Will a Medicare Prescription Drug Plan need to notify a client if its list of covered drugs (formulary) changes?

A plan must notify a client at least 60 days before a drug changes in status (changes tiers) or is removed from the list. 

What does a Medicare drug plan cover?

A plan’s formulary must meet Medicare requirements; however, the drugs covered by plans vary dramatically.  Some of this variation results from the different tiers a plan places a drug on.  Plans vary significantly between what drugs they place on each tier and the amount they charge for the different tiers: 

For example, among the 21 plans with three tiers and flat copayments, the copayment for a 30-day supply varies as follows: 

Median cost sharing for Tier 1 drugs is $5 but ranges from $0 to $10                                        

 Median cost sharing for Tier 2 drugs is $25, but ranges from $15 to $40  

Median cost sharing for Tier 3 drugs is $53, but ranges from $40 to $72.50

A more extreme example is Enbrel, a drug used to treat rheumatoid arthritis.  The cost sharing among plans varies from $20 in one Medicare drug plan to $1,276 in a plan that covers it but places it on a different tier.  (Refer to terms #5, 6&9).

Plans may have rules about what drugs are covered in different drug categories to be sure people with different medical conditions can get the treatment they need. Most plans will have a formulary (refer to drug covered/formulary #1), which is a list of drugs covered by the plan. This list must always meet Medicare's requirements, but it can change when plans get new information.  

Will Medicare Part D cover a client’s diabetic supplies?

Medicare Part D usually will not cover any supplies, because most supplies are covered under Part B. (Called Medicare 4/10/06) 

Will Medicare Part D cover brand & generic medications?

Medicare Part D will help cover brand & generic medications; however, generic medications are usually at a lower cost.

References

“Kaiser Family Foundation” http://www.kff.org/medicare/index.cfm. March 30, 2006.

 “Glossary of Terms”  Centers for Medicare & Medicaid Services.   Department of Health & Human Services.  2001.

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The information in this document and the assistance provided by the presenter of this information is intended as an educational guide for Medicare participants. The Medicare recipient is solely responsible for making the final decision regarding his or her choice of Medicare Part D plans. Specific questions regarding Medicare Part D should be directed to Medicare at 1-800-MEDICARE.