Medicare drug benefit enrollment

Sun Q&A


Sun reporter M. William Salganik answers selected readers' questions

Joe Berkow, Baltimore: Is it true that any plan I use can change their formulary, deductible and co-pay each month while I am stuck with them for a year?

Salganik: Partly true. The prescription plan can't change its premium, deductible or co-pay for the next year. It can change its formulary -- the list of drugs it will cover -- and can move drugs from one co-pay level to another.

For example, if a plan has a co-pay of $10 for generics, $20 for preferred brand names and $50 for non-preferred brand names, it can move a drug -- Lipitor, for example -- from the $20 tier to the $50 tier. If it wants to drop a drug from the formulary, it needs to give 60 days' notice to the members and to the federal government. If your doctor thinks you need the drug that's being dropped, you and your doctor can request an exemption from the prescription plan. If it's not granted, you can appeal to the feds.

Plans must offer, at all times, at least two drugs in each "therapeutic class," such as antidepressants. Also, while members will generally be "stuck" for a year with the plan they choose, for this time only, you can switch once before May 15.

Howard Brown, New Oxford, Pa.: I have co-paid [BlueCross BlueShield] with [major medical and Medicare parts A and B] (hospitalization and doctor fees). Should I make any changes?

Salganik: If you already have company (or union) retiree benefits, the question is: Does your current coverage include prescriptions, and is it as good as the Medicare benefit? The magic phrase is "creditable coverage," meaning prescription benefits that are at least as good as Medicare.

Your company should have sent you a letter telling you whether your coverage is creditable. If it is, most experts advise doing nothing. If your company discontinues the coverage in the future, you can join a Medicare drug plan with no penalty. If you don't have "creditable coverage," you might well want to join one of the new Medicare plans.

Emmitt Mosley, Baltimore: If a person who is eligible for the full low-income subsidy enrolls in a plan with multiple tiers, will they still pay $2 or $5? How will that be determined based on generic vs. brand?

Salganik: For the full low-income subsidy, the co-payments can be as low as $1 for generic drugs and $3 for brand name. It's $2 and $5 for the not-quite-as low income. Assets, as well as income, are counted in determining how much "extra help" you receive. In addition to lower co-pays, the extra help can cover monthly premiums and deductibles.

Gloria Huesman, Baltimore: What is the maximum monthly income one can have to qualify for the benefits?

Salganik: Anyone who's eligible for Medicare (age 65 or with qualifying disabilities) can sign up for the new prescription plans. Those with low incomes and limited assets are also eligible for "extra help," with the federal government covering premiums and deductibles and with low co-payments for each prescription. There's a sliding scale, with those with the lowest annual income getting the most help.

In general, and depending on your assets, you're eligible for some extra help if your annual income is below $14,355 for an individual and $19,245 for a married couple. To get the most extra help possible, you need an annual income below $9,570 for an individual or $12,830 for a couple.

Ruth, Baltimore: I am thinking of going with CareFirst Rx and want to know if the following prescriptions are covered and what their monthly cost and co-pay is? Levoxyl, 1.25 mg Protonix, 40 mg Triamterene hzt, 37.5 mg Avapro, 300 mg Norvasc, 10 mg

Salganik: Actually, CareFirst has two different Medicare prescription plans, with similar monthly premiums ($34.78 vs. $35.07). One has a $250 deductible (the amount you pay out of pocket before insurance kicks in). The other has no deductible, but a higher co-payment for each prescription.

Like CareFirst, lots of insurers are offering two or three different plans. To see which is the best deal for you, you can call 1-800-MEDICARE or go to the Web site, click on "Compare Medicare Prescription Drug Plans," then click on "Find a Medicare Prescription Drug Plan." The Web site will show you the full annual costs -- premiums, deductibles and co-pays -- for your medications.

Carol, Manassas, Va.: My mom has a Blue Cross Blue Shield federal program as a Medigap policy. She's covered by their prescription plan. Does she need to enter any of these plans?

Salganik: People with health insurance as federal retirees already have prescription benefits at least as good as the Medicare benefit, so there's no need to sign up for a Part D plan.

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