1. 2018 Medicare Prescription Drug Benefit
2018 Medicare Part D
2018 Medicare Prescription Drug Benefit
October 2017© Center for Health Care Rights
October 2018 by Center for Health Care Rights

2. October 2017© Center for Health Care Rights
Original Medicare
Part A
Hospital Insurance
Part B 
Medical Insurance
October 2017© Center for Health Care Rights

3. Medicare Part D Drug Plan Choices
Prescription Drug Plan (PDP)
Medicare Advantage Plan (MAPD)
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4. Prescription Drug Plan (PDP)
Obtain Medicare Part D coverage by enrolling in a PDP
Continue to use original Medicare to obtain Part A and B services
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5. Medicare Advantage Plan (MAPD)
Obtain Medicare Part D coverage by enrolling in a MAPD
When you enroll into a MAPD plan, you must receive all Medicare Parts A, B and D services from the plan
October 2017© Center for Health Care Rights

6. Do I Have to Enroll in a Part D Drug Plan?
Enrollment is voluntary
There is a penalty for late Part D enrollment if you do not have drug coverage and delay your enrollment into a Part D drug plan.
The penalty is 1% of the base premium for each uncovered month.
The 2018 national base premium is $33.50
October 2017© Center for Health Care Rights

7. When Can You Enroll in a Part D Drug Plan?
Initial Enrollment Period
New Medicare beneficiaries have a 7 month enrollment period. It starts 3 months before the month of eligibility and ends 3 months later.
Example: month of Medicare eligibility is February; enrollment period starts November 1st and ends May 31st.
October 2017© Center for Health Care Rights

8. When Can You Enroll in a Part D Drug Plan?
Annual Election Period “Open Enrollment”
October 15th through December 7th you can enroll in a Part D drug plan or change to another plan
Part D plan benefits are effective January 1st.
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9. Medicare Advantage Prescription Drug Plan Disenrollment Period
Medicare Advantage Prescription Drug Plan members are able to disenroll from their MAPD plan between
January 1 – February 14
of each year.
October 2017© Center for Health Care Rights

10. During this time, they can make the following changes:
MAPD or +
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(NO) Medicare Part D
drug coverage
Original Medicare +
(YES) Medicare Part D drug coverage
Original Medicare

11. October 2017© Center for Health Care Rights
After this enrollment period, you must remain in the Part D plan until the next enrollment period, unless you qualify for a special enrollment period.
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12. Special Enrollment Periods
You can change your Part D drug plan outside of an enrollment period in certain situations.
Examples:
Lose your employer based drug coverage
Move out of your Part D service area
Enter or leave a nursing home
October 2017© Center for Health Care Rights

13. October 2017© Center for Health Care Rights
Persons who have Medicare and full Medi-Cal can change their Part D plan monthly.
Persons who are eligible for the Part D Low-Income Subsidy “Extra Help” Program can also change their Part D plan monthly.
October 2017© Center for Health Care Rights

14. 2018 Standard Part D Plan Costs and Benefits
2018 California Part D drug plan monthly premiums range from $0 to $
The Part D drug plan annual deductible ranges from $0 to $405.
Initial Coverage Period
After the deductible, you pay 25% of the total retail cost of your drugs when costs are between $405 to $3,750.
October 2017© Center for Health Care Rights

15. October 2017© Center for Health Care Rights
Coverage Gap
When your total drug costs reach $3,750, you are in the coverage gap or doughnut hole --
You pay: 35% of the cost for brand name drugs
44% of the cost for generic drugs
Catastrophic Coverage
You get out of the coverage gap when your total drug expenses reach $7,
Your out of pocket costs are then reduced to a 5%
co-insurance or $3.35/generics and $8.35/brand name
drugs.
October 2017© Center for Health Care Rights

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17. October 2017© Center for Health Care Rights
The Affordable Care Act (ACA) and the Part D Coverage Gap (Doughnut Hole)
Between , the ACA
reduces the amount that Medicare
Part D enrollees pay when they are in the coverage gap.
By 2020, persons in the doughnut hole will pay only a 25% copayment for their prescription drugs.
October 2017© Center for Health Care Rights

18. How to Select a Medicare Part D Drug Plan
Shop for the lowest cost plan that covers all your prescription drugs.
Each drug plan has their own list of covered drugs (formulary) and co-payments.
Use the Medicare Part D Drug Plan Search Tool on the Medicare.gov website to help you choose the plan that is right for you.
October 2017© Center for Health Care Rights

19. Do I need to change my Part D drug plan each year?
The enrollment period to change your Part D drug plan for the following year is October 15th through December 7th.
It is always a good idea to check your drug plan coverage for the new year.
Compare your drug plan coverage and costs to other plans to make sure you are getting good coverage at the lowest cost.
October 2017© Center for Health Care Rights

20. Medicare Part D and Employer/Retiree Drug Coverage
Persons who have drug coverage through an employer health plan do not have to join a Medicare Part D drug plan, if the employer sponsored drug plan is as good as a standard Medicare Part D plan. This is called the “creditable coverage” standard.
If you lose your employer/retiree drug coverage, you will have a special enrollment period to enroll in a Part D plan with no Part D penalty for late enrollment
October 2017© Center for Health Care Rights

21. October 2017© Center for Health Care Rights
2018 Medicare Part D
Part D Coordination with TRICARE For Life and Veterans Administration (VA) Benefits
Persons with TRICARE For Life or VA benefits do not need to enroll in Part D.
They have drug coverage that meets the Part D “creditable coverage” standard.
October 2017© Center for Health Care Rights
October 2018 by Center for Health Care Rights

