Choosing the Right Plan

Instructions for Using the Worksheet to Help People with Mental Illnesses Choose a Medicare Drug Plan

Essential Information for You
If you have a Medicare card, you will soon be able to have many of your prescription drugs paid for by Medicare. Some people will be enrolled in a plan by the government. Others must choose a plan. Even if the government enrolls you, you can change your plan. Some of the plans may not cover some of your drugs, so you will need to choose the plan that gives you the best coverage. This worksheet will help pull together in one place all the information you need to consider as you make that choice.

You can use the internet to find out how Medicare drug plans work. Visit either the official Medicare website, www.medicare.gov, or the Medicare Rights Center’s web page, www.medicarerights.org/101.html. The government also has a webcast explaining how to use the tool on the Medicare website, at www.cms.hhs.gov/partnerships/news/mma/webcasts.asp. To see which plans are available in your state, visit www.cms.hhs.gov/map/map.asp. (The state list is a PDF document, so you need the free Adobe Reader to view and print it. You can download the Reader from www.adobe.com.)

If you would rather talk to someone about it, contact your local Mental Health Association, Alliance for the Mentally Ill (NAMI) or consumer group. However, you should not discuss your medications or agree to a plan with anyone who calls you on the phone or comes to your door.

Many swindlers are at work, asking people for their Medicare numbers and bank account information and offering to “help you sign up.” Legitimate insurers may call you to explain their drug plans, but they are not allowed to enroll you by phone. If an insurer calls and invites you to consider a plan, ask to receive information by mail. Then, once you decide which plan suits you, you make the call or use the internet to enroll.

Why Should I Choose a Plan?

This worksheet is for people who want to take charge of the decision about which Medicare drug plan they will be in. Others may prefer to have their doctor, case manager or family member guide them through the process. Either way, the worksheet is a tool to help you compare plans.
If you use the worksheet, use it for all of your prescriptions, not just your mental health medications. All your drugs can be covered by these plans. You need to be sure that you can get the medications you need to treat all your health problems and that you can afford them.

What If I Also Have a Medicaid Card?

If you have both a Medicaid and a Medicare card, you will automatically be enrolled in a drug plan. But if you find that another plan in your area is better because it will cost you less or has fewer limits on your drugs, you may switch. This worksheet will help you decide if another plan would be better.
People who have both Medicaid and Medicare cards must be in a plan that is approved for Medicaid-covered people or pay extra for a more expensive plan. In your state’s section at www.cms/hhs.gov/map/map.asp, click in the right-hand column on “Stand Alone Prescription Drug Plans Eligible to Receive Auto-Enrolled Beneficiaries.” A PDF document will open showing the drug plans that people with Medicaid cards can use. Also, the federal government will send you information about which Medicare drug plans you can join without paying extra.

What Do I Need to Think About As I Pick a Plan?

The important questions to think about as you decide which plan to join are:

1. Are all my drugs on the plan’s list (called a “formulary”)?
2. What will I pay for each prescription?
3. Do I have to pay a monthly fee (a “premium”)? If so, how much?
4. Will I be able to get my drugs at my regular pharmacy? If not, is there a convenient pharmacy in the plan’s network?
5. Are there any limits on any of my drugs? For example, does my doctor have to get special permission (“prior authorization”) before I can get a particular drug? Is there a limit to the strength of the drug or the number of doses I can get at one time? Do I have to try another drug to see if it will work before the plan will pay for the medicine I take now —and then only if the other drug doesn’t work? (Most mental health drugs that you currently take must be covered without these limits as long as you continue them. But if you stop for any reason and want to start up again, these limits may apply, so you should check.)

The worksheet will help you organize the answers to these questions for each plan you consider. It has spaces to compare six plans. If you think you’ll want to compare more than six plans, copy all or part of the worksheet to fill in more.

