District of Columbia: Medicare Rx Fact Sheet
Medicare's new prescription drug insurance-called Medicare Part D-began January 1, 2006. To get this insurance, most people will have to sign up for one of the Medicare approved Part D plans. For people with limited income, the new prescription drug coverage offers Extra Help with premiums, the annual deductible, co-pays, as well as unlimited drug coverage. Extra Help can greatly reduce prescription drug costs for those who qualify.
The District of Columbia already runs two programs that help people with limited income pay for drugs and a third program that helps pay for other Medicare-related costs like premiums. These programs are: Medicaid, the AIDS Drug Assistance Program (ADAP), and the Medicare Savings programs. If you are now in one of these state programs, this fact sheet explains who they will work with the new prescription drug plans. Find your program below to see what effect the new plan will have, what choices you need to make, and how you can get more information.
Since changes are still being made to the District of Columbia's programs, it is always best to check with your program directly to get the most current information and advice. You may also want to check with your program to see if you may be eligible for more benefits. Contact information for each of the District of Columbia's programs is listed at the end of this document.
For People on Medicaid who are also on Medicare
Will I have to sign up for a new prescription drug plan? And what about Extra Help? Yes. If you didn't, Medicare should have automatically signed you up with a plan in October, but you can change to a different plan anytime. You are automatically eligible for Extra Help.
How will I know what my plan is? In October, Medicare should have sent you a letter telling you which plan you are signed up with and how to change plans if you want to. This plan went into effect on January 1, 2006.
Does it matter which plan I am signed up with? Probably. Each plan only pays for certain drugs. If your assigned plan does not pay for all the drugs you are taking now, you can switch to another. You can ask the District of Columbia Health Insurance Counseling Project (HICP) to help you decide if you should switch plans.
What will I need to know to pick the best plan for me? Start by making a list of all the medicines you take. Then check the different plans to see if your drugs are on their list. You can ask HICP to help you decide which plan is best for you and how to change plans.
How much will I have to pay for my drugs? It depends. You won't have to pay any premiums or deductible. If you live in a nursing home, there will be no costs. For others on Medicaid, the co-pay for each prescription will be $1 for generic drugs and $3 for brand name drugs, which may be more than you pay right now depending on what drugs you take. And you won't be limited to a $1,500 a month payment by your plan.
Can I still fill my prescription if I can't afford the co-pay? Unlike Medicaid, your pharmacist cannot fill your prescription unless you have the co-pay.
Will my plan pay for all my drugs? Maybe, but there are different issues.
No plan is allowed to pay for some types of medications, including barbiturates, benzodiazepines, prescription vitamins, and over-the-counter drugs. Medicaid will pay for some of these types of drugs including some over-the-counter medications.
And each plan has its own list of drugs it pays for. But if your doctor says that you need a drug that isn't on the list, you may be able to get an "exception" from your plan to pay for the drug your doctor prescribed. If your plan won't give you an exception, you will have to pay for it yourself or switch to a different drug that is on your plan's list. You or your physician has the right to appeal the plan's decision not to provide you with a certain drug if your physician thinks it is necessary for you.
Will I have to pay for drugs my doctor says I need but that aren't on my plan's drug list? Maybe. Your doctor can ask the plan to give you an "exception" to pay for your drug. If your plan won't give you an exception, you will have to pay for it yourself or switch to a different drug that is on your plan's list. Or, you or your physician may appeal the plan's decision not to provide you with a certain drug if your physician thinks it is necessary for you.
Where can I get more information?
District of Columbia Medicaid Office
202-442-5988
District of Columbia Health Insurance Counseling Project (HICP)
202-724-4900
202-739-0668
202-973-1079 (TTY for people with hearing loss)
The AIDS Drug Assistance Program (ADAP) pays for drugs used to treat HIV/AIDS and related conditions for a small number of people without any other insurance.
Will I have to sign up for a prescription plan? Yes. If you are now on Medicare, you should have signed up for one of the new plans between November 15 and December 31, 2005, to get help paying for your drugs in 2006.
Will I have to apply for Extra Help? Yes. You can apply at any local Social Security office, local Medicaid office, or the District of Columbia Health Insurance Counseling Project (HICP).
What will I need to know to pick the best plan for me? Each plan only pays for certain drugs. Start by making a list of all the medicines you take. Then check the different plans to see if your drugs are on their list. You can ask HICP for free personal help to decide which plan works best with ADAP for you and how to change plans if you need to.
