Medicare Part D Prescription Drug Coverage

What Is Medicare Part D?
If I Have Medicaid and Medicare, Do I Need Part D Coverage?
What If I Already Have Prescription Drug Coverage?
Who Provides Medicare Part D Benefits?
How Should I Pick a Part D Plan?
How Do I Enroll in Part D Plan?
When Can I Enroll in Part D?
What Happens If I Don't Enroll?
Can I Change to a Different Part D Plans?
Will Part D Pay for All of My Prescriptions?
How Much Does Part D Coverage Cost?
Where Can I Get Help with Part D?

What is Medicare Part D?
Medicare Part D is a new voluntary prescription drug benefit under the Medicare program. Anyone with Medicare Part A or Part B may enroll for Part D benefits. If you have a Medicare card, you are eligible for Part D.

Some people must enroll in Medicare Part D. People who receive Medicaid benefits or VPharm prescription drug assistance from the State of Vermont must enroll in Medicare Part D.

If I Have Medicaid and Medicare, Do I Need Part D Coverage?
Yes. If you have Medicaid or get assistance from Vermont through VPharm, you must enroll in Medicare Part D. If you had Medicaid, or were in a Vermont prescription drug program (VHAP, VScript, or VScript Expanded) as of November, 2005, you should have been automatically assigned to one of the Part D drug plans offered in Vermont.

If you are having coverage problems or need assistance getting coverage from a plan Call the Office of Health Care Ombudsman. Call (800) 917-7787 or (888) 884-1955 (TTY).

What If I Already Have Prescription Drug Coverage?
If you already have prescription drug coverage you may not need Medicare Part D. The plan you have now must be at least as good as Part D coverage. Your current plan should have sent you a letter telling you if its coverage is as good as Part D. Coverage that is as good as Part D coverage is called "creditable coverage". If you did not receive this letter, or if you received it but no longer have it, call your plan and ask them if they are "creditable coverage." Ask your plan to send you a letter saying that your plan is creditable. If your current prescription drug coverage is creditable, you do not need Part D coverage.

Who Provides Medicare Part D Benefits?
Part D benefits are provided by private insurance companies. There are more than 45 different plans to choose from in Vermont. The plans have different coverage and charge different premiums and deductibles, so you need to compare the plans and choose one that works best for you. More information can be found at Medicare.gov.

How Should I Pick a Part D Plan?
You should pick the Part D plan that works best for you. No two plans are alike, and there are many differences in the plans. Here are some things you can do before you pick a plan. Make a list of the drugs you take, including the dosage you take and number of pills you get each time. It helps to know the exact name and the correct spelling of the drug. You also want to know the name of your pharmacy. Try to choose a plan that covers the drugs that you need to take regularly. See which plan has the best coverage and lowest cost for you.

Need help choosing a Part D plan? Call the Senior Helpline at (800) 642-5119. The Senior Helpline will refer you to the Vermont State Health Insurance Assistance Program (SHIP) for free counseling from an advocate.

You can also call Medicare for information and help at 1-800-MEDICARE (800) 633-4227 or TTY: (877) 486-2048 (for the hearing impaired). You can also go online to the Medicare.gov website for information.

How Do I Enroll in a Part D Plan?
You can enroll over the phone, online, or by mail. You should have your Medicare card and know your date of birth to enroll.

For help enrolling, call the Senior HelpLine at (800) 642-5119. You can also use the official Medicare website to enroll on-line in a Part D Plan. You can also call Medicare to enroll at 1-800-MEDICARE (800) 633-4227 or TTY (877) 486-2048 (for the hearing impaired).

When Can I Enroll in Part D?
You can enroll for Part D when you become eligible for Medicare. You can enroll in Part D at any time 3 months before the month you become eligible, and 3 months after you become eligible.

The annual election period for Part D is from November 15 to December 31 every year. If you are eligible for Medicare and have not enrolled in Part D, you will be able to enroll during that annual election period. Some people can enroll in a Part D plan at other times in the year. For example, if you enter a nursing home, or if you lose your creditable coverage, you can probably enroll in a Part D plan right away.

Your Part D coverage should start the first day of the month after you enroll. If you want coverage in January, try to enroll before December 8.

What Happens If I Don't Enroll?
You must enroll in Part D during your initial enrollment period. You will be charged a penalty when you enroll later. The penalty is 1% of the national average premium for each month you didn't enroll. You will have to pay this penalty every month when you pay your Part D premium. You don't have to enroll or pay a penalty if you have creditable coverage from another health insurance plan.

Can I Change to a Different Part D Plan?
Yes. You can change your Part D plan during the annual election period between November 15 and December 31 each year. If you get Medicaid, or are in a Medicare Savings Plan also known as QMB, SLMB, or QI, you can change your plan at any time. Sometimes you can change your plan outside of the annual election period because of a specific event. For example, if you move outside of your current Part D plan area, you can probably change your plan right away. Call Member Services at (800) 250-8427 to find out if you can change your plan. You can also call the Senior Helpline at (800) 642-5119 for help changing plans.