Getting the Information You Need

Before using the worksheet, you will need to get information about each Medicare drug plan that you are eligible to join. You have several ways to do this:

• You can use the Prescription Drug Plan Finder on the website www.medicare.gov. Here you can type in the names of your drugs and find out which plans in your area cover them, with what limits. You can also check which pharmacies participate in these plans.
• You can get the same information from Medicare’s Customer Service Representatives through a toll-free phone number, 1-800-MEDICARE (1-800-633-4227).
• The government has sent you a Medicare and You handbook. In the section about drug plans in your state or area, you will find much of the information you need.
• Each plan will send you a Summary of Benefits. This will tell you most of the drugs the plan covers, what these drugs will cost you and what limits the plan has on your getting the drug. This summary may not be complete.
• Each plan will also have a website (look for its address in the plan’s information materials) where you can get details about that plan. Or you can call the plan and ask for more information.

You can print the information from the Prescription Drug Plan Finder on the government’s website after you finish checking it. You should do this because it will give you an official written record. Or you can ask the Customer Service Representative at the 1-800 number to mail you a printout of the information.

Filling Out the Worksheet

The worksheet will make it easy to use the information you gather to compare the plans and choose the one that works best for you. Here is how you can use it.

Getting Ready to Use the Worksheet

1. In the left-hand column of the large table on the worksheet, write the name of each medicine you now take as it appears on the label. List mental health drugs first and then other drugs. You can use the drug’s brand name or generic name.
2. Next to the name of the drug, write in the dose you take now.
3. In the smaller table, enter the name of your favorite pharmacy in the top space. If you are not sure what pharmacy you want to use, you can skip this.
4. Now log onto the website, www.medicare.gov, or call 1-800-MEDICARE. On the website, click “Compare Medicare Prescription Drug Plans.” On the page that comes up, scroll down and click “Find a Medicare Prescription Drug Plan.”

Step1, Search Options: You need to “authenticate” your information to see how much the drugs you have written on the worksheet will cost you. This is important because different people have to pay different amounts.
On the web page, enter this information in the boxes:

— Your Medicare number or HICN number (on your Medicare card)
— Your last name
— Your date of birth
— Part A or B effective dates (also on your Medicare card)
— Your zip code

Then click “Search Plans.”

If you call the 1-800 number, the Customer Service Representative will ask for the same information.

Step 2. Current Coverage Information: On the next web page your current enrollment plan will be listed, if you have one. At the bottom of that page, click “Choose a Drug Plan Type.” Here you can learn about various drug plans, sign up for one or, if you wish, change your health care coverage.

Step 3, Review Plan Results and Options: Some plans, including Medicare Advantage (formerly Medicare+Choice), offer both health care and drug benefits. If you are thinking of joining this type of plan, you can sign up under option B on this page. But if you have Original Medicare as your current health care coverage and want to keep it, you can choose your drug plan by clicking the button ”Search for Medicare Prescription Drug Plans” under option C at the bottom of the page.

Step 4, Medication and Pharmacy Selection: This page has three sections, A, B and C.

• You could view all available plans under A, but first you will want to make some choices. Go to C to choose how you want to limit your plans. For example, you can say if you don’t want to pay more than $150 or $200 a year deductible, or you want to be able to order your prescriptions by mail. If you choose any limits, click on “Apply Limits” and a list of fewer plans will pop up under A.
• Click on “Hide Plan List" and go to B. Click on “Enter My Medications.” Type in the name of the first of your drugs and click “Search for Drug.” Do the same thing for each drug you take, one by one.

After you have entered all your drugs, click on “Choose My Drug Dosage.” Enter the dose information you have written on the worksheet. You’ll also see a monthly quantity box. It shows “30” by default, but you can change that to “60” or “90” or whatever quantity is prescribed for you. This is important because it can affect the cost.

After you have entered dosages and quantities for all your drugs, click on “Review Your Drug List.” Make sure the list is correct and shows the drugs for all of your health conditions. Then click “Continue with Selected Drugs.”

