Important information for AHCCCS members eligible for Medicare
- Starting January 1, 2006 Medicare, instead of AHCCCS,
began offering new drug coverage to help pay for most of the
prescriptions you need. AHCCCS will still continue to pay for your other health care costs.
- Medicare
prescription drug coverage is available to all people with
Medicare.
- You must join and remain in a drug plan for
Medicare to pay for your drugs.
- You are automatically
eligible for extra help with your Medicare premiums and
deductibles through the Social Security Administration's
Extra Help.
- Medicare prescription drug coverage will
pay for brand name and generic drugs.
- Medicare will enroll
you into a plan with prescription drug coverage, based on
your current enrollment status with AHCCCS. You can switch
to another equivalent plan at any time.
Frequently Asked Questions about Medicare Prescription
Drug Coverage and AHCCCS
(Click on the question below to get
further information about the changes in your drug coverage)
What is Medicare Part D?
The Medicare Modernization Act of 2003 created a
prescription drug benefit, called Medicare Part D, for
people who are eligible for Medicare Part A and/or enrolled
in Medicare Part B. Medicare Part D will change the way
people with Medicare get their prescriptions, including
those who are enrolled with AHCCCS.
What is the basic Part D benefit?
Most people who participate in Medicare Part D will have to
pay a share of their prescription drug costs. Those who
qualify for Extra Help will receive help with paying for
their Part D premiums, deductibles and co-payments (AHCCCS
members and people who receive help with Medicaid costs
under QMB, SLMB or QI-1 automatically qualify for Extra
Help).
If a person qualifies for Extra Help, cost sharing
includes:
- Premiums: AHCCCS members do NOT pay monthly
premiums, unless you change to a plan that has premiums
higher than the subsidy amount of $24.62.
- Deductibles: AHCCCS members have NO
deductibles.
- No Coverage gap: AHCCCS members will not have
a coverage gap from $2,250.01 through $5,100 of your
annual prescription costs.
- Co-payments: Most AHCCCS members will pay
co-pays in the amount of $1 to $5 depending on monthly
income and whether you use generic or brand name drugs.
If you are in a nursing facility for longer than a
calendar month, or you enter a nursing home and are
expected to remain there for a full calendar month, you
will have no co-pays. In addition, once the co-payment
amounts that you have paid exceed $5,100 in a calendar
year, you will not have any co-pays.
When
does it start?
Medicare Part D will be implemented on January 1, 2006.
Also on that date, a person with Medicare who is also
eligible for Medicaid (called a dual eligible), will no
longer be able to have prescriptions paid for by AHCCCS
(except for a few classes of drugs that are not covered by
Part D), even if they choose not to participate in Medicare
Part D.
People with Medicare can choose the Medicare drug plan
they want to enroll with beginning on November 15, 2005.
What
should I do?
WATCH YOUR MAIL. You should have received a "Medicare & You
2006" handbook. You should also receive a letter from
Medicare or your Medicare health plan in November with more
information about the changes in your drug coverage. The
"Medicare & You 2006" contains important information. Read
it carefully. *Note: This book contains wrong
information. The handbook says if you are a duel
eligible you won't have to pay a premium no matter which
plan you choose. It should say that if you choose a
plan with a premium higher than $24.62, you will have to pay
the excess amount.
- If you receive a letter from your PLAN and you have
further questions, contact your PLAN.
- If you receive a letter from MEDICARE about your new
prescription drug plan, either contact your NEW PLAN or
CALL 1-800-MEDICARE (633-4227).
How does enrollment work for AHCCCS members?
Current AHCCCS members eligible for Medicare will fall into
three categories. All three categories will result in
prescription coverage for members:
- If you are currently enrolled in a Medicare
Advantage plan, Medicare will automatically enroll you
in the same plan for your Medicare drug benefit.
- If you are currently enrolled in an AHCCCS health
plan that IS participating in Medicare prescription drug
coverage, Medicare will automatically enroll you in the
same health plan for your Medicare Part A and Part B
benefits, and your Medicare Part D drug benefit.
- If you are NOT currently enrolled in either of these
Medicare plans, you will automatically be enrolled by
Medicare into one of five stand alone Prescription Drug
Plans. Those five plans are: HealthNet, Humana Inc.,
SierraRX, Unicare, and United HealthCare.
Do I have to join a Medicare drug plan?
As of January 1, 2006, AHCCCS will no longer be able to pay
for most prescriptions for people who are eligible for
Medicare and Medicaid. Therefore, unless you have other
insurance coverage for your prescriptions, you will need to
enroll in a Medicare drug plan to continue to receive
prescription benefits.
