• Less is More
• Preparing for the New Medicare Prescription Drug Law

As of January 1, 2006, people on Medicare, whose prescription drug costs are covered by MassHealth, will now get their prescriptions through a private insurance plan affiliated with Medicare.

Three names for the new law are the Medicare Modernization Act (MMA), Medicare Part D, and the Medicare Prescription Drug Law.

Who is not affected by the new MMA law?

Recipients who don't have Medicare, but only have MassHealth are not affected by this new law.

Who is affected b y the MMA law?

Everyone on Medicare, except people who were just recently approved for SSDI who haven't gotten Medicare yet.

What Do I Need to Do?

People who have both Medicare and Medicaid are called "dual-eligibles." These people will be automatically enrolled in a new insurance plan in the fall. This is only done as a backup protection. You will still need to review the plans and pick one that works best for you.

If you receive both Medicare & MassHealth (including CommonHealth), you will receive a full subsidy of your costs for a new Medicare Prescription Drug plan. This is automatic-you do not have to apply or do anything. Medicare does not consider your income or assets for this help.

You will need to choose an insurance plan to cover your prescriptions:

Although we don't know which companies will be providing coverage, we do know the type of plans that will be offered.

There may be as many as 25 plans to choose from, according to the Boston Globe (Sept 23, 2005), Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim HealthCare and Tufts Health Plan, as well as several out of state, for-profit health plans. Each provider may offer more than one insurance plan.

The insurance companies are going to use "formularies" to decide which drugs they will cover. A formulary is a list of the medications and rules like "needs prior approval" that applies to each category of medication covered.

The law requires that for most medication families, at least two medications be provided. However, "all or substantially all" of the medications of the following types must be in the formularies: antipsychotics, antidepressants, anticonvulsants, immunosuppressants, cancer drugs and Aids-related medications (anti-retrovirals).

Some drugs will not be included on formularies, such as benzodiazepines (e.g. Ativan, Klonopin, Xanax), Phenobarbital, weight-related medications, and some over-the-counter medications. However, you can continue to gets these medications through MassHealth, if you have MassHealth.

Two other types of formularies keep costs down for insurance companies. The first is called "step therapy," more commonly known as "fail first." This type of formulary requires you to begin a type of medication on the first "step," which generally has only generic drugs. If this medication doesn't work, you would then "step up" to the next medication.

The other type of formulary is based on the amount you have to pay towards a medication, using "tiers" instead of steps. In this formulary, you will pay a higher percentage of more expensive drugs on upper tiers. Here's an example:

FORMULARY FOR COMPANY ABC

To reduce the costs to you:

People on both MassHealth and Medicare will be given "subsidies" to reduce their costs.

If you have both MassHealth and Medicare you won't have to pay any deductibles or "gaps" in coverage. If your income is low you'll have a co-payment of only $1.00 for generic and $3.00 for brand-name medication. If your income is higher, you'll pay $2.00 for generic and $5.00 for brand-name drugs.

People with only Medicare, with low income and resources, are also eligible for subsidies.

Without subidies, Medicare plans include out-of-pocket monthly premiums, an annual deductible, co-payments for medications, and, in some cases, a gap where you must pay 100% of your medication costs.

If you have just Medicare and also have low income and resources you are also eligible for help with costs. You have to apply for this help. You can go online, or go to your local Social Security office or to your local Office of Medicaid. The amount of the subsidy varies-you must be below the income and resource limit to be eligible. Certain items are not counted against you, such as a house, car, etc.

How do I choose an insurance plan?

You may want to consider moving into a Medicare Advantage managed care company. Here are some things to think about to help decide what plans to eliminate and which to consider when they become known:

• Do any of my friends or family get health care from local carriers, such as Tufts, Harvard Pilgrim and Blue Cross Blue Shield for Eastern Mass? How satisfied are they?
• Does my doctor think there might be changes in my medications? If so, is he or she willing to participate in the appeals process with me?

There will be more to consider when more information about the insurance companies will be offering becomes known, and other more specific information is available about enrolling, choosing a plan, etc…

The Key Dates:

If you need information about what plans are available to you or help choosing a Medicaid Prescription Drug plan that best meets your needs, contact an insurance consultant at S.H.I.N.E. (Serving the Health Needs of Elders). This agency can help people with disabilities, and can be reached at 800-AGE-INFO or 800-243-4636.