1. 2019 Medicare Prescription Drug Benefit
2019 Medicare Part D
2019 Medicare Prescription Drug Benefit
October 2018© Center for Health Care Rights
Center for Health Care Rights
USC Emeriti Center
October 26, 2018
October 2018 by Center for Health Care Rights

2. October 2018© Center for Health Care Rights
Original Medicare
Part A
Hospital Insurance
Part B 
Medical Insurance
October 2018© 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 2018© 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 2019 national base premium is $33.19
October 2018© 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.
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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. NEW Medicare Advantage Open Enrollment Period
Starting January 2019, persons who are in a Medicare Advantage plan can now change their part D plan once during the 3 month period of
January 1 - March 31 of each year.
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10. During this time, you can make the following changes:
A different Medicare Advantage Plan
with drug coverage
A different Medicare Advantage Plan
with no drug coverage
Medicare Advantage
Prescription
Drug plan
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with a Part D prescription drug plan
Original Medicare +
with no Part D prescription drug plan
Original Medicare

11. October 2018© 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
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13. October 2018© Center for Health Care Rights
Current Part D Special Enrollment Period for Persons who Qualify for the Part D Low Income Subsidy Program
In 2018, persons who qualify for the Part D Low Income Subsidy “Extra Help” program can change their Part D plan once a month.
Persons who have Medicare and full Medi-Cal benefits qualify for “Extra Help” automatically.
Other persons can apply for “Extra Help” through Social Security.
October 2018© Center for Health Care Rights
Part D “Extra Help”

14. October 2018© Center for Health Care Rights
2019 New Limits on the Part D Special Enrollment Period for Persons who Qualify for the Part D Low Income Subsidy Program
Starting in January 2019, persons who qualify for the Part D Low Income Subsidy “Extra Help” program will no longer be able to change their Part D coverage on a monthly basis. Instead, persons who have “Extra Help” will be permitted to change their Part D plan once a quarter during the first 9 months of the year.
October 2018© Center for Health Care Rights
Sep
Aug
Mar
Feb
Apr
Jul
Jun
May
Jan
One change

15. No special enrollment period
2019 New Limits on the Part D Special Enrollment Period for Persons who Qualify for the Part D Low Income Subsidy Program
During the last quarter of the year from October to December, there will be no special enrollment period to change to another Part D plan. But, persons who qualify for the “Extra Help” Program will continue to qualify for all other special enrollment periods available to all persons who have Part D coverage.
October 2018© Center for Health Care Rights
No special enrollment period
Oct
Nov
Dec

16. 2019 Standard Part D Plan Costs and Benefits
California Part D drug plan monthly premiums range from $0 to $
The Part D drug plan annual deductible ranges from $0 to $415.
October 2018© Center for Health Care Rights

17. Medicare Part D Coverage Periods
If you reach the $3,820 limit you’re headed into the doughnut hole.
Initial Coverage
After the deductible you pay 25% of the cost for your prescriptions until you reach $3,820.
Catastrophic Coverage
You pay 5% or $3.40 for generics and $8.50 for brand names.
October 2018© Center for Health Care Rights
Doughnut Hole
You pay 37% for generics and 25% for brand names.
You leave the doughnut hole when your total drug costs reach $7,
Adapted from “The Part D Coverage Gap in 2019” - NCOA.org

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 2018© 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 2018© 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 2018© Center for Health Care Rights

21. October 2018© Center for Health Care Rights
2019 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 2018© 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 2018© Center for Health Care Rights

23. How the Medicare Drug Benefit Works with Medi-Cal
If you have Medicare and full Medi-Cal, you must enroll into a Part D drug plan or Medicare will assign you to a plan.
Select a Part D drug plan that covers all your drugs.
Your Part D drug plan copayments are:
$1.25/generic drug
$3.80/brand name drug
October 2018© Center for Health Care Rights

24. 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 2018© Center for Health Care Rights

25. 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.
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26. 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.
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27. 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 2018© Center for Health Care Rights

28. Part D Appeals Process – PDP and MAPD drug coverage
Redetermination by the Plan
Reconsideration by the Independent Review Entity
Administrative Law Judge
(ALJ) Hearing
Medicare Appeals Council
Federal District Court
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29. 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 2018© Center for Health Care Rights

30. October 2018© Center for Health Care Rights
Low Income Subsidy Program Partial Subsidy
Income Limits (150% of poverty level)
Equal to or less than $1,538/month (individual)
Equal to or less than $2,078/month (married couple)
(In-kind support is not counted.)
Asset Limits*
Less than $14,100 (individual)
Less than $28,150 (married couple)
(Your home, cars, and life insurance policies are not counted.)
*Asset limits include $1500 burial allowance per person.
October 2018© Center for Health Care Rights

31. October 2018© 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 $7,653.75)
$3.40 to $8.50 co-payments
(after total costs are greater than $7,653.75)
October 2018© Center for Health Care Rights

32. Where to get information on Medicare Drug Plans
2019 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 2018© Center for Health Care Rights
October 2018 by Center for Health Care Rights