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Medicare Part D Drug Benefit
If the person with dementia has Medicare, then he or she can enroll in Medicare's Part D prescription drug plan. Be sure to review Medicare Part D plans carefully regarding Alzheimer's drug coverage.
See which Medicare national plans cover Alzheimer's drugs, and which plans require prior approval.
2016 prescription drug plan chart (PDF)
Medicare works with insurers and other private companies to offer different prescription drug plans that vary in cost and drug formularies. During the Medicare Part D annual open enrollment period, Medicare beneficiaries can enroll in a drug plan. Beneficiaries already enrolled in a Part D drug plan can change to a different plan during this period. The enrollment period is from October 15 - December 7, 2015.
Key things to consider when choosing a drug plan:
- Will the drug plan pay for all or most of the drugs you take now?
- Are your Alzheimer's drugs on the formulary? Check the 2016 prescription drug plan chart (PDF).
- Does the plan cover the doses of the drugs that you take?
- Do the plan's rules limit coverage of your Alzheimer's drugs and/or your more costly drugs by requiring "prior approval"? Check the 2016 prescription drug plan chart (PDF).
- Do the plan's rules require you to try a less expensive, similar drug ("step therapy") before the plan will pay for your drug(s)?
- Are there limits on the number of pills that a prescription may cover ("quantity limits") over a specific period of time?
- What will the plan cost you? Be sure to compare all of the costs for each plan, including the deductible, copayments and co-insurance, not just the amount of the monthly premiums.
- Is my local pharmacy in the plan's pharmacy network? If you prefer to use mail order for your drugs, does the plan offer it as an option?
Things to Consider when Choosing a Medicare Drug Plan (PDF)
Important notes about drug coverage and availability
Closing the "donut hole" for seniors
The "coverage gap" or "donut hole" is a certain point ($2,960 in 2015 and $3,310 in 2016) when Medicare stops paying part of the costs of beneficiaries’ prescription drugs, requiring them to pay the full cost themselves. This gap will be phased out by 2020.
In 2015, you will pay 45% of the plan's cost for covered brand-name prescription drugs once you reach the gap. What you pay for generic drugs during the gap will decrease each year until it reaches 25% in 2020. In 2015, you will pay 65% of the price.
Brand name medications and quantity limits
Nearly all national plans have stopped paying for brand name cholinesterase inhibitors, the class of drugs most commonly prescribed for Alzheimer’s. This includes all forms of Aricept and Razadyne, and Exelon tablets, capsules and solution. Most plans will pay for Exelon patches and generic cholinesterase inhibitors. Most plans also have imposed Quantity Limits (QL) on Alzheimer's drugs. Quantity limits restricts the number of pills an individual can receive over the course of a period of time, usually a standard 30-day supply.
Memantine, which recently became available as a generic drug, may not be covered through Medicare Part D. If you or someone you know is taking memantine, check with your plan to inquire about coverage, or contact your State Health Insurance Program (SHIP) through Medicare and ask to speak to a counselor. You may also want to talk to your doctor regarding your options.
Medicare beneficiaries who receive "extra help" or who receive Medicaid benefits were sent letters from the Centers for Medicare & Medicaid Services (CMS) regarding their current plan.
Use the Medicare Plan Finder to find and compare drug plans and enroll.
If you received a blue letter: A blue letter means the beneficiary’s plan is either: 1) leaving the Medicare program in 2015 or 2) charging a higher premium in 2015. CMS will automatically reassign the beneficiary to a new Medicare drug plan for the coming year unless the individual selects a new plan.
Get help with enrollment.
State Health Insurance Assistance Programs (SHIP) provides free one-on-one help with Medicare drug coverage and enrollment questions. Go to SHIPtalk to find out a program in your area.
If you received a tan letter: A tan letter means the beneficiary qualified for “extra help” but joined a plan on their own or switched to a different drug plan than the one Medicare enrolled the beneficiary in. If the beneficiary chooses to stay in the current plan, the tan letter will inform the person that he or she is responsible for the difference between the monthly plan premium and the subsidy (“extra help”). CMS will not automatically reassign the beneficiary to the new plan.
People with Medicare who have limited income and resources may qualify for extra help paying for prescription drugs. The Social Security Administration (SSA) and CMS are working together to provide this extra assistance.
- People with both Medicare and Medicaid (called "dual eligibles") will automatically qualify for extra help.
- Other individuals may apply for extra help from the SSA. Apply online at www.socialsecurity.gov, or call 800.772.1213 for a paper application or to make an appointment.
Help Is Available
AARP Doughnut Hole Calculator helps those with Medicare Part D to find out if they are at risk in falling into the coverage gap or "doughnut hole." This online tool may also help you reduce prescription drug costs.
BenefitsCheckUp, a free service of the National Council on Aging (NCOA), helps you find state, federal and private benefits programs available where you live. These benefits programs can help pay for prescriptions, health care, food, utilities and more.