22. Income-Related Part D Premiums for Higher Income Beneficiaries
Medicare beneficiaries with incomes greater than $85,000/year (single person) or $170,000/year (married couple) pay an additional Medicare Part D income related premium.
The Part D income related premium is based on income reported on the IRS tax return from two years prior.
October 2017© Center for Health Care Rights

23. What Can I Do If My Prescription Is Not Covered by My Part D Plan?
Transition Fills
If you recently enrolled into a Part D drug plan, you
may be entitled to a “transition fill” of the drug if:
The medication is not a new prescription,
You are in the first 90 days of being in a new Part D drug plan.
If you meet these requirements, in most cases, the Part D plan must provide you with a 30 day supply of the drug.
October 2017© Center for Health Care Rights

24. What Can I Do If My Prescription Is Not Covered by My Part D Plan?
Exception Request
If you are not entitled to a transition fill of the medication, ask your doctor if you should switch to a formulary drug covered by your plan.
If the formulary drugs are not appropriate for your medical condition, you have the right to file an “exception request”.
Your doctor must explain your medical need for the requested drug and explain why other covered drugs are not appropriate for you.
October 2017© Center for Health Care Rights

25. How Long Will it Take to Process My Exception Request?
An expedited review will take 24 hours if you suffer from serious health conditions.
A standard review will take 72 hours.
October 2017© Center for Health Care Rights

26. What Can I Do if My Exception Request is Denied?
You have the right to appeal.
The first level of the appeal process provides for a standard and expedited time frame.
Expedited – 72 hours
Standard – 7 days
October 2017© Center for Health Care Rights

27. October 2017© Center for Health Care Rights
Part D Appeals Process
Redetermination by the Plan
Reconsideration by the Independent Medical Review
Administrative Hearing
Federal Court
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28. Financial Help with Medicare Part D Costs
You may qualify for help
with Part D expenses even
if you are not eligible for
Medi-Cal.
The program is called the Low-Income Subsidy Program or Extra Help Program.
October 2017© Center for Health Care Rights

29. Low Income Subsidy Program Full Subsidy
Income Limits (135% of poverty level)
Equal to or less than $1,357/month (individual)
Equal to or less than $1,827/month (married couple)
(In-kind support is not counted.)
Asset Limits *
Less than $8,890 (individual)
Less than $14,090 (married couple)
(Your home, cars, and life insurance policies are not counted.)
* Asset limits include $1500 burial allowance per person.
October 2017© Center for Health Care Rights

30. With Full Subsidy You pay:
No premium
No annual deductible
$3.35 to $8.35 co-payments until costs equal $7,
Medicare pays 100% of covered costs when total costs are greater than $7,
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31. October 2017© Center for Health Care Rights
Low Income Subsidy Program Partial Subsidy
Income Limits (150% of poverty level)
Equal to or less than $1,508/month (individual)
Equal to or less than $2,030/month (married couple)
(In-kind support is not counted.)
Asset Limits*
Less than $13,820 (individual)
Less than $27,600 (married couple)
(Your home, cars, and life insurance policies are not counted.)
*Asset limits include $1500 burial allowance per person.
October 2017© Center for Health Care Rights

32. October 2017© Center for Health Care Rights
With Partial Subsidy You pay:
Monthly premium (sliding scale)
$83 annual deductible
15% of drug costs
(until total costs reach $7,508.75)
$3.35 to $8.35 co-payments
(after total costs are greater than $7,508.75)
October 2017© Center for Health Care Rights

33. October 2017© Center for Health Care Rights
2018 California Part D Prescription Drug Plans that are Extra Help Qualified
These Part D drug plans have no monthly premium if you qualify for Medicare Part D Extra Help.
Aetna Medicare Rx Saver
Humana Preferred Rx Plan
SilverScript Choice
Symphonix Value Rx
WellCare Classic
October 2017© Center for Health Care Rights

34. Medicare’s Limited Income NET Program – LI NET
Medicare’s Limited Income Newly Eligible Transition (NET) Program provides temporary drug coverage for persons who are eligible for the Low Income Subsidy Program but are temporarily not in a Part D plan.
This program provides immediate prescription drug coverage for any Part D covered drug with no network pharmacy restrictions.
The LIS eligible person should be charged the copayment appropriate for their level of LIS assistance.
October 2017© Center for Health Care Rights

35. How to use the Plan Search Tool
Visit
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36. October 2017© Center for Health Care Rights
Click on Find health and drug plans. The following screen appears.
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37. October 2017© Center for Health Care Rights
Type in your zip code. Click Find Plans. The following screen appears.
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38. October 2017© Center for Health Care Rights
Type the name of your drugs. Click Find My Drug. See screen below.
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39. October 2017© Center for Health Care Rights
The screen below appears. Select the option that applies to you.
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40. October 2017© Center for Health Care Rights
Pick your pharmacy. Click Add Pharmacy. See screen below.
October 2017© Center for Health Care Rights

41. October 2017© Center for Health Care Rights
Select the type of plan you are searching for. Click Continue to Plan Results.
October 2017© Center for Health Care Rights

42. Where to get information on Medicare Drug Plans
2018 Medicare Part D
Where to get information on Medicare Drug Plans
Medicare Website
Medicare Telephone Hotline
Medicare Part D Plans
Center for Health Care Rights
October 2017© Center for Health Care Rights
October 2018 by Center for Health Care Rights