HHS Answers Your Prescription Drug Benefit Questions

ABC News asked viewers and readers to submit their questions on the new Medicare prescription-drug benefit for the Department of Health and Human Services. The following are several of those questions, and the answers from HHS.

Question from Jim: Sec. Leavitt [Sunday] on "This Week" said that "all" seniors should sign up with an insurance company for a new prescription-drug plan. Should he have added an exception for those, like myself, who are currently employed full time and have an employer health care and prescription-drug insurance plan?

Answer from HHS: If you currently have insurance coverage for your medications through an employer or a retiree plan that is "creditable coverage," -- meaning it is as good as or better than the Medicare prescription-drug coverage -- you do not need to enroll in a Medicare drug plan at this time. Your current or former employer should have sent you a letter stating whether its prescription-drug coverage is as good as that offered under Medicare. The best sources of information about your prescription-drug coverage are the communications you get from your current or former employer or union (or the plan that administers your prescription-drug coverage).

Medicare is working to support good quality retiree coverage by providing subsidies to employers who offer that coverage. That way, if you are a retiree with good coverage, you get to keep it.

You can sign up for a Medicare prescription-drug plan later without penalty if your current or former employer is offering creditable coverage.

Question from Eric: Is it true that, while a senior who selects a plan based on his medications is locked into that plan for one year, the plans may change the drug coverage they offer at any time, possibly making the senior's plan selection undesirable?

Answer from HHS: Enrollment in a Medicare prescription-drug plan is generally for the calendar year. You can choose to switch your current plan every year during the open-enrollment period between Nov. 15 and Dec. 31. In addition, in certain cases, such as if you move or enter a nursing home, you can switch your plan at other times.

If you have both Medicare and Medicaid, you can change plans at any time.

The prescription-drug plans approved by Medicare must cover all medically necessary treatments. Most plans will have a formulary, which is a list of drugs covered by the plan. In many cases, those limitations on those formularies will come when there are many drugs that treat common conditions. This list must always meet Medicare's requirements, but it can change when plans get new information. Your plan must let you know at least 60 days before a drug you use is removed from the list or if the costs are changing. In addition, Medicare requires that the plans cover all or substantially all of the drugs for conditions such as HIV/AIDS or cancer.

Question from Sharon: On Sunday's program, Secretary Leavitt said that all medically necessary drugs are required to be covered by the new Medicare prescription-drug program. That is a misleading statement, if not a deliberate untruth. I need vitamin supplements, ordered by my doctors for tested medical conditions. One is for vitamin B-12 and others are calcium, magnesium, vitamin D, and others to treat osteoporosis. Because of new research about using vitamin D to fight MS, my neurologist has ordered it. In other cases, drugs like basic painkillers are "necessary" for a decent life, but available over the counter. Medicare is not required to buy them and doesn't. They will buy some, but not all, prescription drugs manufactured by phARMA, but not other needs like OTCs and vitamins, even if they are "medically necessary". Many of us can't afford even these and this isn't the kind of program we need. Will you please ask Secretary Leavitt about this and urge him to include these coverages in the program? Otherwise, it is a farce, because doctors try to keep costs down by ordering OTC drugs instead of pharmaceuticals when they can, and in some cases, the necessary treating chemicals are vitamins.

Answer from HHS: When Congress wrote the law designing the prescription-drug benefit, it specifically excluded certain types of medications from coverage, including vitamins and certain lifestyle drugs such as those for weight loss or hair loss, and some potentially addictive medications known as benzodiazepines. Within the confines of the law, we don't have authority to cover these medications, or, for that matter, over-the-counter medications. You may consider talking with your physician about alternative prescription-drug options. In addition, certain prescription-drug plans may make coverage for certain over-the-counter or other excluded medications available to beneficiaries as a "supplemental benefit" for an additional premium.

Question from Marcy: There are several prescription drugs that I take only occasionally (Ambien for one -- I take one or two a month at most) and one I take every three months (estring). How can I fit these into your computer Medicare program so that I can be sure that the insurance company the computer recommends is the right one for me? It tells me I take 30 Ambien a month rather than one or two, for example. I can't seem to adjust the number to accord with my reality. Help!

Answer from HHS: The Web-based prescription-drug plan comparison tool at www.medicare.gov does allow users to enter dosages for each prescription. Once you have entered the names of the medications, you'll need to look for the button that says "Change/Update My Drug Dose & Quantity." The comparison tool defaults to a typical dosage and quantity for the drugs that you enter, but once you select "Change/Update My Drug Dose & Quantity" button, you will be able to modify the dosage and quantity. You can also call 1-800-MEDICARE to get this information.

Question from Maxine: I am retired from General Motors and the union said we do not have to sign up for part D because we have drug coverage. With GM being so unstable, if they cancel our drug coverage do we get penalized for signing up late?

Answer from HHS: By now you should have received information to let you know whether your retiree prescription-drug coverage is as good as or better than standard prescription-drug coverage. You need to know this information before you decide whether to join a Medicare drug plan, and if you do not know yet, you should call your former employer. If your coverage is as good or better than Medicare's standard coverage, you will not have to pay a penalty if your employer decides to drop coverage at a later date. If your retiree prescription-drug coverage is not, on average, at least as good as standard Medicare prescription-drug coverage, you may have to pay a penalty if you wait to join a Medicare drug plan until after you are first eligible.