Will Part D Pay for All of My Prescriptions?
Part D plans may not cover all of your drugs. Certain types of drugs are never covered by Part D. These include: 1) over-the-counter drugs, except insulin which is covered; 2) weight-loss and weight-gain drugs; 3) drugs to relieve cough/cold symptoms; 4) cosmetic drugs and drugs to promote hair growth; 5) fertility drugs; 6) prescription vitamins, except for prenatal vitamins and fluoride which are covered; 7) barbiturates and benzodiazepines; and 8) drugs to help you stop smoking. If you are eligible for Medicaid or VPharm, these drugs are usually covered by Vermont.

Part D plans may not cover other drugs as well. This is because each Part D plan has a list of drugs it will cover. This list is called the plan's formulary. A Part D plan's list of covered drugs can be complicated and can change. If you have questions about different plans, call the Senior Helpline at (800) 642-5119.

You can also get information about each plan's list of covered drugs by going to the Medicare website's formulary finder. The Vermont Medical Society's website also has a list of drugs included in each plan.

If a plan does not cover all the drugs you need, you can ask them to make an exception. If your plan does not cover your drug, or if you need help requesting an exception, call the Office of Health Care Ombudsman at (800) 917-7787.

How Much Does Part D Cost?
The cost of Part D plans can vary. People with low incomes can get help with these costs from Vermont. Part D drug plans have four different costs: the premium, the deductible, co-payments, and the coverage gap or "doughnut hole."

The premium is the amount you pay each month to the Part D plan for coverage. Each Part D plan has a different monthly premium. If you are on Medicaid, you should not have to pay any premium. If you are on VPharm, you should not have to pay a Part D premium, but you still have to pay your monthly $15, $20, or $42 premium to the State of Vermont. The yearly deductible is the amount you must pay out of your own pocket before your coverage begins. This amount is in addition to your Monthly Premium. The standard deductible in 2007 is $265. This means that this year, you pay for the first $265 of your drug costs. Different plans may have higher or lower deductibles. If you are on Medicaid or VPharm, you should not have to pay a deductible.

A co-payment is money you must pay out of your pocket when you fill your prescription at the pharmacy. Some plans do not require you to make a co-payment. Other plans may require you to pay $25 or more for every prescription. The more prescriptions you have to fill, the more you have to pay in co-payments. If you are on Medicaid, your co-payment should not be more than $5.35 for any one drug. If you are on VPharm, you should not have to make any co-payments.

Many Part D plans have a coverage gap, also known as the "doughnut hole." If your plan has a coverage gap, your plan will stop covering your prescription costs after it spends a certain amount for your medications. You will have to pay for your medications out of pocket until you spend enough on prescriptions for your plan to begin picking up the costs again. The standard coverage gap is between $2401 - $5451 in total drug costs. This means that once you and your plan spend a total of $2400 on your medications, you will have to pay for your prescriptions yourself until you have spent $3051 more. After this, your plan will begin covering your medications again. Some plans don’t have coverage gaps. Some plans that have coverage gaps have different gaps. If you have Medicaid or VPharm, the State of Vermont should pay for your drugs while you are in the coverage gap.

The chart below shows the costs of the standard Part D benefit in 2007, if you do not have Medicaid, VPharm, or other extra help:

STANDARD BENEFIT 2007	Your Plan Pays...	You Pay...	Total Drug Cost in Each Phase
PHASE 1: Deductible	$0	$265	$265
PHASE 2: Regular Coverage ($266 - $2400 spent)	74% ($1601)	25% ($534)	$2135
PHASE 3: Coverage Gap ($2401-$5451 spent)	0% ($0)	100% ($3051)	#3051
GRAND TOTAL ($5451)	$1601	$3850	$5451
PHASE 4: Emergency Coverage ($5451 + spent)	95% of all drug costs	5% of all drug costs for the rest of the year	5% of all drug costs for the rest of the year

The costs for plans change every year in January. You should get a letter from your plan telling you about any change in your plan.

Where Can I Get Help with Part D?
If you are a low income senior or a person with a disability, you should apply for VPharm coverage. VPharm can be a big help and can reduce your drug costs. Apply for VPharm at the local Department for Families and Children (DCF) office in your area or by calling Member Services at (800) 250-8427. To find the location of the DCF nearest you, go to the DCF website.

For more information about getting help to pay your Part D costs, call the Senior Helpline at (800) 642-5119.

For help choosing the best plan for you, or for general questions about Medicare Part D, call the Senior HelpLine at (800) 642-5119. The Senior HelpLine in your area runs a program called the Vermont State Health Insurance Assistance Program (SHIP) to help people like you.

You can get general information about Medicare Part D from the government by calling 1-800-MEDICARE (800) 633-4227, or TTY: (877) 486-2048 (for the hearing impaired), or by going to the Medicare website. The local Social Security Office should also have information about Medicare Part D.

The Medicare Rights Center has a comprehensive explanation of the Medicare Part D benefit here.

The information on this page is current as of February 2007. With permission, this information was based in part on information provided by the Legal Services for the Elderly in Maine

Vermont Law Help, 2008. This is a website about Vermont law. We give this information as a public service. It is not legal advice. We are not acting as your lawyer.
Always consult a lawyer, if you can, before taking legal action.