If you do not choose a plan, Medicare will automatically
enroll you in a plan effective January 1, 2006 so you won't
have a break in your prescription coverage.
If you choose not to join a Medicare drug plan at all you
will lose most of your prescription coverage.
If you are Deemed Eligible (QMB, SLMB, QI-1) -You
are expected to choose a prescription drug plan on your own.
If you do not choose a Part D plan by May 15, 2006, Medicare
will choose one for you.
Will I need to pay for this new benefit?
If you are receiving AHCCCS benefits you will have
continuous drug coverage and pay a small amount out of your
own pocket in the form of co-pays.
NOTE: However if you switch plans from the one you were
automatically enrolled in you will need to double check that
the cost of the premium is at/or below the national average
premium cost. Otherwise you will be responsible for paying
the difference in premium.
Are all Medicare Drug Plans the same?
No.
- Each plan has the flexibility to decide which
prescription drugs it will cover (called the formulary),
as long as they cover at least one generic and one brand
name drug within each class of covered drugs.
- Each plan will contract with certain pharmacies.
- Each plan will negotiate an allowable cost for
prescription drugs with their network of providers.
There are also different types of plans:
A PDP is a Medicare Part D Prescription Drug Plan.
These plans will be available to the people with Medicare
who are not enrolled with a MA-PD or a SNP.
A MA-PD is a Medicare Advantage-Prescription
Drug plan. Effective January 2006, Medicare Plus or
Choice plans will be called Medicare Advantage plans. MA
plans are not required to, but may also provide Part D
prescription drug coverage. If they do, the Medicare
Advantage plan will be a MA-PD. These plans will be
available to people with Medicare who are enrolled with the
Medicare Advantage plan.
A SNP is a Medicare Special Needs Plan.
Some AHCCCS health plans have become a Medicare Special
Needs Plan. These plans are only available to people with
dual eligibility, both Medicare and Medicaid. We estimate
that in Arizona about half of the dual eligibles are
enrolled with these plans. These people may get their
Medicaid, Medicare and Part D prescription drug services all
from the same health plan.
How do people enroll in a drug plan?
Dual Eligibles (people with both Medicare and
Medicaid)) will be automatically enrolled with a plan prior
to January 1, 2006. If they believe that a different plan
would better meet their needs, they can change enrollment at
any time.
Deemed Eligibles (people with QMB-only, SLMB or
QI-1) can enroll before December 31, 2005, to begin coverage
January 1, 2006. Otherwise, they will be automatically
enrolled with a plan effective June 1, 2006, if they do not
choose to enroll with a plan prior to that date. If they
believe their needs would be better met by another plan,
they can change enrollment at any time.
Other people (who are not dual eligible or deemed
eligible) will NOT be automatically enrolled with a plan.
These people will need to pick a plan and contact the plan
to enroll.
Persons selecting a plan or changing from one plan to
another will simply contact the new plan to begin
enrollment. Persons who are not dual or deemed eligible will
also need to make a decision about whether they will want to
pay the Part D premium directly to the plan, or instead have
SSA withhold the premium from their Social Security benefit
and forward the payment to the plan .
For information on comparing different plans on the
internet use the Prescription Drug Plan Finder at
www.medicare.gov. To
receive assistance over the phone about enrollment call
1-800-MEDICARE (633-4227).
What should people consider when choosing a drug plan?
4 things should be considered: Cost, Coverage, Convenience,
and Peace of Mind—Now and in the future.
Some questions related to those 4 considerations include:
- If you choose a plan with a premium more than
$24.62, you will have to pay the excess amount.
- Which plan covers the prescription drugs that I am
currently taking?
- Are there any special drugs that I take that will
only be provided by one of the plans?
- What is the plan's process for getting an exception
to their formulary?
- Is there any difference in the amount of co-pays
being charged by the different plans?
- With which plan does my pharmacy participate?
- Am I willing to change my pharmacy if I need to?
How will Medicare help people choose a drug plan?
Medicare will:
- Mail information about Part D to all people with
Medicare.
- Conduct a public information campaign to provide
information about how all people with Medicare will
enroll in a Part D drug plan.
- Make plan comparison information available on their
web site at
www.medicare.gov.
- Help people over the phone at 1-800-MEDICARE
(633-4227).
- In October 2005, automatically enroll all dual
eligible individuals into a Part D drug plan to be
effective January 1, 2006, but will also give them the
opportunity to change monthly if desired.
- In May 2006, automatically enroll the QMB-only, SLMB
and QI-1 population into drug plans effective June 1,
2006 if they have not enrolled in a plan by then.
