FW: Medicare Part D Newsletter from Q1Medicare.com - Questions aboutFormulary Changes

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Subject: Medicare Part D

Newsletter from Q1Medicare.com - Questions aboutFormulary Changes

Medicare

Part D Prescription Drug Plan Newsletter

Q1Group LLC

Saint Augustine, Florida

Q1Medicare.com

May

/ June 2012

1. Watching

for Changes in Your 2012 Medicare Part D Plan’s Drug Coverage

2. Updates to

our 2012 Drug Search and Formulary Browser Tools

3. How Your

Prescription Purchases Count Toward Your Donut Hole

4. Saving

Money with the 2012 Medicare Part D Donut Hole Discount

5.

Reminder: You May Now Qualify for Financial Extra Help

6. . . . and A Few Closing Notes

1. Watching

for Changes in Your 2012 Medicare Part D Plan’s Drug Coverage

Question:

I spent a lot of time last year choosing my 2012 Medicare Part D plan and I was

just told that one of my medications, Lipitor, is being dropped from my plan

next month because my plan now covers the generic Atorvastatin. Are Medicare

drug plans allowed to change their drug list during the year?

Yes. Your Medicare Part D plan is allowed to make

changes to your prescription drug plan formulary throughout the plan year.

But, to protect plan Members, Medicare Part D plans are restricted as to the

types of changes made to a drug list. For instance, in your case, your

Medicare Part D plan is permitted to make a lower-costing generic drug

substitution for a brand-name drug as a formulary “maintenance

change”. In other words, since a generic drug equivalent to Lipitor is

now available (Atorvastatin), your Medicare Part D plan can replace the

brand-name Lipitor that you are using with the lower

costing generic equivalent, Atorvastatin.

Please note, a Medicare Part D plan can

also remove a medication from your formulary if there is a health risk related

to the drug or the drug is no longer available from the manufacturer. When

there is a health risk, your plan can remove the drug immediately. When a

prescription drug is being discontinued by the manufacturer, your plan may provide

coverage until there is no longer a supply of the medication available.

Question:

So, is it possible that my Medicare Part D plan could drop any of my

medications from my plan’s formulary - at any time?

Yes, but the change may not affect

you this year. As mentioned above, your Medicare Part D plan is allowed to remove a medication from

their formulary when a lower costing generic equivalent is available or when a

medication poses a health risk. But, if your Medicare prescription drug plan

just removes a medication that you are using during the plan year, without

providing you with a generic alternative, your plan must provide you with

coverage for that medication through the remainder of the plan year - at the

same cost-sharing tier.

Question:

What should I do if my medication is dropped from my drug plan formulary and

the generic form of the medication does not work for me?

Request a Formulary Exception.

If your Medicare Part D plan’s formulary has changed and your medication

is no longer covered (or not covered as before), you have the right to ask your

Medicare plan for a Formulary

Exception (also known as a Coverage Determination). A Formulary Exception

is when you ask that, because of medical necessity, a non-formulary medication

be covered by your plan. Usually, a statement from your physician or

prescriber is included with your request to establish medical necessity.

Remember, you are not guaranteed that your plan will grant your Formulary

Exception request, but if you receive a negative decision, you can appeal the

decision several times. You can click

here to read more about Coverage Determinations. You can also click

here to read more about the appeals process if your Coverage Determinations

is denied.

Question:

Besides dropping a medication from my formulary, what other changes can my

Medicare prescription drug plan make to my formulary during the year?

Besides removing a

medication from your plan’s drug list, your Medicare Part D plan can: add new

medications to your formulary, change usage management requirements, move a

medication to a lower cost-sharing tier, or move a drug to a higher

cost-sharing tier.

Question:

I was notified by my Medicare plan that my medication was not dropped, but

instead now requires that I get prior authorization before my prescription is

filled. Can a plan make such changes as this?

Yes, but the change may not affect

you this year. As mentioned, your 2012 Medicare Part D

plan’s formulary can change in a number of ways throughout the plan-year,

including the addition of utilization management (or drug usage management)

requirements, such as whether you are required to use step-therapy or your

medications are subject to quantity limits or you need to obtain prior

authorization from your plan before your medication is covered.

But, because you are already using this medication before the formulary

change, you may be exempted from such utilization management changes that are

considered by Medicare as “non-maintenance” changes. In other

words, if your Medicare Part D plan has simply added a prior authorization

requirement to one of your existing medications mid-year, you may be exempt

from this change for the remainder of 2012. On the other hand, your Medicare

Part D plan can make utilization management changes that affect you immediately

if there is a legitimate health and safety concern based on the issuance of a

new FDA warning.

