HealthCare Choices Resource Center - AgeOptions



HealthCare Choices Resource Center

Topical Brief

2012-2013 Medicare Part D

Open Enrollment Period

October 24, 2012

|Medicare Part D Open Enrollment Period |

The Medicare Part D Open Enrollment Period begins October 15th and ends December 7th of 2012. Any changes made during this time period will take effect January 1, 2013. During the open enrollment period, people with Medicare can enroll, disenroll or switch to any Part D plan of their choice, including Medicare Advantage plans. Note: a beneficiary who decides to switch from one plan to another does not need to disenroll from the plan he or she has now. Enrollment into a new 2013 plan will automatically disenroll him or her from the 2012 plan on January 1, 2013.

|Medicare Part D Plans |

A Medicare beneficiary can receive Medicare Part D in one of two ways:

• A stand-alone prescription drug plan (PDP) OR

• A Medicare Advantage plan that includes prescription drug coverage

PDPs are insurance plans offered by private companies that contract with Medicare and offer only Medicare prescription drug coverage for prescriptions on the plan’s formulary (list of covered drugs). Each plan has its own formulary, and premium, deductibles and co-pays vary from plan to plan. PDPs only work with Original Medicare and you must be enrolled in Medicare Part A and/or Part B to be eligible to enroll.

Medicare Advantage plans are another way a beneficiary can receive his or her Medicare benefits in place of original Medicare. Medicare Advantage plans are commonly referred to by many names including MA plans, Medicare Part C or Medicare Health Plans. These types of plans are offered by private companies that have contracts with Medicare. Medicare pays the plan a fixed amount every month to provide health coverage for each person enrolled in the plan. A beneficiary must have Medicare Parts A and B to enroll in an MA plan. MA plans provide all required Part A and B benefits, assistance with out-of-pocket costs in Medicare coverage, and may offer additional benefits such as transportation to the doctor, discounted eyeglasses or hearing aids. The plans may have different co-pays than Original Medicare (e.g., $15 for a doctor’s visit instead of 20%).

MA plans may also include prescription drug coverage; these types of plans are called MA-PD plans and are also considered Part D plans. Beneficiaries enrolled in an MA or MA-PD plan will continue to pay the monthly Part B premium in addition to the MA plan premium, if the plan has one. Beneficiaries who enroll in a Medicare Advantage plan will receive all of their Medicare services through the private Medicare Advantage plan. This means that all claims are submitted and paid by the Medicare Advantage plan and not original Medicare.

In Illinois, Medicare Advantage plan premiums range from $0 to $175 in 2013, depending on the plan. Regardless of the premium, members of the plan are still responsible for a co-payment or co-insurance amount every time they use a service of the plan. Currently the following types of Medicare Advantage plans are offered in Illinois:

• Medicare Health Maintenance Organizations (HMO)

• Preferred Provider Organizations (PPO)

• Private Fee-For-Service (PFFS)

Click here for more information on the how each of these types of plans work.

Medicare beneficiaries and counselors can compare both types of Part D plans on Medicare’s online prescription drug Plan Finder at to determine if their current plan will continue to work for them next year or to find a new plan that will better suit their needs. The Centers for Medicare and Medicaid Services (CMS) have released the list of Medicare Part D plans that will be available in 2013. These plans include stand-alone prescription drug plans (PDPs) and Medicare Advantage (MA and MA-PD) plans. For a complete set of the lists of plans available in 2013 go to: .

|How Part D Will Work in 2013 |

The Medicare Part D standard benefit will change slightly next year. Below is a chart that describes the different phases of Medicare Part D and how the amounts will change from 2012 to 2013.

| |How It Works |2012 Amounts |2013 Amounts |

|Annual Deductible |The amount you pay each calendar year before the plan will begin to |Up to $320 |Up to $325 |

| |provide coverage | | |

|Initial Coverage Limit |You pay a co-pay or co-insurance amount for each prescription and the|$2,930 |$2,970 |

| |plan pays the rest (as long as the drug is on the plan’s formulary). | | |

| |Once what both you and the plan have paid together hits the Initial | | |

| |Coverage limit, you will move into the “Donut Hole” phase. | | |

|Donut Hole (Coverage Gap) |During the “Donut Hole” phase, the Part D plan will not pay anything |$2,930 - $6,657.50 |$2,970 – |

| |toward the cost of your drugs. In 2013, you receive a 52.5% discount|(Donut Hole Phase ends once |$6,733.75 |

| |on brand names and 21% discount on generics during the Donut Hole |TrOOP is met-see below.) |(Donut Hole Phase ends once |

| |phase. | |TrOOP is met-see below.) |

|Catastrophic Coverage |After this point, the plan pays 95% of drug expenses and you pay 5% |$6,657.50 or more |$6,733.75 or more |