How will this change affect what I have to pay? Everyone in ADAP will pay more for the drugs ADAP now pays for.
If you qualify for Extra Help, your other medications will be cheaper.
If you do not qualify for Extra Help, you will have to pay a premium, deductible, higher co-pays, and other costs that you don't have to pay in ADAP.
ADAP may help pay for some of these new costs and may also pay for drugs that ADAP now pays for even if they are not on your plan's approved list.
ADAP hasn't decided if it will help with any of these costs. Call the program for new information.
Will my plan and ADAP pay for all my drugs? Maybe but there are two different issues.
No plan is allowed to pay for some types of medications no matter what plan you are on. These include barbiturates, some anxiety drugs and drugs to help you gain or lose weight. You will probably have to pay for these drugs yourself.
And each plan has its own list of drugs it pays for. But if your doctor says that you need a drug that isn't on the list, your doctor may be able to ask your plan an "exception" to pay for the drug prescribed. If your plan won't give you an exception, you will have to pay for them yourself or switch to a different drug that is on your plan's list.
Will I have to pay for drugs my doctor says I need but that aren't on my plan's drug list? Maybe. Your doctor can ask the plan to give you an "exception" to pay for your drug. If your plan won't give you an exception, you will have to pay for it yourself or switch to a different drug that is on your plan's list.
Where can I get more information?
AIDS Drug Assistance Program (ADAP)
202-332-2437 (AIDS Hotline)
District of Columbia Senior Health Insurance Counseling Project (HICP)
202-724-4900
202-739-0668
202-973-1079 (TTY for people with hearing loss)
Social Security
1-800-772-1213 (Toll-free)
1-800-325-0778 (Toll-free TTY for people with hearing loss)
Medicare Savings Programs pay your Medicare Part B premium, and may pay your Medicare Part A premium, deductibles, and/or co-pays.
Will I have to sign up for a prescription drug plan? No, but it is always a good idea to sign up for a plan, even if you are not taking any prescription drugs now. There are no premiums and drug costs will be very low. If you don't sign up with a plan between November 15, 2005 and May 15, 2006, Medicare will selected a plan for you and sign you up. Until then, you can decide which plan is best for you. You will be able to choose from several different plans.
Will I have to apply for Extra Help? No. You will automatically get Extra Help so you don't have to apply. You should receive a letter soon (or you may have already) telling you that you qualify.
Does it matter which plan I am signed up with? Probably. Each plan only pays for certain drugs. If the plan you are assigned to does not pay for all the drugs you are taking now, you can switch to another plan. You can ask District of Columbia Health Insurance Information Program for help in choosing the best Plan for you, but you are limited to the plans that work with the Medicare Savings Programs.
What will I need to know to pick the best plan for me? Start by making a list of all the medicines you take. Then check the different plans to see if your drugs are on their list. You can ask HICP to help you decide which plan is best for you and how to change plans.
How much will I have to pay for my drugs? For drugs on your plans approved list, your co-pay for each prescription will be $2 for generic drugs and $5 for brand names.
Will my plan pay for all my drugs? Maybe.
No plan is allowed to pay for some types of medications no matter what plan you are on. These include barbiturates, benzodiazepines, prescription vitamins, and over the counter drugs, some anxiety drugs and drugs to help you gain or lose weight. You will have to pay for these yourself.
And each plan has its own list of drugs it pays for. But if your doctor says that you need a drug that isn't on the list, you may be able to get an "exception" from your plan to pay for the drug your doctor prescribed. If your plan won't give you an exception, you will have to pay for it yourself or switch to a different drug that is on your plan's list. You or your physician have the right to appeal the plan's decision not to provide you with a certain drug if your physician thinks it is necessary for you.
Will I have to pay for drugs my doctor says I need but that aren't on my plan's drug list? Maybe. Your doctor can ask the plan to give you an "exception" to pay for your drug. If your plan won't give you an exception, you will have to pay for it yourself or switch to a different drug that is on your plan's list. Or you or your physician may appeal the plans decision not to provide you with a certain drug if your physician thinks it is necessary for you.
Where can I get more information?
Medicare Savings Program
1-800-MEDICARE (1-800-633-4227)
District of Columbia Medicaid Office
202-442-5999
District of Columbia Health Insurance Counseling Project (HICP)
1-202-739-0668
1-202-973-1079 (TTY for people with hearing loss)
Download The New Medicare Prescription Drug Coverage: District of Columbia PDF