Question:

Will my Medicare Part D plan provide me with a notification that they are

changing my plan’s drug list?

Yes, if you are affected by the

change. Your Medicare

Part D plan must either provide you with a 60-day advance written notice of any

changes to your formulary that might affect you or notify you at the time of a

refill and then provide you with a 60-day supply of your medication after you

learn of the formulary change. In practice, most Medicare Part D plans make

every effort to ensure that you are aware of any formulary changes that will

affect you and will send you a written notice of any drug list changes in your

monthly Explanation

of Benefits (or EOB) letter,

plan newsletter, or a special mailing. Your Medicare Part D plan’s

website may also have regularly updated information about formulary changes

online.

If you have a question about formulary changes that we missed, click

here and to let us know.

2. Updates

to our 2012 Drug Search and Formulary Browser Tools

To help you get an idea of the most recent changes to your Medicare

plan’s drug list, we have updated both our online 2012 FormularyBrowser

and DrugFinder

tools with the latest Medicare Part D prescription drug formulary data

available from CMS.

Searching for a Medication Across all

Medicare Plans: Our DrugFinder

Do you want to see which Medicare prescription drug plans now cover a

certain medication? Our updated DrugFinder

allows you to quickly search across all Medicare Part D plans or Medicare

Advantage plans by using either the drug name or 11-digit National Drug Code

(or NDC) that is usually found on your prescription drug container. You can

find our DrugFinder

at: Q1Medicare.com/DrugFinder.

The DrugFinder results show details of how each Medicare plan covers a

particular drug along with the 2012 Medicare plan features and costs. For

instance, you can compare step-therapy, quantity limit, and prior authorization

requirements - along with comparing the cost-sharing (what you pay) for a

specific medication covered by all plans in your area. For example, you can click

here if you would like to see all stand-alone Medicare Part D plans in Florida

covering Plavix 75mg tablet. The follow table shows two examples of the 32

plans in Florida

coverage Plavix 75mg.

Drug: PLAVIX

75MG TABLET (NDC: 63653117105)

2012 Medicare Part D

Plan Information

Plan Name

Monthly

Prem.

De- duct-

ible

Gap

Coverage

Plan

ID

Drug Tier Information

Cost-Sharing

Drug

Usage

Mgmt

Tier

Nbr.

Tier

Description

30-Day

Prfrd.

Pharm

90-Day

Mail

Order

CIGNA Medicare Rx Plan Two (PDP)

$69.10

$0

Few Generics

S5617

-181

3

Preferred Brand Drugs

$41.00

$102.50

None

Browse Plan Formulary

Aetna Medicare

Rx Premier (PDP)

$86.50

$0

Many Generics

S5810

-240

4

Non-Preferred Brand Drugs

$80.00

$225.00

Q:1/1Days

Browse Plan Formulary

Browsing Medications on Your Medicare

Plan’s Drug List: Our FormularyBrowser

Our FormularyBrowser allows you to review drug coverage for any Medicare

Part D plan or Medicare Advantage plan and provides details on cost-sharing,

drug tier, mail order options, and drug usage management (or utilization

management).

You can use the FormularyBrowser by first selecting your state (or

entering ZIP code) and then the name of your Medicare Part D plan. You then

can browse all prescription drugs found within your Medicare Part D

plan’s formulary by drug letter. Using the example in the chart above,

if you were to click the link to “Browse Plan Formulary”, you would

go to either the Florida

CIGNA Rx Plan Two formulary or the Florida

Aetna Medicare Rx Essentials formulary for all drugs starting with the

letter “P”.

If you would like to see if your Medicare Part D plan or Medicare

Advantage plan covers a particular medication, you can access our

FormularyBrowser at: Q1Medicare.com/FormularyBrowser.

Still not sure how these tools work or need more information about your

Medicare Part D plan’s formulary? Click

here to let us know.

3. How Your

Prescription Purchases Count Toward Your Donut Hole

Question:

My Medicare Part D plan told me that I will go into the Donut Hole based on

what I paid for my medications plus what the insurance company paid. Is this

true?

Yes. You will enter the 2012 Donut Hole or Coverage Gap portion of your

Medicare Part D plan when the total " retail cost " of your medication

purchases exceeds your plan’s Initial Coverage Limit of $2,930. This

" retail cost " figure is a combination of what you pay for you your

medications plus the portion paid by your Medicare Part D plan.

