covered services, including your prescription drugs, from providers in the plan s network. If you are in a PPO plan, you will be charged more when you use providers who are not part of the PPO network. Are all the Medicare drug plans the same? No. They have different: Formularies. A formulary is a list of prescription drugs that the plan covers. Premiums and co-payment costs. Each plan determines how much they will charge for covered drugs. To compare California Medicare drug plans, see our 2012 California Medicare Prescription Drug Plans chart. Medicare Part D Center for Health Care Rights Page 2

3 When can I enroll in a Medicare drug plan or switch to another plan? If you have Medicare and full Medi-Cal, or if you are in the Low Income Subsidy Program, you can change your plan once a month. If you are new to Medicare, you can sign up for a Part D plan when you enroll in Medicare Part B. The Annual Election Period to change your Medicare drug plan is October 15 - December 7 of each year. During the period of January 1 - February 14, you can make the following changes if you have a Medicare Advantage Part D plan: Change from a MA-PD HMO or PPO a Part D PDP (drug only) plan Change from a MA-PD HMO or PPO original Medicare with no Part D coverage. If you lose your employer/retiree coverage or move out of your Part D plan service area, you will also have a special enrollment period to enroll in a Medicare drug plan or change plans I have prescription drug coverage through a former employer. Do I need a Medicare drug plan? If your drug coverage is as good as the standard Medicare drug benefit, you do not need a Medicare drug plan. If you are not sure, call your former employer or your insurance company. Medicare Part D Center for Health Care Rights Page 3

4 I have Medicare and Medi-Cal. Do I have to enroll in a Medicare drug plan? How much will it cost? Yes. Everyone who has Medicare and Medi-Cal must enroll in a Medicare drug plan. If you do not choose a plan, Medicare will choose one for you. Each drug plan has its own list of covered drugs. Contact the plan to find out if it covers all the drugs you need. Your co-payment will be $1.10 to $3.30 for each prescription. I don t have Medi-Cal. Can I get financial help with my Part D expenses? Yes, the Low Income Subsidy (LIS) Program or Extra Help Program will help pay your Part D costs if you qualify. The chart below outlines the eligibility guidelines and the level of assistance provided. Full LIS Extra Help Monthly Income Limit $1, $1, Asset Limit * $8,440 $13,410 * These resource limits include $1,500 per person for burial expenses. Full LIS Extra Help No annual deductible You pay $2.60 to $6.50 co-payments No cost sharing in the coverage gap (doughnut hole) Medicare Part D Center for Health Care Rights Page 4

5 Partial LIS Extra Help Monthly Income Limit $1, $1, Asset Limit * $13,070 $26,120 * These resource limits include $1,500 per person for burial expenses. Partial Extra Help $0 to $65 annual deductible You pay 15% of drug costs After total drug costs are greater than $6,657.50, you pay $2.60 to $6.50 co-payments To apply for Extra Help call the Center for Health Care Rights at If I have Tricare or Veterans Administration (VA) benefits, do I need to enroll in a Part D plan? No. Persons who have Tricare or VA drug coverage do not have to enroll in a Part D plan. What can I do if my Medicare prescription drug plan does not cover a drug I need? Ask the drug plan to cover the prescription drug you need. This is called an exception request. If you request an exception, your doctor must tell the plan why the drug is medically necessary for you. The process takes: 24 hours if your medical condition is serious. 72 hours if your medical condition is not serious. If the plan denies your request, you can appeal. For more information, call us toll free at Medicare Part D Center for Health Care Rights Page 5

6 Does the new Health Care Reform Law reduce what I have to pay for my prescription drugs? Yes, between the new law will gradually reduce the amount that you must pay for prescription drugs when you are in the Part D coverage gap or doughnut hole. By 2020, your out of pocket costs will be reduced to a 25% copayment for your prescription drugs when you are in the doughnut hole. I have a higher income, will I have to pay more for my Part D drug plan? Medicare beneficiaries who have incomes greater than $85,000/year for a single person and $170,000/year for a married couple will pay a higher Part D premium that is based on their income. The higher premium includes the regular plan premium plus an extra amount that is based on your income. The extra amount you pay is based on what you reported as your adjusted gross income on your IRS tax return from two years ago. Where do I get more information on Medicare Part D plans? Call Medicare s toll-free hotline at Go to Medicare s Web site at Call the Center for Health Care Rights at We are here to help you! Need more information? Call the Center for Health Care Rights at Medicare Part D Center for Health Care Rights Page 6

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