HealthCare Choices Resource Center - AgeOptions
Make Medicare Work Coalition
Topical Brief
2013-2014 Medicare Part D
Open Enrollment Period
November 8, 2013
|Medicare Part D Open Enrollment Period |
The Medicare Part D Open Enrollment Period begins October 15th and ends December 7th of 2013. Any changes made during this time period will take effect January 1, 2014. 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 2014 plan will automatically disenroll him or her from the 2013 plan.
| Plan Finder Resources |
Medicare has created a training website and provided training scenarios for counselors who would like to practice using the Plan Finder. To access the site and training scenarios please visit click here.
Medicare has also created YouTube videos that explain how to use and navigate the Plan Finder. Click here to view the videos.
The MMW Coalition also recently hosting a webinar tutorial on how to use Medicare’s Plan Finder tool. Click here for the webinar recording and slides and scroll down to the section called “Medicare Plan Finder Resources”.
|Medicare Part D Plans |
A Medicare beneficiary can receive Medicare Part D in one of two ways:
• A stand-alone prescription drug plan also called a PDP OR
• A Medicare Advantage plan that includes prescription drug coverage (called a MA-PD)
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 beneficiary 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 Medicare’s out-of-pocket costs, 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 $159 in 2014, 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 2014. These plans include stand-alone prescription drug plans (PDPs) and Medicare Advantage (MA and MA-PD) plans. To view the landscape lists of all Part D plans available in 2014 go to: .
|How Part D Will Work in 2014 |
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 2013 to 2013.
| |How It Works |2013 Amounts |2014 Amounts |
|Annual Deductible |The amount you pay each calendar year before the plan will begin to |Up to $325 |Up to $310 |
| |provide coverage | | |
|Initial Coverage Limit |You pay a co-pay or co-insurance amount for each prescription and the|$2,970 |$2,850 |
| |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 reaches 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 |$2,970 - $6,733.75 |$2,850 – |
| |toward the cost of your drugs but you will receive discounts. In |(Donut Hole Phase ends once |$6,455 |
| |2014, you receive a 52.5% discount on brand names and 28% discount on|TrOOP is met-see below.) |(Donut Hole Phase ends once |
| |generics during the Donut Hole phase. | |TrOOP is met-see below.) |
|Catastrophic Coverage |After this point, the plan pays 95% of drug expenses and you pay 5% |$6,733.75 or more |$6,455 |
| |or a co-pay of $2.55 (for generics or preferred multi-source drug) or| | |
| |$6.35 (for all other drugs on formulary) – whichever is higher | | |
|True Out-of-Pocket Threshold |TrOOP expenses determine when a beneficiary’s catastrophic coverage |$4,750 |$4,550 |
|(TrOOP) |will begin and is tracked by the Part D plan. | | |
|Stand-Alone PDPs in Illinois |
|Stand-Alone PDPs in Illinois |
| |2013 |2014 |
|Number of PDPs in IL |34 |33 |
|Annual Deductible |$0 - $325 |$0 - $310 |
|Monthly Premium |$15.00 - $118.90 |$12.60 - $125.50 |
|Number of plans that offer a $0 premium with full |10 |12 |
|LIS | | |
|Number of plans that offer some coverage in the gap|11 |6 |
|Benefit type |18 Basic |17 Basic |
| |16 Enhanced Plans |16 Enhanced |
** Please note the chart above does not include sanctioned Part D plans.
Click here to view a landscape (spreadsheet) of all stand-alone PDPs offered in Illinois in 2014. The chart also lists which plans will offer a $0 premium with full Extra Help (also referred to as the Low-Income Subsidy or LIS).
MMW has also created a chart that compares 2013 and 2014 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 link below to view the chart:
|Full LIS $0 Premium Plans |
Stand-Alone PDPs
In 2014, twelve 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 2014 is $28.59. This amount is calculated by CMS for each geographic region and changes every year. Please note some Part D plans may decide to waive the premium for people with full Extra help if the plan’s premium is less than $2 over the benchmark amount (called the “de minimis amount”).
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. For example, in 2014 in Illinois, the Humana Walmart Rx plan has a monthly premium of $12.60 which is below the LIS benchmark amount for 2014. However, a beneficiary with full Extra help who enrolls in this plan would be responsible for a $6.10 monthly premium because this plan in an Enhanced plan and LIS will not pay the portion of the premium that makes the plan enhanced.