If you want to get your drugs from your regular pharmacy, click on the button, “Select My Preferred Pharmacy.” If not, click on “Continue to Plan List.”

If you are doing this on the phone, tell the Customer Service Representative which drugs you take and their dosage.

Are Your Drugs Available?

You will see a chart listing the drug plans and information about them. This where you will find some of the information to enter on the worksheet.

5. Now go to your worksheet:

• In the space at the top of each block (“Plan A”, “Plan B”, etc.), write the name of each of the plans on the list that you think you would want. (If you need more than six blocks, you can copy all or half of the worksheet.) If you get the names over the phone, write in each one as it is given to you.
• Go to the first plan on the website list and click on its name. This will show which of your drugs are covered and will give information about the cost and limits on each of your drugs. For the moment, look at whether the drugs are covered.
• For the first plan, check if the first drug you have written on the worksheet is covered. If it is, circle “Yes” in the box under that plan name, in the column “Covered?” If it is not covered, circle “No” in that box.

6. Click on “Return to Personalized Plan List” and do the same thing for each of the drugs you take.

7. Be sure to repeat this for all the plans you may want to sign up for.

If you are on the phone, ask which of your drugs are covered by each of these plans and circle “Yes” or “No” in the box under that plan name, in the column “Covered?”

Ways the Plan Might Limit Your Choice of Drugs

Now you should check whether any of the these plans have limits that might keep you from getting any of your drugs.

8. Go again to the first plan on the website list and click its name. Now look at the information on limits.

If you are using the 1-800 number, ask the person to tell you all the limits, starting with the first drug you listed on your worksheet.

If there are any limits at all in the first plan for the first drug on your list, circle “Yes” in the worksheet column headed “Limits” for this plan. If there are none, circle “No.” If you circled “Yes,” go to the next column headed “Type of Limit” and circle one or more of the codes, depending on what you see or are told:

•     If the plan requires prior authorization, circle PA. This means you can only get this drug if your doctor gets special permission from the plan.

•     If the plan has “step therapy” circle ST. This means you have to try another drug before you can have this one.

•     If the plan has limits on the number of pills or the strength of the pills, circle QL for quantity limits.

9. Now do the same thing for each of your other drugs. You should then know what limits the first plan has for each drug you want to take.

10. Repeat these steps for each of the plans on your worksheet so you know the limits on each of your drugs in all the plans.

Checking Costs

Step 5, Review plan details and enroll.

11. On the website, go back to the first plan in the chart and click again on its name. Look for your monthly cost share for each of your drugs and enter that information on the worksheet.

12. Repeat this step for each of the plans, so you know exactly what you will pay for each drug you use under each of the plans.

Plans may have different cost shares for generic drugs (the cheapest), preferred brands (next) and other brand-name drugs (more expensive). Plans call these Tier 1, 2 and 3. A drug you have now may be generic, a brand that is preferred by one or more of the plans, or another brand-name drug. That is why your costs will be different in different plans. You could save money by switching to a cheaper drug, but you may not do this on your own. You can ask your doctor to change your prescription if it is safe for you.

13. Now go back and look at the website list of plans. You will see some other cost information in several columns.

•     In the chart, you will find the annual deductible and monthly drug premium on the right, under the heading “What You’ll Pay.”

•     You will find the estimated annual cost in the third column on the left, under “Plan Summary,” next to “Plan Name.” This is the deductible plus the 12 monthly premiums and the cost share for all the drugs you have listed.

On the worksheet, go to the boxes with dollar signs on the lines for “Plan Premium,” “Plan Deductible” and “Estimated Annual Cost.” For each of the plans, enter these dollar amounts from the chart.

If you are using the phone, ask the Customer Service Representative to give you these three numbers for each of your plans.

(People who have both a Medicare and Medicaid card and others who get extra help paying for the drug plan may find that some of these amounts are zero.)