| |or a co-pay of $2.65 (for generics or preferred multi-source drug) or| | |

| |$6.60 (for all other drugs on formulary) – whichever is higher | | |

|True Out-of-Pocket Threshold |TrOOP expenses determine when a beneficiary’s catastrophic coverage |$4,700 |$4,750 |

|(TrOOP) |will begin and is tracked by the Part D plan. | | |

|Stand-Alone PDPs in Illinois |

|Stand-Alone PDPs in Illinois |

| |2012 |2013 |

|Number of PDPs in IL |33 |34 |

|Annual Deductible |$0 - $320 |$0 - $325 |

|Monthly Premium |$15.10 - $115.20 |$15.00 - $118.90 |

|Number of plans that offer a $0 premium with full |10 |10 |

|LIS | | |

|Number of plans that offer some coverage in the gap|9 |11 |

|Benefit type |17 Basic plans |18 Basic |

| |16 Enhanced plans |16 Enhanced Plans |

Click here to view a landscape (spreadsheet) of all stand-alone PDPs offered in Illinois in 2013. The chart also lists which plans coordinate with Extra Help (also referred to as the Low-Income Subsidy or LIS).

MMW has also created a chart that compares 2012 and 2013 PDPs in Illinois. The chart includes: changes in plan premiums, deductibles, and type of coverage offered in the gap, which plans will no longer be offered, and which plans will offer a $0 premium with full Extra Help. Click on the link to view the chart:

.

|Full LIS $0 Premium Plans |

Stand-Alone PDPs

In 2013, ten stand-alone PDP plans will offer a $0 monthly premium to people who have full Extra Help. CMS will pay the entire monthly Part D plan premium for beneficiaries with full Extra Help if the plan is a basic plan and the monthly premium is at or below a certain premium amount, called the Extra Help benchmark. In Illinois, the Extra Help benchmark premium amount for 2013 is $30.94. This amount is calculated by CMS for each geographic region and changes every year.

Note: Individuals with full Extra Help may enroll in any plan they choose (they are not limited to plans on the list below) but they will be responsible for any amount of the monthly premium that is over the benchmark. However, Extra Help will still pay the annual deductible and provide them with low prescription drug co-pays for drugs on the plan’s formulary regardless of the Medicare Part D plan they are enrolled in (over or under the benchmark). If an individual with full Extra Help enrolls in an “enhanced” plan instead of a basic plan, the individual will be responsible for the portion of the plan’s premium that accounts for the “enhanced” benefit.

In 2013, depending on the level of Extra Help a beneficiary receives (full or partial), he or she will pay the following co-pays for each 30-day supply filled:

Full Extra Help - between $1.15 and $6.50 for each 30-day supply

Partial Extra Help - $2.65, $6.60 or up to 15% coinsurance for each 30-day supply

Below is a list of PDP plans that will offer a $0 premium with full Extra Help in 2013.

|Company Name |Plan Name |Monthly Drug Premium (Medicare|Annual Drug Deductible |

| | |will pay this premium for |(Medicare will pay the deductible for |

| | |individuals with full LIS) |individuals with full LIS) |

|Aetna Medicare |Aetna CVS/pharmacy Prescription Drug Plan |$29.30 |$325 |

| |(S5810-051) | | |

|CIGNA Medicare Rx |CIGNA Medicare Rx Plan One |$31.30 |$325 |

| |(S5617-224) | | |

|EnvisionRx Plus |EnvisionRxPlus Silver |$29.70 |$325 |

| |(S7694-017) | | |

|HealthMarkets Medicare |Reader’s Digest Value Rx |$32.00 |$325 |

| |(S0128-018) | | |

|HealthSpring Prescription Drug Plan |HealthSpring Prescription Drug Plan-Reg 17|$32.90 |$325 |

| | | | |

| |(S5932-016) | | |

|Humana Insurance Company |Humana Walmart-Preferred Rx Plan |$18.50 |$325 |

| |(S5884-107) | | |

|SilverScript |SilverScript Basic (called CVS Caremark |$31.20 |$325 |

| |Value in 2012) | | |

| |(S5601-034) | | |

|SmartD Rx |SmartD Rx Saver |$29.60 |$325 |

| |(S0064-017) | | |

|United American Insurance Company |United American – Select |$30.00 |$325 |

| |(S5755-088) | | |

|United Healthcare |AARP MedicareRx Saver Plus |$15.00 |$325 |

| |(S5921-362) | | |

PDP plans that will no longer offer a $0 premium with full LIS in 2013

• Community CCRx Basic (plan discontinued in 2013) (S5803-086)

• First Health Part D Premier (S5768-042)

• WellCare Classic (S5967-154)

New PDP plans that will offer a $0 premium with full LIS in 2013

• Readers Digest Value Rx (S0128-018)