For example, if you buy a medication at your local

pharmacy that has a retail cost of $100, you will pay your plan’s

co-payment or cost-sharing, maybe $30, and your plan will pay $70 or the

balance of the $100 retail cost. From this example purchase, the total retail

cost of $100 is counted toward meeting your plan’s $2,930 Initial

Coverage Limit. So once you have purchased medications with a retail value of

over $2,930, you enter your Medicare Part D plan’s 2012 Donut Hole.

Please remember that your Medicare Part D plan’s Initial Coverage Limit

can change every year and in 2013, the standard Initial Coverage Limit will

increase to $2,970. (You can click

here to see how the Initial Coverage Limit has changed

since 2006).

Question:

How much would I need to spend per month on prescription drugs to enter the

2012 Donut Hole?

A monthly retail drug cost of $244 or

more. You will enter the 2012 Donut Hole or Coverage Gap

portion of your Medicare Part D plan after you have purchased $2,930 worth of

medications. So if you have had coverage since January and your monthly

negotiated retail drug costs exceed $244, you should enter the Donut Hole

sometime in December 2012 ($2,930/12= $244.17). This year, all stand-alone

Medicare Part D prescription drug plans use the standard 2012 Initial Coverage Limit of $2,930

as the entry point into the Donut Hole. However, some Medicare Advantage plans

that provide prescription coverage may have different Initial Coverage Limit

values. In other words, depending on your Medicare prescription drug coverage,

you may enter the Donut Hole or Coverage Gap a little earlier than someone who

uses the same medications, but is in another Medicare prescription drug plan.

You can also use our 2012 Donut Hole Calculator or PDP-Planner

to illustrate when you would enter the donut hole. For instance, if you have

monthly retail drug expenses of $500, you would enter the donut hole in month 6

(or June if your plan started on January 1st).

Question:

I currently use two prescriptions and my Medicare Part D insurance does not pay

anything for either one of these drugs. Does the retail cost of these two

medications add into the calculation towards my Doughnut Hole?

No. If a

medication is not covered by your Medicare Part D plan, then the purchase price

for this non-formulary drug is not included in the calculation used to determine

when you reach the Donut Hole – or when you exit the Donut Hole and enter

the Catastrophic Coverage phase of your Medicare prescription drug plan

coverage. You may wish to ask your Medicare plan to include these medications

on your plan’s formulary by requesting a formulary

exemption or coverage determination. With your medications covered, you

will save money with your plan’s cost-sharing. And since only formulary

drugs receive a discount

in the Donut Hole, you would save even more by having the medications

included under your Medicare plan, should you reach the Donut Hole.

4. Saving

Money with the 2012 Medicare Part D Donut Hole Discount

Question:

If I am in the Doughnut Hole and I paid $100 for my medications, and the

Medicare Gap Discount Program has paid $50, does that total of $150 go towards

True Out of Pocket expenses?

Not exactly. If

you are in the Donut Hole or Coverage Gap and you purchase a covered (or formulary)

brand-name medication that has a retail price of $100, you will pay $50 and the

50% Donut Hole Discount will cover $50. However, you will get the full retail

cost credit of $100 toward your total drug spend or TrOOP

(True out of pocket costs). If your medication is a generic drug, your

discount would be 14% and this discount would NOT count toward TrOOP.

Question:

If I am already in the Donut Hole, how much money could I possibly save with

the 2012 Donut Hole Discount?

Around $1,984.

Your actual savings in the 2012 Donut Hole will depend on several things

including your Medicare Part D plan’s cost-sharing structure, how much

you have spent before entering the Donut Hole, and whether you purchase generic

or brand-name medications while in the Donut Hole (generic drugs receive a 14%

discount and brand-name drugs receive a 50% discount). So, if you only

purchase brand-name medications and spend your way through your entire Coverage

Gap or Donut Hole, the maximum amount that you could save would be around

$1,984. You can click

here to read more about how much you might be able to save with the 2012

Donut Hole discount or you click

here to see how the Donut Hole discount increases over the next few years.

Question:

I use a brand-name drug, but it is not covered by my Medicare Part D plan.

Will the 50% discount on brand-name drugs still apply to this drug when I am in

the Donut Hole?

No. The Donut Hole

discount only applies to medications that are included on your plan’s

formulary. If you wish to have your non-formulary medication covered by your

Medicare Part D plan, you would need to ask for a Formulary

Exception or Coverage Determination. If your Medicare plan grants your

request, your medication will be included on your own “personal”

formulary and the Donut Hole discount would apply.

Still have more questions about the 2012 Donut Hole that need answered?

Click

here to let us know.

