Prescription Drug Assistance
Where to Go to Get Prescription Drug Assistance
You think you have drug coverage until you pick up the doctor-ordered prescription at the drug store. Think again. Seniors on Medicare believe that the government program automatically pays for their drug prescriptions, but not without Medicare prescription drug coverage. To get Medicare drug coverage, you must first join a plan run by an insurance company or another private company approved by Medicare. Each plan varies in cost and drugs covered.
So much to learn.
Medicare Prescription Drug Plan (Part D)
Sometimes called "PDPs" adds drug coverage to the Original Medicare (Part A and Part B), some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Insurance companies and private companies offer Part D Plans but Medicare must approve them.
Medicare Advantage Plan (Part C)
HMO or PPO or other Medicare health plans offer Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans, with prescription drug coverage, are sometimes called "MA-PDs." You must have Part A and Part B to join a Medicare Advantage Plan.
Medicare Advantage Plans may also offer prescription drug coverage that follows same rules as Medicare Prescription Plans.
If your Medicare Advantage Plan (Part C) includes prescription drug coverage and you join a Medicare Prescription Drug Plan (Part D), your Medicare Advantage Plan is void and you return to Original Medicare.
Enrollment for either plan limits the enrollment to specific times. You are not allowed to join when you are ready. So, know the facts and when you can sign up for Part C and Part D. Here's a video that explains the process. Video on Facts of Part C and Part D Medicare
You don't need to sign up for Medicare each year but at that time you can review the coverages and change plans. If circumstances change in your life, you're not stuck.
Medicare allows you to make changes to your prescription plan when certain events happen in your life. One is, if you move to a new address and the plan is not covered in that new area. Two, you lost coverage because either you found a better plan or just left the plan.
These changes are Special Enrollment Periods. But before you leave a plan because you're dissatisfied, know the rules when you can make changes and the type of changes you can make.
The costs of drug coverage on the following:
- The drugs you use
- The plan you choose
- Whether you go to a pharmacy in your plan's network
- Whether the drugs you use are on your plan's formulary
- Whether you get Extra Help paying your Medicare Part D costs
The cost of Medicare Part D coverage based on your income as reported on your IRS tax return from 2 years ago. If your income is above a certain limit, you'll pay an income-related monthly adjustment amount in addition to your plan premium.
Filing Status and Yearly Incomes
IN 2014, YOU PAY YOUR PREMIUM PLAN ONLY IF
- Individual Tax Return is $85,000 or less
- File joint tax return $170,000 or less
- File married & separate tax return $85,000 or less
IN 2014, YOU PAY $12.10 + your plan premium IF
- Individual Tax Return is $85,000 - $170,000
- File joint tax return above $170,000 up to $214,000
- File married & separate tax return not applicable
IN 2014, YOU PAY $31.10 + your plan premium IF
- Individual Tax Return is above $107,000 up to $160,000
- File joint tax return above $214,000 up to $320,000
- File married & separate tax return not applicable
IN 2014, YOU PAY $50.20 + your plan premium IF
- Individual Tax Return is above $160,000 up to $214,000
- File joint tax return above $320,000 up to $428,000
- File married & separate tax return above $85,000 up to $129,000
IN 2014, YOU PAY $69.30 + your plan premium IF
- Individual Tax Return is above $214,000
- File joint tax return above $428,000
- File married & separate tax return above $129,000
Costs of Plans
Costs of Medicare Advantage Plan coverage offered by Health Maintenance Organizations and Preferred Provider Organizations. Like employer health insurance plans, they restrict the doctors, services and hospitals that you can use to their network. Some let you pay a higher price to go out of network and promote preventative care.
An analysis by the Plan Prescriber's in 2013 of the files provided by the Centers for Medicare and Medicaid Services (CMS) and available online at CMS.gov. There are a total of 43,306 Medicare Advantage plans available throughout the United States; a decrease from the 43,329 plans available nationwide in 2012.
Summary of Medicare Advantage Plan Costs and Benefits
Average Premiums: In 2013, the average monthly premium for all available Medicare Advantage plans is $60.09, up from $57.56 in 2012 and $48.33 in 2011.
Average Medicare Out of Pocket: In 2013, the average out-of-pocket maximum for a Medicare Advantage plan was $4,516, unchanged from the limit of $4,516 in 2012 and up from $4,376 in 2011.
Enhanced Drug Benefits: In 2013 the average monthly premium for a Medicare Advantage plan with an enhanced drug benefit was $68.05, up from $65.78 in 2012 and $59.86 in 2011.