• Smart D Rx Saver (S0064-017)

Click on the following link for a printable version of this chart along with the current LIS income and asset limits:

|Medicare Advantage Plans in Illinois and Cook County |

|State of Illinois: MA-PDs (MA plans that include drug coverage) |

|Illinois |2012 |2013 |

|Number of MA-PD plans |614 |700 |

|Annual drug deductible |$0 - $320 |$0 - $325 |

|Monthly premium range in IL |$0 - $165 |$0 - $175 |

|Number of plans that offer some coverage in the gap |157 |156 |

| | | |

|Cook County: MA-PDs |

|Cook County |2012 |2013 |

|Number of MA-PD plans offered in Cook County |11 |12 |

|Annual deductible |$0 - $320 |$0 - $325 |

|Premium range in Cook County |$0 - $121 |$0 - $132 |

|Number of plans that offer some coverage in the gap |3 |3 |

Click here to view a landscape of all 2013 Medicare Advantage plans offered in Illinois by county.

Click here to view a list of Medicare Advantage plans offered only in Cook and the Collar counties:



Medicare Advantage Plans for Individuals with Extra Help

Medicare Advantage plans that include prescription drug coverage (MA-PD plans) also work with Extra Help. MA-PD plans vary in premium. Some plans offer $0 monthly premium and others have a premium for health and prescription coverage. Beneficiaries in Medicare Advantage plans continue to pay their monthly Part B premium in addition to any extra premium amount the plan charges. (Some plans that offer a $0 premium do so because Medicare pays the private Medicare Advantage plan a fixed rate per member to provide beneficiaries with their Part A and B benefits.)

If an individual qualifies for Extra Help and is also enrolled in a MA-PD plan, Extra Help will help him or her pay for the prescription drug coverage portion of the plan premium, but not the health portion. The beneficiary is still responsible for the plan’s set co-pay or co-insurance amounts for health services such as the doctor’s co-pay amount, specialist co-pay, etc. Extra Help will not help to pay for the health co-pays set by the plan – just the prescription drug co-pays.

The same Extra Help guidance for people in stand-alone PDPs applies to people in MA-PD plans. This means they will receive help with their drug co-pays, annual drug deductible, and if the MA-PD plan has a premium, any portion of the premium that is specified for drug coverage and below the Extra Help benchmark as discussed earlier in this Brief.

Click here for a tip sheet created by MMW that lists the MA-PD plans in Cook and the Collar counties that offer $0 drug premium for beneficiaries with full Extra Help:



Click here to view a useful CMS spreadsheet that lists the amount of the premium Extra Help will pay for all Part D plans in Illinois (MA-PD and PDP plans), including partial Extra Help coverage:



Medicare Advantage Plan Maximum Out of Pocket Limits

Beginning January 1, 2011, CMS requires all MA plans, including Special Needs Plans, to set an annual maximum out-of-pocket (MOOP) limit of no more than $6,700 for Part A and Part B services received at in-network providers. This means that once a beneficiary reaches the MOOP amount, they no longer have to pay any co-pays or co-insurance for in-network Part A and B services for the remainder of the calendar year. MOOP limits vary by plan - many are lower than $6,700. Please note: prescription drugs are not included in the MOOP amount. You may find the MOOP amount for a specific MA plan by contacting the plan or doing a health plan search (prescription drug Plan Finder) on .

|Special Needs Plans |

Medicare Special Needs Plans (SNPs) are Medicare Advantage plans for people with Medicare Parts A and B and who:

• are dual-eligibles (have both Medicare and Medicaid)

• are institutionalized or

• have a specific chronic or disabling condition.

The three types of SNPs are different than regular MA plans in that they are designed to tailor benefits, provider choices and formularies to the needs of the specific group of people the SNP serves. All SNPs must include prescription drug coverage, and an individual must fall into one of the categories listed above to be eligible to enroll.

|Special Needs Plans in Illinois |

|Illinois |2012 |2013 |

|Number of SNPs |34 |216 |

|Monthly premium range |$0 - $30.20 |$0 - $30.90 |

|Annual drug Deductible |$0 - $320 |$0 - $325 |

|Coverage in the gap |None of the plans offer coverage in the gap |1 |

|Type of SNP |Chronic or disabling condition: 16 |Chronic of disabling condition: 189 |

| |Dual-eligible: 14 |Dual-eligible: 23 |

| |Institutional: 4 |Institutional: 4 |

(Continued on next page)

|Special Needs Plans in Cook County |

|Cook County |2012 |2013 |

|Number of SNPs |3 |4 |

|Monthly premium range |$13.70 - $30.20 |$7.50 - $30.90 |

|Annual drug Deductible |All plans have a $320 drug deductible |All plans have a $325 drug deductible |

|Coverage in the gap |None of the plans offer coverage in the gap |None of the plans offer coverage in the gap |

|Type of SNP |Dual-eligible: 2 |Dual-eligible: 3 |

| |Institutional: 1 |Institutional: 1 |

| |Chronic or disabling condition: 0 |Chronic or disabling condition: 0 |

Click here to view a landscape of Special Needs Plans offered in Illinois by county.

