Part D 101

Given all the changes with Medicare reform, understanding your Medicare benefits may be more difficult. This guide was prepared to help make Medicare changes easier to understand.

The Medicare Modernization Act passed in 2003 provided for the introduction of Medicare prescription drug coverage, also known as Medicare Part D. Coverage began on January 1, 2006. Anyone who is entitled to Medicare Part A or enrolled in Medicare Part B is eligible to enroll in the new prescription drug coverage, which offers substantial federal help to people with Medicare by paying some of the costs of prescription drugs.

Key elements of the standard Part D coverage
Each year, CMS defines the minimum benefits and maximum allowable member out of pocket costs health plans must meet in order to offer a prescription drug plan. This is called the standard Part D coverage. In 2012, beneficiaries with standard Medicare prescription drug coverage will pay a $320 annual deductible and then 25 percent of drug costs from $321 to $2,930. When total yearly drug costs (i.e., paid by the beneficiary and the plan) reach $2,930, the beneficiary pays 86 percent for generic drugs and a discount on brand name drugs until the beneficiary’s yearly out-of-pocket costs reach $4,700. At that point, the beneficiary pays the greater of 5 percent coinsurance or $2.60 for generic drugs and $6.50 for all other drugs. Extra help will be available for those with limited incomes and resources.

Here’s another way of looking at it:

This is insurance coverage
Medicare Prescription Drug Plans provide insurance coverage for prescription drugs. Like other insurance, if you join you will pay a monthly premium and a share of the cost of your prescriptions. Costs will vary depending on the drug plan you choose.

Under Part D, Medicare beneficiaries will have a choice of at least two plans — a drug-only benefit offered by a private plan that contracts with Medicare (Prescription Drug Plan) or a Medicare-approved HMO or PPO plan that provides both drug coverage and other health care services (Medicare Advantage — Prescription Drug Plan).

If you have a Medicare Advantage HMO or PPO plan
If you are enrolled in a Medicare Advantage plan, you must get your Part D prescription drug coverage through the plan. The plan may offer enhanced drug benefits for an additional premium.

Like Part B, Medicare Part D prescription drug coverage is entirely voluntary
The Part D program has an "opt-in" rule, which means that, with few exceptions, beneficiaries need to actively sign up for the drug coverage by completing an enrollment form and joining a Medicare-approved plan (either a Prescription Drug Plan or a Medicare Advantage Prescription Drug Plan).

This is different from how you sign up for Part B, which is through the Social Security Administration. With Part D, you sign up with a private plan that has been approved by Medicare to cover prescription drugs. While some Medicare beneficiaries may be automatically enrolled in a Part D drug plan based on income level, for most people it works like this: If you don’t sign up with a drug plan, you don’t get the Part D drug benefit.

Paying your Part D premiums
Like Medicare Part B, there is a monthly premium for your Medicare Part D drug coverage. Just like your Part B premium, your Part D premium can be automatically deducted from your Social Security check and you won’t need to write a check each month. You can also pay the monthly Part D premium directly to the Prescription Drug Plan or Medicare Advantage Prescription Drug Plan.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.

Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.

Y0041_HM_12_300a Pending CMS Approval