In 2014, 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 $1.20 and $6.35 for each 30-day supply
Partial Extra Help - $2.55, $6.35 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 2014.
|Company Name |Plan Name |Monthly Drug Premium (Medicare will pay |Annual Drug Deductible |
| | |this premium for individuals with full |(Medicare will pay the deductible for |
| | |LIS) |individuals with full LIS) |
|Advantage-Plus Meridian |Advantage-Plus Meridian (S7610-001) |$27.40 |$310.00 |
|Aetna Medicare |Aetna CVS/pharmacy Prescription Drug |$27.80 |$310.00 |
| |Plan | | |
| |(S5810-051) | | |
|Cigna Medicare Rx |Cigna Medicare Rx Secure (called Cigna |$26.40 |$310.00 |
| |Medicare Rx Plan One in 2013) | | |
| |(S5617-224) | | |
|Cigna-HealthSpring |Cigna-HealthSpring Rx -Reg 17 |$29.10 |$310.00 |
| |(S5932-016) | | |
|EnvisionRx Plus |EnvisionRxPlus Silver |$30.60 |$310.00 |
| |(S7694-017) | | |
|HealthMarkets Medicare |HealthMarkets Value Rx (called Reader’s|$28.30 |$310.00 |
| |Digest Value Rx in 2013) | | |
| |(S0128-018) | | |
|HISC - Blue Cross Blue Shield of |Blue Cross MedicareRx Basic |$23.00 |$310.00 |
|Illinois |(S5715-012) | | |
|Humana Insurance Company |Humana Preferred Rx Plan |$22.80 |$310.00 |
| |(S5884-107) | | |
|Symphonix Health |Symphonix Value Rx |$27.90 |$310.00 |
| |(S0522-001) | | |
|United American Insurance Company |United American - Select |$29.30 |$310.00 |
| |(S5755-088) | | |
|UnitedHealthcare |AARP MedicareRx Saver Plus |$22.60 |$310.00 |
| |(S5921-362) | | |
|WellCare |WellCare Classic |$19.90 |$0 |
| |(S5967-154) | | |
New PDP plans that will offer a $0 premium with full LIS in 2014
• Advantage-Plus Meridian (S7610-001)
• Blue Cross MedicareRx Basic (S5715-012)
• Symphonix Value Rx (S0522-001)
• WellCare Classic (S5967-154)
These plans will offer $0 premiums for current members with LIS in 2014, but are not enrolling new members:
• SivlerScript Basic (S5601-034) (Under sanction effective 1/15/2013
• SmartD Rx Saver (S0064-017) (Under sanction effective 4/23/13)
Click here 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 |2013 |2014 |
|Number of MA-PD plans |700 |648 |
|Annual drug deductible |$0 - $325 |$0 - $310 |
|Monthly premium range in IL |$0 - $175 |$0 - $159 |
|Number of plans that offer some coverage in the gap |156 |151 |
|Cook County: MA-PDs |
|Cook County |2013 |2014 |
|Number of MA-PD plans offered in Cook County |12 |15 |
|Annual deductible |$0 - $325 |$0 - $310 |
|Premium range in Cook County |$0 - $132 |$0 - $152 |
|Number of plans that offer some coverage in the gap |3 |5 |
Click here to view a landscape of all 2014 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) 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. The 2014 amount is $6,700 but many have lower amounts and limits vary by plan. 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 |2013 |2014 |
|Number of SNPs |216 |86 |
|Monthly premium range |$0 - $30.90 |$0 - $28.60 |
|Annual drug Deductible |$0 - $325 |$0 - $310 |
|Coverage in the gap |1 |1 |
|Type of SNP |Chronic or disabling condition: 189 |Chronic or disabling condition: 52 |
| |Dual-eligible: 23 |Dual-eligible: 30 |
| |Institutional: 4 |Institutional: 4 |
|Special Needs Plans in Cook County |
|Cook County |2013 |2014 |
|Number of SNPs |4 |4 |
|Monthly premium range |$7.50 - $30.90 |$8.90 - $28.50 |
|Annual drug Deductible |All plans have a $325 drug deductible |All plans have a $310 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: 3 |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.
Click here 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 2014 |
In 2014, the Medicare Part D coverage gap (also referred to as the donut hole) will begin when the beneficiary has filled $2,850 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 2014, beneficiaries will receive a 52.5%) discount on brand name drugs (same as in 2013) and a 28% 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 2014, 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 28% 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 ($4,550 in 2014) 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 28% 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 network 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 network pharmacies offer lower co-pays than a network pharmacy. Therefore, it is important to check the difference in cost sharing at a ‘preferred network’ vs. a ‘network’ pharmacy. Doing so may save the beneficiary money during the year. For example, the First Health Part D Value Plus plan has network and preferred pharmacies in 2014. A tier 1 preferred generic drug filled at one of this plan’s network pharmacies costs $10 for a one-month supply, but the same drug is $3 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. Click here to view a step-by-step guide created by the MMW Coalition on how to view a list of preferred pharmacies.
|Coverage of Generics in Deductible Phase |
One new feature to look for when comparing plans is whether the plans provide coverage of generics during the deductible phase. In 2014, some of the plans that have a deductible (the amount the beneficiary is responsible for paying before the plan begins to pay its share) will provide coverage for certain generics even if the deductible is not met. If a certain drug is covered during the deductible phase, this information will appear on the plan finder tool. You can click on a specific plan’s name for more details.
|New SEP for People in Low-Rated Part D plans |
CMS has established a 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 mailed letters to 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 2014 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).
To access the Make Medicare Work Coalition’s materials on Medicare, Medicaid, and the Affordable Care Act or to sign up for our MMW e-mail list, please visit our website:
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