5. Reminder:

You May Now Qualify for Financial Extra Help

As a reminder, if you are having difficulties this

year paying for your prescriptions, you may want to learn more about the

Medicare Part D Extra Help program by calling the Social Security

Administration at 1- or your local state Medicaid office. Extra

Help is a government program that helps people pay all or part of their monthly

Medicare Part D plan premiums and may cover a significant portion of their

prescription drug costs.

If you qualify for Medicaid, you will automatically

qualify for Extra Help and do not need to apply. However, even if you do not

meet the financial qualifications for Medicaid, you may still qualify for at

least partial benefits from the 2012 Medicare Part D Extra Help program based

on your annual

income and financial

resources. You can click on the following link to learn

more about qualifying for the Medicare Part D Extra Help program: Q1Medicare.com/ExtraHelp.

As many of you know, the Extra Help qualification

limits change each year and Medicare has recently increased the 2012 Extra Help

program financial resource limits for both individuals and couples by 3.4%. In

addition, the 2012 Extra Help annual income limits for individuals increased by

2.6% and the annual income limit for couples increased 2.9%. Households with

more than two persons can determine income requirements by using the 2012 Federal Poverty Level Guidelines.

Unfortunately, some people lost their 2012 Extra Help

benefits this past January when the 3.6% Social Security benefit increase

pushed them above the Extra Help limits, but these people are urged to re-apply

for Extra Help now based on the newly released 2012 Extra Help qualification

limits.

As in past years, if your financial status changes

during the year – in other words, your income and resources fall below

the 2012 Extra Help limits, you may qualify at that point for Extra Help, and

you will continue to receive Extra Help assistance with your Medicare Part D

plan premiums and prescription costs for the remainder of the year, even if

your income or resources were to rise above the established Extra Help limits

later in the year.

Typically, the Extra Help application uses the most

recent tax return information sent to Social Security from the IRS. This would

currently be your 2010 tax return. However, if you have had significant

changes in your income in comparison to your 2010 tax return, you can appeal to

Social Security to use more recent income figures. Please see: How

to appeal the decision Social Security made on your application for Extra Help.

Also, we want to remind our readers about the Medicaid “Spend

Down” program. Medicaid “Spend down” allows you to subtract

your medical expenses (like what you pay for your prescription medications)

from your annual income so that you might become eligible for your

state’s Medicaid program. In other words, you may be eligible for your

state’s Medicaid program based on the principle of “Spend-Down”,

even if you would otherwise earn too much to qualify for Medicaid. You can click

here to read more about Medicaid Spend Down.

6. . . .

and A Few Closing Notes

Protecting yourself against the

summer heat: With the start of summer, remember to take

extra care as the temperatures and humidity climbs. If you are going outside

during the daytime heat, be sure to drink plenty of liquids and avoid drinks

with caffeine (coffee, tea, and some types of soda) or alcoholic beverages that

actually take water from your body. Try to limit your time outside during the

warmest hours of the day and dress to best protect your skin from overexposure

to the sun. If you are indoors, but you are still having trouble staying cool,

try to get to a public place with air conditioning like the local library,

Council on Aging, senior center, shopping mall, movie theatre, or your local place

of worship.

Still Have a Few More Questions?

If you are looking for answers to your Medicare Part D or Medicare Advantage

plan questions simply click

here for our Customer Help Desk contact form.

Would You Like to Receive our Free

Newsletter? Click

here to receive your own copy of the Medicare Part D Newsletter. There is

no cost and your eMail information will not be shared with any third parties.

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use our link function to help you link to one of our pages on Q1Medicare.com

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each page on our website with the text “Click here to link to this page

on your website”. If you click on this link, you will be provided with

the HTML code needed for the particular page. You can use the link just as

listed, or customize the link to your needs. Link

to our online content, but …

Please No Unauthorized Reproduction.

Happy Summer and Best Regards,

, MBA, MSEd, JD

and your Q1Medicare.com Online Team

Q1Group LLC

Q1Medicare.com

About Us: Q1Medicare.com is one of the

nation’s largest online resources for Medicare prescription drug plan and

Medicare Advantage plan information. The Q1Medicare.com site is independently

operated by Q1Group LLC (Saint Augustine,

Florida).

Our Newsletter

and your Privacy: We never share your personal information or

your eMail address with any third parties.

Please Note: As a policy, we do

not send unsolicited eMails. If you no longer wish to receive our Medicare

Part D Newsletter, simply reply to this Newsletter with “unsubscribe”

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Copyright Q1Group LLC, Saint Augustine, Florida

(2012)

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