road all-too-well traveled: a year of Medicare Part D and what we have learned so far, The

Progress in Transplantation,  Mar 2007  by Hays, Rebecca,  Paykin, Cathy

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A year after the first transplant recipients enrolled in Medicare Part D prescription plans we now realize that although these plans can cut prescription costs, they are by no means a cure-all. We also know that resourcefulness and persistence are key to getting the most out of Part D benefits. Although these plans can save enrollees money, they are also, paradoxically, costly. In this article we describe dilemmas faced by enrollees in Part D plans as well as tips and tools for getting the maximum benefits from Part D.

How Can Part D Help?

The short answer is that it is definitely better than nothing. Part D offers the strongest benefits to people who lack prescription coverage, people with significant medication costs, and people who either never reach the infamous "donut hole" (or coverage gap) in Part D coverage or who crawl out of it relatively early and so use the catastrophic coverage for medication costs of more than $5100 per year. More specifically for the transplant population, Part D can help cover antirejection medicine for those who did not have Medicare at the time of their transplantation (and therefore do not get their antirejection medicines through Part B). Part D can also help cover diabetes supplies not covered under Part B. Finally, many other prescription plans now require people to enroll in Part D to get additional, supplementary coverage (eg, a state-run prescription assistance program, a retirement benefit).

What Is the Range of Part D Coverage?

Because Part D is a broad name for many different prescription plans run by private companies, the phrase "Part D" does not actually tell you much about what your benefit will look like or what your costs will be. A Kaiser Foundation study1 in April 2006 found that the cost to enrollees differs tremendously between plans. An enrollee could pay from $15 to $62 for the same drug, depending on the prescription drug plan. But so far, according to the Kaiser study, most people have enrolled in Part D plans solely on the basis of the deductible amount and premium cost.1,2 Other factors may make a difference in your experiences with the plan, including the following:

* Is there a cost incentive to get medicines at a certain pharmacy, through the mail, or in 90-day supplies?

* How do your medicines fit into your plan's tier system? Do you pay a higher copay on your medicines because they are in the top tiers of your plan? Has a quantity limit, "step therapy" (ie, needing to try less expensive medicine first), or difficult previous authorization process been imposed?

* Do you get some coverage during the "donut hole," or coverage gap, when your medication costs are more than $2250 but have not yet reached $5100? Be aware that the availability of donut hole coverage in 2007 is drastically reduced.

* Are you able to get answers about your coverage from your plan?

Tips and Tools: What You Can and Can't Change

Learn as much as you can about your coverage and in general make peace with it for the rest of 2007. Most people will not be able to change Part D coverage-or enroll in a plan-until Open Enrollment, which is from November 15 to December 31, 2007, with new plans starting January 1, 2008. However, if any of the following apply to you, changing plans-or enrolling in a plan-may be possible before November 2007:

* You get Medicaid as well as Medicare.

* You qualify financially for "extra assistance" from Part D (in general, this is if you earn less than $14355 as a single person or $19000 as a couple and have limited assets, but call 1-800-MEDICARE to check your eligibility).

* You are a Hurricane Katrina evacuee.

* You had equal or better insurance that for some reason ended.

Learn Your Coverage

Recipients and professionals armed with transplantspecific Medicare knowledge may be better able to negotiate this complex new Medicare benefit. A basic knowledge of how Medicare Part B and D interact can go a long way when negotiating with pharmacies, plan administrators, and Medicare employees and volunteer counselors, who may only know Medicare as it relates to the population older than 65 years. Learn about this Medicare information through the following resources:

* www.kidneydrugcoverage.org was specially designed for kidney transplant recipients and professionals and has 40 different fact sheets to address different situations. Much of this information is transferable to other organ recipients. If you do not have Internet access, call the National Kidney Foundation at (800) 622-9010 for printed material.

* Go to www.medicare.gov, call (800) MEDICARE, or request copies of the books Medicare Coverage of Kidney Dialysis and Kidney Transplant Services or Medicare and You.

* Be clear on your antirejection coverage. If you had Medicare at the time of your transplantation, Part B will pay 80% of antirejection medicines and Part D will not pay anything.

* When calling with coverage questions, have available your Medicare number, start date, insurance cards (and perhaps a magnifying glass to read the numbers), and prescription information (ie, brand name, generic name, and a 1 -word description of what the medicine is for, such as "blood pressure").'