Plans with $0 Monthly Premiums: Among the 43,306 plans available in 2013, 13,741 plans (32 percent) offered at a cost of $0 above what a Medicare beneficiary already pays for Medicare Part B. By comparison, 14,297 plans (33 percent) were available with a $0 monthly premium in 2012 and 13,821 plans (35 percent) were available in 2011.
Plans made available on a county-by-county basis, which means the same plan is often counted numerous times throughout the same state.
View the PlanPrescriber's.
Extra Help with Medicare Prescription Drug Plan Costs
Medicare beneficiaries can get extra help to pay for their Medicare prescription drug plan costs. The Extra Help is worth $4,000 per year and you qualify if you're receiving Medicare, have limited resources and income ($17,235 for an individual or $23,265 for a married couple living together) , and reside in one of the 50 States or the District of Columbia.
If you have Medicare, you can get Medicare prescription drug coverage.
To apply go here or call:
Apply online at Extra Help
Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to apply over the phone or to request an application, or
Apply at your local Social Security office.
State Pharmaceutical Assistance Programs Medicare
Some states offer a state pharmaceutical assistance program (SPAP) to help residents pay for prescription drugs. Each program works differently. Some states offer programs that can help people with certain illnesses pay for their prescription drugs.
Check with you state's program to see how it works with Part D. If your SPAP and your Part D plan covers a drug, what you pay plus what the SPAP pays for the drug, counts toward the out-of-pocket maximum you have to reach before your Medicare drug costs go down.
Here's where to go to learn more: Many states and the U.S. Virgin Islands offer help paying drug plan premiums and/or other drug costs. Select a state or territory below then click "Search" to see if any programs are available in your area. View the state assistance programs.
See the full state by state chart to find out if your state has an SPAP or other drug assistance program and how to contact the program for more information or to enroll.
If you don't qualify for either of the Extra Help or the State Pharmaceutical Assistance Programs, or even if you do, here are ways to lower your drug costs.
6 Ways to Lower Your Costs in the Drug Coverage Gap (the "donut hole")
The gap begins after spending a certain amount for covered drugs. In 2014, after spending $2,850 to cover drug costs (you and your plan which is the combined amount plus your deductible), you're in the coverage gap. This amount changes each year.
Medicare.gov gives a great example of the coverage gap for BRAND-NAME prescription drugs.
"Mrs. Anderson reaches the coverage gap in her Medicare drug plan. She goes to her pharmacy to fill a prescription for a covered brand-name drug. The price for the drug is $60 and the dispensing fee is $2. Mrs. Anderson will pay 47.5% of the plan's cost for the drug and dispensing fee ($62 x .475 = $29.45). Mrs. Anderson will pay $29.45 for her prescription, but $59.45 is counted as out-of-pocket spending that helps Mrs. Anderson get out of the coverage gap because both the amount that Mrs. Anderson pays ($29.45) plus the manufacturer discount payment ($30.00) count as out-of-pocket spending. The remaining $2.55, which is 2.5% of the drug cost and 52.5% of the dispensing fee paid by the drug plan, isn't counted toward Mrs. Anderson's out-of-pocket spending."
Medicare.gov gives a great example of the coverage gap for GENERIC prescription drugs.
"Mr. Evans reaches the coverage gap in his Medicare drug plan. He goes to his pharmacy to fill a prescription for a covered generic drug. The price for the drug is $20 and there's a $2 dispensing fee that gets added to the cost. Once the 28% coverage applies to the $22, he'll pay $15.84 for the covered generic drug. The $15.84 amount he pays counts as out-of-pocket spending to help him get out of the coverage gap."
Here are the 6 ways to lower drug costs
- Switch to generics or other lower-cost drugs: Talk to your doctor to find out if there are generic or less-expensive brand-name drugs that would work as well as the ones you're taking now. Find out if you can save money by using mail-order pharmacies. Find health & drug plans - click here .
- Get a plan that offers coverage during the gap (donut hole): Plans that offer coverage during the gap: Check with the drug plan first to see if your drugs would be covered during the gap. Find health & drug plans - click here.
- Pharmaceutical Assistance Programs: Offer help for people enrolled in Medicare Part D. Find out whether there's a Pharmaceutical Assistance Program for your drugs.
- Remember to check with your State Pharmaceutical Assistance Programs:
- Remember to apply for Extra Help: If you qualify, you could pay between $1-$6 for each drug - see if you can save on drug costs.
- Check out the national and local charitable groups (like the National Patient Advocate http://www.npaf.org/, Foundation or the National Organization for Rare Disorders http://www.rarediseases.org/, to help with drug costs. Learn about programs in your area on the Benefits Checkup here https://www.benefitscheckup.org/.
After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.
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