The list of plans on the website has a column on the right where you could enroll in a plan. However, before enrolling you may want to finish filling out your worksheet and take some time to decide which plan is best for you. You can enroll later on the website, www.medicare.gov, or toll-free via 1-800-633-4227 any time before May 15, 2006.

Extra Benefits

14. Some plans may offer “Supplementary Benefits,” or something in addition to drugs. Look in the information the plan sends you to see if there is a Supplementary Benefit that would help you. Plans feature such extras to encourage you to sign up with them. If a plan offers a supplementary benefit you like, circle “Yes” in the column marked “Extras.” If it doesn’t, circle “No.” Be sure to go through all the plans.

Can I Go on Using the Same Pharmacy?

15. Now you are ready to fill in the box on the bottom left of your worksheet. All plans must list the pharmacies in their network. This is important, because other pharmacies might charge you more.

•     On the website, go back to the Plan Comparison Chart and click on the number that appears in the column headed “# of Pharmacies.” This is a link that will give you a list of the pharmacies in your zip code that are in the plan’s network. If your favorite pharmacy is listed, circle “Yes” next to “Your favorite pharmacy” for that plan on the worksheet.

•     If you are on the phone, ask the Customer Service Representative if your favorite pharmacy is in your first plan’s network. If the answer is yes, circle “yes” next to “Your favorite pharmacy” for that plan on the worksheet. Repeat this step with each plan.

If you circled “Yes” for all the plans, you are finished with this part of the worksheet.

16. If a plan does not include your favorite pharmacy, check which other pharmacies those plans cover.

•     When you see (or hear on the phone) the name of a pharmacy you could easily use, write in its name and check “Yes” in the column for that pharmacy under each plan that covers it.

Get a Paper Copy

17. You can now print a copy of the information on the website or, if you called the 800 number, ask the Customer Service Representative for a printed copy.

You have now completed the worksheet.

How Do I Choose a Plan?

You may be lucky and find that one plan covers all your drugs at a reasonable cost and has a pharmacy you can use in its network. That makes your choice easy. You can enroll in that plan on or after November 15, 2005. If you wish, you can enroll directly on the web page.

More likely, some of your drugs are either not covered or are covered with higher cost shares (sometimes called copayments) or too many limits. Changing to drugs with lower costs or fewer limits could help, but only your doctors can tell you if it is safe to switch drugs.

The worksheet will help your doctor help you make the right choice. After you have completed it, take the worksheet to your primary care doctor or your psychiatrist (or both) for help in making a final choice. Talk to your doctors about which plan you like best, or ask what they would recommend for you.

When you compare the plans’ costs, you should consider both cost share and premiums. For each plan you like, calculate how much the cost share for your prescriptions would add up to each month. Add that total to the plan’s monthly premium. Then you can compare the monthly costs for each plan. (If the plans have very different annual deductibles, their estimated annual cost will be different. You can check this by multiplying the monthly cost of each plan by 12 and adding the deductible for each. Then compare the annual totals to see which plan is cheaper.)

Can I Get Help Paying for My Drugs?

You may find that other people pay more or less than you pay for the same drug. If you get Medicaid or if you have received a notice telling you that you will have help paying for your Medicare drug plan, your payments will be lower.

The rules on getting help paying for your plan are complicated, but it is easy to find this information. Look on the internet at www.socialsecurity.gov/prescriptionhelp or call 1-800-MEDICARE (1-800-633-4227) and ask if you can get help.

When to Sign Up and When to Switch Plans

Sign up by December 31, 2005 to get this coverage as soon as it is available. If you find the plan you sign up with is not as good as you hoped, you can change again, either before January 1, 2006 or between November 15 and December 31 of any year. You can also switch plans if you move to another part of the country.

If you have both a Medicaid card and a Medicare card, the government will enroll you in a Medicare drug plan because your Medicaid drug coverage ends on January 1, 2006. You can change it, however. After December 2005, people with both cards are allowed to switch plans once a month.