Use the link below to view a list of Special Needs Plans (SNP) in Cook and the Collar counties that offer a $0 drug premium if a beneficiary has full Extra Help:



|Part D and the Donut Hole in 2013 |

In 2013, the Medicare Part D coverage gap (also referred to as the donut hole) will begin when the beneficiary has filled $2,970 worth of formulary drugs with their Part D plan. This is the full cost of the drugs, not just the co-pay amounts the beneficiary is charged at the pharmacy. This amount includes what the beneficiary and the plan pay. Due to the Affordable Care Act, beneficiaries will continue to receive discounts once they enter the donut hole. In 2013, beneficiaries will receive a 52.5% discount on brand name drugs and a 21% discount on generics. The discounts are off the full cost of the drugs and will be applied immediately at the pharmacy counter once a person enters the donut hole.

The donut hole discounts are provided in part by drug manufacturers and in part by the federal government. In 2013, 50% of the brand name drug discount will be covered by the drug manufacturer, and the other 2.5% will be provided by the government. The full 21% generic discount is provided by the government. The portion of the donut hole discount that is covered by the drug manufacturers counts toward a beneficiary’s True Out-of-Pocket (TrOOP) costs. This means what the individual pays out of his/her own pocket and 50% of the discount they receive during the coverage gap on brand-name drugs will apply to the amount they need to get out of the donut hole ($4,750 in 2013) and move into catastrophic coverage. The portion of the donut hole discounts that is paid by the government does not count toward TrOOP. This means that the additional 2.5% brand-name discount and the full 21% discount on generics do not apply to a beneficiary’s TrOOP amount. Coverage gap discounts are reflected in the online prescription drug Plan Finder when searching and comparing plans.

The discounts for brand name and generic drugs will increase each year until 2020 when the donut hole is eliminated. Beginning in 2020, beneficiaries will pay the standard Medicare Part D

cost-sharing amount (the regular co-pay or co-insurance amounts) for their drugs throughout the calendar year.

|Network and Preferred Pharmacies |

Network and Preferred Pharmacies

Each Medicare Part D plan works with a network of pharmacies their members may use to fill their prescription drugs. If a member uses a pharmacy that is not part of the plan’s network, the plan may not cover the member’s drugs. Each pharmacy network varies from plan to plan.

A preferred pharmacy is in a plan’s network and has an agreement with the plan to provide additional savings to members if that pharmacy is used. Preferred pharmacies offer lower co-pays than a network pharmacy. Therefore, it is important to check the difference in cost sharing at a ‘preferred’ vs. a ‘network’ pharmacy. Doing so may save the beneficiary money during the year. For example, the First Health Value Plus plan has network and preferred pharmacies in 2013. A tier 1 preferred generic drug filled at one of this plan’s network pharmacies costs $7 for a one-month supply, but the same drug is $0 if filled a preferred pharmacy. (Please note that while all Part D plans have a network of pharmacies for their members to use, not all of them have preferred pharmacies.)

You may view a list of network pharmacies on the Medicare online prescription drug Plan Finder at and pull up a list of preferred pharmacies for a specific plan. Use the link below to view a step-by-step guide created by the MMW Coalition on how to view a list of preferred pharmacies:



|New SEP for People in Low-Rated Part D plans |

CMS has established a new special enrollment period (SEP) for beneficiaries in low performing Part D plans. The new SEP will allow individuals in Part D plans that received an overall star rating of less than three stars for three or more years to switch to another higher-rated Part D plan. These low rated plans are highlighted on the online prescription drug plan finder with the following special symbol: [pic]

In late-October, CMS will mail letters to an estimated 525,000 beneficiaries in low performing plans. The letter informs them that their plan received a low rating, and if they do not make a switch during the Annual Enrollment Period (October 15 – December 7), they will receive a one-time SEP in 2013 to change plans (if they choose do so). Individuals will only be able to use this SEP to switch to a higher-rated plan with three or more stars. In addition, an individual who decides to use this SEP will need to call 1-800-Medicare directly and cannot make the switch by calling the plan.

Click here to view the 2013 CMS guidance letter to Part D plans that contains information about this new SEP (see page 87).

Please visit to access all the handouts listed in this Topical Brief.

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As always, feel free to contact us with any comments or questions. If you would like to unsubscribe and not receive updates and information from the Make Medicare Work Coalition, please contact us by calling (708)383-0258 or emailing Erin.Weir@.

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