January 13, 2006

On Medicare Part D

As of January 1, 2006, if you are elderly, disabled, or both you are eligible to receive a prescription drug benefit through Medicare. If you are one of the millions of Americans who had no coverage for prescription drugs, this is welcome news. If you are one of the millions of other Americans who already had coverage for prescription drugs through a private plan, this means confusion as you try to decide whether to switch to a new plan, and if so, to which one. If you are one of the approximately 7 million people who are enrolled in both Medicare and in Medicaid, the new law means an obligatory change to the Medicare prescription drug plan, which in turn may result in some degree of confusion during the transition period.

Medicare is providing information on the web to help you decide what to do (go to www.medicare.gov); many local pharmacies are offering advice; and the Medicare Advantage programs (which used to be known as Medicare plus Choice or Medicare Part C) have their own hotlines. While the decisions you make should depend on your individual circumstances and your own preferences, a few general observations may help:

To Enroll or Not to Enroll

  1. Medicare enrollees who are taking many medications and who previously had no health insurance coverage for drugs will almost undoubtedly benefit by enrolling in Medicare Part D. The part D plans will not pay for everything: in addition to a monthly premium charge, there is a $250 deductible for most plans, patients typically have to pay 25% of the next $2000 of drug costs, and generally you will have to pay the entire cost of the next $2850. Only after you have purchased $5100 worth of medicines will most plans start paying at a rate of approximately 95%. Nonetheless, for patients with high expenditures, such a plan is far superior to no plan at all.
  2. Medicare enrollees who are taking few medications and previously had no health insurance coverage for drugs will not benefit from enrolling in Medicare Part D over the short run. However, you should recognize that there is a penalty for enrolling after May 15, 2006: the rates will be higher for people who join after this date. Moreover, the majority of older people eventually will take quite a few medications. Thus, you may find it advantageous to enroll in Medicare Part D now. If you are willing to gamble that you will remain very healthy, if you have ample savings, or if you are already extremely elderly (perhaps over age 90), you may prefer to take your chances and not enroll in Medicare part D.
  3. Medicare enrollees who are already enrolled in a plan that covers prescription medicines will probably find that it makes sense to switch to a Medicare plan because the Medicare plans are typically more comprehensive. Doing so sooner rather than later (ie by May 15, 2006), allows you to get the best rate. However, some plans in which older people are currently enrolled may offer better coverage than the Medicare part D plans. It’s crucial to compare plans carefully. Also keep in mind that the companies that currently provide health care plans for retirees may decide to drop the coverage in the future—this has been happening with great regularity.
  4. The “dually eligible,” those who are on both Medicaid and Medicare, were automatically switched to a Medicare Part D plan as of January 1, 2006. You can opt for a different Medicare plan from the one you were assigned to, but you cannot continue coverage under Medicaid. Your new plan is likely to be different from your old plan in a number of ways: there may be copays for medications of $5, whereas previously you may have paid only $1-2 or nothing at all. Certain medications are explicitly excluded from coverage under Medicare Part D that were covered under Medicaid, such as benzodiazepines and drugs for weight loss or weight gain, although provisions may be made to remedy this problem.

Which Plan to Choose

  1. Choosing based on price: the cheaper plans offer less comprehensive coverage, although all plans provide at least 2 drugs within each “class,” for example 2 drugs to lower blood sugar. Each plan’s formulary, or list of covered medicines, includes “all or substantially all” antidepressant medications, antipsychotic medications, cancer medicines, and anti-seizure medicines. There are plans with no deductible, plans that cover the “gap” or “doughnut hole” (between $2250 and $5100 where the basic plan offers no coverage), and plans that charge different co-payments depending on the brand (ie $5 for a generic medication, $10 for a relatively inexpensive brand name medication, and $25 for a more expensive brand name medication). Plans that provide broader coverage will have higher premiums.
  2. Choosing based on specific medicines: if you are taking several medications currently and if it is important to continue taking exactly the same version of those medications, you should look for a plan that includes those medicines. In general, substituting one medicine of a particular class for another one in the same class may be confusing initially but it rarely makes a difference in terms of your health. Sometimes patients respond better to one drug rather than another, or have side-effects from one drug and not another similar drug. If you know that you are best off with precisely the medicines you are taking, because you have already been on other versions and have had problems, then you should seek a plan that covers your current medicines.
  3. Choosing based on convenience: you should check which plans your local pharmacy accepts. You should also consider whether a given plan offers a mail order service. If you take medications on a regular basis and are on a fairly stable regimen, it may be very useful to be able to send away for your medications. You will then get a 90-day supply in the mail.


For more details on what Medicare Part D means for the dually eligible, see RA Elliott, SR Majumdar, MR Gillick and SB Soumerai, “Medicare Drug Benefit: Benefits and Consequences for the Poor and the Disabled,” New England Journal of Medicine 2005; 353: 2739-41.

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