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Health Care Reform:

Health Insurance & Affordable Care Act

Medicare Rx Benefit: Sorting Out the Options

WebMD looks at the choices facing Americans who enroll in Medicare's prescription drug benefit.

WebMD Feature

The start of enrollment for Medicare's new prescription drug benefit is just six weeks away. Medicare Part D, as it's called, will be the biggest addition to the program since it was founded in 1965. Although Part D will offer more choices for drug plans, it will also add layers of complexity to a national health insurance program that for decades has prided itself on simplicity, at least from the patient's perspective.

Part D sign-up will offer 42 million elderly and disabled Americans varying degrees of help paying for prescriptions. But getting the coverage requires that beneficiaries make some key decisions. A full two-thirds of Medicare members already have some form of private or public drug coverage. If you're one of them, you'll have to know how your coverage might change and what form of insurance is best for you.

Starting around Oct. 15 Medicare expects to launch a web site designed to help beneficiaries choose the best plan in their area based on the prescriptions they take, the extra costs they can afford to pay, and their existing forms of insurance.

Switching From Medicaid

More than 6 million low-income Americans on Medicare already have their prescription drugs provided through state Medicaid programs. But when Part D kicks in on Jan. 1, 2006, all of that coverage will switch to Medicare automatically.

In an effort to avoid confusion, Medicare is automatically placing so-called "dual eligibles" into a Part D plan. But to avoid favoritism, the government is picking the plans at random in each geographical area. But since each area will be offering 10 to 20 plans, you'll still need to check if the plan you've been placed in is right for you; if not, you'll need to switch.

With the change in drug coverage, dual eligibles may notice that their drug coverage is decreased from what was previously covered by Medicaid.

By the end of October the government will mail out letters to all dual-eligible beneficiaries informing them of the switch. The next step is to check the plan's covered drug list, or formulary, to see if all the drugs you take are all covered. Chances are they may not be, so it's up to you and your doctor to decide whether other covered brand name drugs or generics are similar enough to switch.

"They should run to their physicians with that letter," says Sam Muszynski, an attorney and director of the office of health care financing at the American Psychiatric Association.

Concerns for Mentally Ill Patients

The American Psychiatric Association is especially concerned about dual-eligible patients with mental illnesses requiring medication. Many of these patients use multiple medications but may not be able to make decisions about plan choices.

In addition, Medicare is not covering some psychoactive drugs, including benzodiazepines, used by some patients.

State health insurance programs (SHIPs) are taking the lead in providing advice directly to low-income patients on how to sign up for a drug plan. For mentally ill patients and their loved ones or caregivers, the National Alliance for the Mentally Ill and the National Mental Health Association are both offering resources to help.

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