Are my prescription drugs covered?
Once you receive information about your new plan, either
from your new auto enrollment plan or CMS, contact that plan
and ask if their formulary includes the drugs you are
taking. If they do not cover your drugs, you can:
- Formally request an exception from your drug plan
- Ask your doctor to change your prescription to one
that is covered by your drug plan
- Switch to a drug plan that does cover your drug(s).
Will Part D cover the same prescriptions as AHCCCS?
Most likely, but not all. You need to check with your
Medicare prescription drug plan.
If my drugs are now covered by AHCCCS and I live in a
nursing home or other medical institution, will I need to
join a Medicare drug plan?
Because you are eligible for both Medicare and Medicaid, you
will be automatically enrolled with a Medicare Drug Plan
effective 1/1/06.
- Check with your facility to find out which pharmacy
they use.
- Make sure your Part D plan works with that pharmacy.
If not, you can change to a Part D plan that does work
with that pharmacy.
What happens if a drug I take stops being covered?
If a drug is no longer covered by your Medicare drug
plan, or if it is covered at a higher cost, your Part D plan
must let you know 60 days before the change. If you don't
get a 60-day notice, the Part D plan must let you get a
60-day supply when you get your next refill for the previous
cost. Also at that time, you may want to talk to your doctor
to see if there are other drugs that will meet your needs
that are covered by your Medicare drug plan. Your other
option is to change to a plan that covers your drug.
Will Medicare drug plans cover drugs that treat mental
illness?
Some classifications of drugs for mental illnesses are
excluded from part D coverage. Since Medicare cannot pay for
them, they may still be covered by AHCCCS.
If I change plans, when will the change be effective?
The change will take effect the first of the following
month.
Do I need to stay enrolled with my Medicare HMO?
It is up to you. Most Medicare HMOs (now called Medicare
Advantage Plans) will also offer the new Part D prescription
benefits. If your MA plan does not, you can change to a MA
plan that includes Part D prescription coverage or you can
enroll with one of the Part D prescription drug plans.
What is the Extra Help?
As an AHCCCS member you will automatically receive this
Extra Help—YOU DO NOT HAVE TO APPLY for this benefit.
The Low Income Subsidy (LIS) programs provide help in
paying the Part D premium, deductible and co-payments for
low income individuals. The amount of the help varies
depending on:
- Whether an individual is also receiving Medicaid,
- Whether a person is receiving QMB, SLMB or QI-1,
- The amount of the person's income, and
- In some cases, the amount of the person's resources.
People with Medicare who are not receiving Medicaid, QMB,
SLMB or QI-1 will need to apply for help with the Social
Security Administration (SSA). SSA will be:
- Conducting numerous outreach activities with the
help of advocacy groups (such as SHIP and Area Agencies
for the Aging) to help people with Medicare fill out the
low income subsidy application.
- Helping people who call 1-800-MEDICARE by answering
their questions about applying for help with their
Medicare Part D costs.
- Processing Extra Help applications beginning in
July.
For more information about Extra Help, call the Social
Security Administration at 1-800-MEDICARE.
How are the new Medicare drug plans that are starting in
2006 different from the Medicare-approved drug discount
cards that are already available?
The Medicare-approved drug discount cards that became
available in May 2004 are a way for you to get a discount on
your prescriptions at the pharmacy. They work like other
grocery store or pharmacy discount cards you may have. You
can sign up for one of these cards only until December 31,
2005. They were offered as a transition step to help people
with Medicare save money on prescription drug costs until
Medicare prescription drug plans became available.
Medicare prescription drug plans are a new type of
insurance that can give you prescription drug coverage from
Medicare. These plans work like other insurance you may
already have. If you join one of these plans, you will pay a
monthly premium, unless you are dual or deemed eligible, and
you will have to pay a co-payment for each prescription you
fill. You will first be able to sign up for one of these new
plans beginning November 15, 2005.
How can I get more information?
AHCCCS Members: If your questions are not answered on this
website and/or you need further assistance please call
602-417-7000 (In Maricopa County) or 1-800-792-6690 (outside
Maricopa).
Medicare members who do not receive AHCCCS benefits:
Remember this site is not intended to provide comprehensive
information about the prescription drug benefit. Please
contact 1-800-MEDICARE (633-4227) or go to
www.medicare.gov
 for
more information. For local assistance call the State Health
Insurance Assistance Program at 1-800-432-4040. See
"Resources" page for additional online help and information.
Medicare Prescription Drug Coverage Home Page
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