You have a legal right to this information. If you have not received the information, you should ask your former employer or union (or the plan that administers your retiree prescription-drug coverage) for it. Some employers and unions will include this information with other communications they may give you about your retiree prescription-drug coverage.

If your employer chooses to discontinue its retiree coverage at a later date (after May 15, 2006), the employer is required to give you two months' notice and you will have a special enrollment period with the Medicare prescription-drug plans. During the special enrollment period, you can select a plan that will serve your needs without a penalty.

Question from Anthony: I belong to the VA prescription-drug benefits program. Do I still have to sign up for the Medicare program? I just heard Sec. Mike Leavitt say on ABC every senior citizen should sign up even for the lowest program so they won't feel penalized later. What are the facts?

Answer from HHS: As long as you still qualify, your TRICARE, VA or FEHB prescription-drug coverage is not changing. You should contact your benefits administrator or FEHB insurer for information about your TRICARE, VA or FEHB coverage before making any changes. It will almost always be to your advantage to keep your current coverage without any changes. If you lose your TRICARE, VA or FEHB coverage, and you join a Medicare drug plan after May 15, 2006, in most cases, you won't have to pay a penalty, as long as you join within 63 days of losing TRICARE, VA or FEHB coverage.

Question from D.J.: Why is there a penalty period at all?

Answer from HHS: Congress developed the drug-benefit enrollment periods and penalties to encourage people to enroll in the beginning, or when they first become eligible, instead of waiting until they are sick and their health care costs are higher. This policy is intended to ensure affordable premiums for everyone, and it works very similar to Medicare Part B, which covers physician visits and outpatient services. People who sign up later for Medicare Part B also pay more.

As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay your lowest possible monthly premium for as long as you have prescription-drug coverage. If you don't join a plan by May 15, 2006, and you don't currently have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage, then you will have to wait until the next open-enrollment period to join. The next open-enrollment period is from Nov. 15 to Dec. 31 of 2006. When you do join, your premium cost will go up at least one percent per month for every month that you wait to join.

People who are fortunate enough now to not take many prescription drugs still may need the coverage as a form of protection against unforeseen higher costs in the future. In everywhere but Alaska, there are prescription-drug plans that offer this peace of mind for less than $20 a month.

Question from Darrell: What happens if sometime during the next year, you get a new prescription that is not covered by the plan you chose. What to do if your premium is more than your actual medicine expense?

Answer from HHS: If you need a drug that is not on the covered drug list, or that is on the list but you think it should be covered for a lower co-payment, you can do the following:

  • Contact the plan and ask for an exception. You will probably have to provide information from your doctor about why you need the drug your plan won't cover.
  • If your plan denies the exception, you can appeal. Your plan must give you information on how to appeal.

On your second question -- if you have very low drug costs, such that they are actually lower than your monthly premium, there are still two very good reasons to enroll. First, you will be avoiding the late-enrollment premium penalty in later years when you might have expenses that exceed your premiums. This penalty amounts to at least one percent per month, for every month that you wait to join, and it applies for as long as you have prescription-drug coverage. Second, should you ever have an unexpected illness or accident that requires you to begin using more medications; you will have the coverage you need at that point. In addition, there are also some very low-cost plan options available, with monthly premiums below $20 in every state but Alaska.

Question from John: I am 72. I don't use any drugs. Should I sign up? If so, which specific plan should I sign with?

Answer from HHS: If currently you don't use any prescription drugs, you should still consider joining a Medicare drug plan in 2006. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay the lowest possible monthly premium for as long as you have prescription-drug coverage. If you don't join a plan by May 15, 2006, and you don't currently have a drug plan that, on average, covers at least as much as standard Medicare prescription-drug coverage, you will have to wait to join until the open-enrollment period next year that runs from Nov. 15 through Dec. 31, 2006. When you do join, your premium cost will go up at least one percent per month for every month that you wait to join. Like other insurance, you must pay this penalty as long as you have Medicare prescription-drug coverage.

You may want to consider a basic, low-cost plan that would offer you peace of mind against high drug costs that could come in the future. The plan choices depend on where you live. If you have questions about your options, you can call 1-800-MEDICARE or go online at www.medicare.gov.

Question from Robert: An HMO is available without a Medicare drug plan for $10/mo. I can add a Medicare drug plan for $4.10/mo. If I do this, I will be dropped from the HMO. An HMO that includes a drug plan cost $69. I see no savings here. Is this right?

Answer from HHS: Many of the Medicare managed-care plans offer a more extensive benefits package in return for a higher premium. The two plans you compare may have significant differences in the coverage they offer which would explain the difference in their premiums. You have to look at the details of the plans to identify the differences. A number of our Medicare managed-care plans are offering coverage for hospital and physician services, along with prescription drugs, at very reasonable costs, as compared to traditional fee-for-service Medicare. In fact, our studies indicate that individuals enrolled in the Medicare managed-care plans spend less than those in traditional Medicare. Our Website, www.medicare.gov, has a tool called the "Medicare Personal Plan Finder" that can help you see what plans are available to you, and the specifics of the packages they offer. You can also call 1-800-MEDICARE if you have further questions.