Julie’s

“Medicare Prescription Benefit”

Twyla Stech

&nbs= p; Twyla is an area manager of SHIIP (Senior Health Insurance Information Program) which is a part of Medicare, and they answer questions about insurance. Th= ere are 80 local offices throughout the state where questions can be answered.<= span style=3D'mso-spacerun:yes'> Her presentation was about Medicar= e Part D, the Medicare Prescription Benefit. They also answer questions about Medicaid and long term care insuran= ce.

&nb= sp;

The one requirement to consider Medicare Part D is that you have to have Medicare Part A, or Medic= are Part A and B.

Medicare Part D was p= assed into law in 2003, and goes into effect this year ( Jan. 1, 2006). It was legislated through the Medi= care Moderation Act. The first enr= ollment period started last November, and ends May 15, 2006. Flollowing the initial enrollmnet period, an annual enrollment will occur from November 15 to December 31. This is called the “annual coordinated election period.” You can change plans during that period or enroll. There are groups who do not have to worry about this. If you have Tricare for Life, retired military insurance, you do not have to enroll. Employer group insurance may inclu= de prescription insurance, and you will want to stay with this. In the future should that plan cha= nge, keep your letter that denotes “credible coverage,” and you will have no penalty for joining Medicare Part D later. If you are a federal employee and = have group insurance your prescription coverage may be better than Part D.

Those who do not have prescription coverage and do not enroll by May 15^th, 2006, will = have a penalty for late enrollment that will be 1% per month, based on the natio= nal average now ($32.20 per month). If you waited 2 years your premium would go up $7-$8 per month. Medicare Part D has been privatize= d, which means that you can only get the insurance through a private insurance company.

If you are in relativ= ely good health and have few prescriptions, and pick a plan that is an inexpensive p= lan, you would not have a penalty down the road, as you can change your plan dur= ing the “annual coordinated election period.” You needed to act before May 15th, 2006, with the penalty enacted in August 2006. You sign up one month, and your be= nefit begins the first of the next month.

The Indiana average for plans is $35.69 per month (varies from state to state). The rule is that the plans have to average across plans where indivi= dual pays 25% of the coverage and Medicare pays 75%, but this may differ from pl= an to plan: it is an average over plans.

How does this work with the insurance companies<= /span>? = Medicare says there are many categories of illness called “therapeutic categor= ies and classes.” She said = she has seen a list of 126 categories and one of 146 categories. A category would be all the drugs = to cover a certain condition such as Parkinson’s Disease, osteoporosis, = high blood pressure, etc. The insurance companies had to go to all the pharmaceutical manufacturers and m= ake agreements for at least 2 drugs in each of those categories of treatment (s= ome plans have more than 2 drugs for a category). One plan may have a good price on = one category and not for another category.&nbs= p; You need to find the cheapest plan for the combination of medications you are currently taking, covering the categories that apply to you. <= /o:p>

After Medicare has sp= ent $2250 dollars, you go to the next level of the plan called the “cover= age gap,” where you pay 100%. After you have spent $3600 of your own money Medicare covers 95% abo= ve this, which is called catastrophic coverage. You will get a statement every mon= th that tells you what has occurred in this coverage. There are many plans offered= all over the state. Some pl= ans offer coverage for some medications during the “coverage gap.”<= o:p>

How do you choose a plan?<= /p>

SHIIP will help you c= hoose the 3 best plans.

Call 1-800-Medicare (1-800-633-4227)

On the voice activate= d system say “Agent,” until you get a person.

That person will ask = you a series of questions, which include:

= 1.&n= bsp; your Medica= re #,

= 2.&n= bsp; your Medicare effective date

= 3.&n= bsp; date of bir= th,

= 4.&n= bsp; zip code

= 5.&n= bsp; if you prefer a certain pharmacy,

= 6.&n= bsp; which prescription drugs you are ta= king now, the dosage (how many milligrams), and how many times a day you are tak= ing the medication.

You can enroll on line also.

After you are enrolled, you will get a letter and a confirmation number you can u= se at the pharmacy. <= /span>

She recommends you enroll in a plan and see how it works, because you can make changes. Be sure the plan you= have enrolled covers your prescriptions.

When you see your doctor and they change your prescription, and your plan does n= ot cover this prescription, there is a process you go through to add this to y= our formulary. The doctor has to = be involved in this exception.

How is the pricing of drugs affected? There is a tier system. Tier 1 drugs are generic and there is &nbs= p; a co-pay amount specified. Tier 2 is the preferred brand drug, where the co-pay may be higher.<= span style=3D'mso-spacerun:yes'> Tier 3 drugs are not discounted an= d you would pay even higher co-pay. There is a Tier 4 for very rare drugs. Co-pay means a certain dollar amount you would pay for each prescription. Co-insurance is the percentage you= would pay on the plan. <= /span>

Most pharmacies will be very helpful.

For more information contact:

Indiana Department of Insurance Consumer Service

311 West Washington St= .

Indianapolis, IN 46204-2787

317-232-2395 or 1-800-622-4461

doi@dol.state.in.us<= /p>