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Ask the Care Manager . . .
By: Darla Heivly, Senior Solutions

Q: My mother-in-law pays for Medicare Part D to help with prescription drug costs. It seems as though not all of her prescriptions are covered and she is paying much more out of pocket than when she first signed up. Why is this happening and what can she do about it?

A: To understand what is happening, you first must understand how Medicare Part D works. Medicare Part D is a prescription drug plan that is available to all who have Medicare, regardless of income, health, etc. People with private insurance coverage that includes prescription drug benefits may not need Medicare Part D if their current coverage is “creditable” - greater than or equal to the Medicare Part D coverage. Your insurance company can tell you whether you have “creditable” coverage already. Those needing Medicare Part D choose from a variety of plans available. Pennsylvania and West Virginia offer the greatest number of plans, 63 plans! Plans differ in their monthly premium, which drugs are covered, and which pharmacy accepts them. Monthly premiums have increased since inception for some plans. This may account for some of the increase in your mother-in-law’s expenses. In 2008, there is a $275 deductible which must be paid. This deductible has also increased since the inception of the program. This too may account for some of your mother-in-laws increased expense. After the deductible is met, the senior pays 25% of the cost of covered drugs (the copay) up to $2510. After that, there is a gap in coverage “the donut hole”. The consumer must pay out of pocket until the total of all deductible and copays reaches $4050 (monthly premiums do not count). After this point, the consumer pays only a 5% copay. If your mother-in-law has reached the “donut hole” her expenses would increase greatly until such time as she reaches the “other side” ($4050 out of pocket).

The medications that are covered differ from plan to plan. When choosing a plan, it is important to choose one accepted by your pharmacy and that covers most of your prescription drugs. Please note that the drugs covered by a plan can change at any time. However, consumers living in the community can usually only change plans once yearly from November 15 through December 31. (There are exceptions for nursing home residents, etc.). Your mother-in-law’s plan may have changed the drugs it covers. This could also account for increased out of pocket expenses. Her plan may no longer be the most appropriate one for her.

I urge your mother-in-law and all Medicare Part D participants to review the Medicare Part D plan yearly. The yearly enrollment change period is coming up soon (11/15 – 12/31). You can find a list of all plans at www.medicare.gov. An hour or two of research is well worth the time if it results in increased coverage and reduced prescriptions drug costs.

Darla Heivly, MS, CMC, is a geriatric care manager and president of Senior Solutions, Inc. Your can call her with questions at 610-435-6677 or e-mail her at ssrsolutions@aol.com.

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