MEDICAREPART D

Understanding the ins and outs

2019

and your patients

Patients who have Part D may

qualify for financial assistance

through the Extra Help program.

If a prescription is rejected by a

patient’s insurance plan, a coverage

determination or appeal form may

be submitted to the plan by the

patient or physician for a reevaluation

of coverage.

Medicare Part D and Extra Help Patient Center

Additional information for patientsMedicare Part D

Phone

1-800-633-4227Online

www.medicare.gov/part-d/

Extra Help

Phone

1-800-772-1213Online

www.ssa.gov/benefits/medicare/ prescriptionhelp/

In person

Local Social Security office www.ssa.gov/locator/

Medicare Part D 2019 standard benefit design2D

C

The 4 parts of Medicare1

This design is only indicative of the standard benefit and may vary by plan.

Includes hospital stays, nursing home/skilled care facility, home healthcare, and hospice care.

Covers medically necessary doctor services, diagnostic testing, medical equipment, and other preventive care.

Covers medication

costs.

Offered by a health plan; combines Parts A and B and usually Part D as well.

AB

PHASE 3

Coverage gap

PHASE 4

Catastrophic coverage

PHASE 2

Initial coverage limit

PHASE 1

Annual deductible

>$5100Part D plan and Medicare cover the remaining 95%

$5100Manufacturer and Part D plan cover the remaining 75%

$3820Part D plan covers the remaining 75%

$415Patient is responsible for 100%

Patient financialresponsibility in each phase

Total prescription cost until next phase

25%100% 25% 5%

Medicare Part D 2019 standard benefit design2

The Extra Help (low-income subsidy) program2,3

Patients who received Extra Help and did not enter the coverage gap had improved medication adherence compared with those who did not have Extra Help and entered the gap.‡

Patients receive partial or full Extra Help based on their income level in relation to the federal poverty level.

Identifying patients eligible for Extra Help1,2:

• Receive both Medicare and Medicaid (dual eligible)

• Aged 65 years or older with Medicaid

• Enrolled in a Medicare Savings Program

• Receive Supplemental Security Income

• Pay the costs listed in the images above at the pharmacy

* Costs shown are for 2019. Costs for brand-name medications in 2018 are $3.70 or $8.35. Costs for generic medications in 2018 are $1.25 or $3.35. † Costs shown are for 2019. Cost for brand-name medications in 2018 is $8.35. Cost for generic medications in 2018 is $3.35.‡Based on an historical patient cohort study (N=10,190) of patients who received antipsychotic medications.

Full Extra Help benefits

• No monthly premium, annual deductible, or coverage gap (donut hole)

• No copay if patient lives in a nursing home

• Lower cost if at or below the federal poverty level

MEDICATION COST*

Partial Extra Help benefits

• Sliding-scale premium based on income

• Annual deductible of $85

• No coverage gap (donut hole)

• Up to 15% coinsurance

MEDICATION COST†

Brand name

$3.80 or $8.50Brand name

$8.50

Generic

$1.25 or $3.40Generic

$3.40

Patient examples Key terms for your patients to know

Copay

What a patient pays out of pocket for medical care or prescription medications.

Coinsurance

Percentage-based payments for medical care or prescription medications instead of flat fees.

Coverage gap

The phase, alternatively called the “donut hole,” during which patient costs may change until catastrophic coverage begins.

Deductible

How much a patient pays in total each year before health insurance cost sharing begins.

Premium

How much a patient pays each month for health insurance.

Elizabeth, 73, is a Medicare Part D member

who uses both a diuretic and a beta blocker.

She takes a generic diuretic and a

brand-name beta blocker.

Elizabeth is dual eligible because she has both

Medicare and Medicaid, so she receives full

Extra Help. She has no Part D deductible or

premium, does not enter the coverage gap,

and pays only $3.80 for her beta blocker and

$1.25 for her diuretic.

Walter, 65, recently qualified for a Medicare

Part D plan. His doctor prescribed a brand-name

antipsychotic, which is covered on formulary

because it is a protected medication type on

Medicare Part D plans.5

Patients who use brand-name medications and

do not receive Extra Help are more likely to reach

the coverage gap. If medication affordability

is a concern, it is possible that Walter may

qualify for partial Extra Help. If he does, he will

pay a maximum of $8.50 for his brand-name

antipsychotic.

Full Extra Help

Partial Extra Help

REFERENCES1. Centers for Medicare and Medicaid Services. Medicare and You 2018. https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf. Published November 2017. Accessed August 2018. 2. 2019 Medicare Part D Outlook. Q1 Medicare website. https://q1medicare.com/PartD-The-2019-Medicare-Part-D-Outlook.php. Accessed August 2018. 3. Social Security Administration. HI 03001.020 Eligibility for Extra Help (prescription drug low-income subsidy). https://secure.ssa.gov/poms.nsf/lnx/0603001020. Published March 2018. Accessed August 2018. 4. Fung V, Price M, Busch AB, et al. Adverse clinical events among Medicare beneficiaries using antipsychotic drugs. Med Care. 2013;51(7):614-621. 5. Centers for Medicare and Medicaid Services. Analysis of Medicare Part D enrollees who use antidepressant or antipsychotic medications. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Antidepres-sant-and-Antipsychotic-Drug-Use-Analysis-2012-v030515.pdf. Published March 2015. Accessed August 2018. 6. Centers for Medicare and Medicaid Services. Module: 9. Medicare prescription drug coverage. https://www.cms.gov/outreach-and-education/training/cmsnationaltrainingprogram/downloads/2017-mod-9-medicare-prescription-drug-coverage.pptx. Accessed August 2018.

FAQs

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NON109183_v2 08/18

The potential savings seem substantial, but what role does true out-of-pocket (TrOOP) cost play?

TrOOP is used to determine when a patient exits the coverage gap. TrOOP is the combined amount that a patient pays through copays, coverage gap payments, and deductibles, as well as manufacturer discounts and payments from certain third parties.6

Are dual-eligible patients allowed to change their health plan?

Yes, dual-eligible patients may switch health plans at any time during the year.1

Is the Medicare or Medicaid formulary utilized for dual-eligible patients?

Dual-eligible patients obtain drug coverage through the Medicare Part D formulary. Medicare Part B covers physician-administered drugs.1

Is being dual eligible and receiving Extra Help the same?

No, dual-eligible patients are automatically enrolled in Extra Help, but not all patients with Extra Help are dual eligible.

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