APA Expert Opinion
An APA expert answers common questions about Medicare Part D, Medicare's new prescription drug program

This month's expert: Carol L. Alter, M.D., vice chair of APA’s Committee on Managed Care, executive director, the TEN Project, and Associate Professor, Georgetown University.

I have heard of Medicare and Medicaid, what exactly are they?

Medicare is generally known as the federal health insurance program for people 65 years of age or older, but it also covers certain younger people with disabilities. Medicare Part A pays for hospital care, Part B pays for doctor visits, Part C includes the managed care option, and Part D is the new prescription drug benefit.

Medicaid is a joint federal-state program that provides medical coverage for people with low incomes and limited resources. Medicaid programs vary from state to state.

So what exactly is the new Medicare Part D program?

Starting January 1, 2006, the Medicare program will provide a new prescription drug benefit, Medicare Part D, which will help cover some or all of the drug costs for people who join. This new program has many dates and facts to remember. All people with Medicare - especially people who have both Medicare and Medicaid (sometimes referred to as “dual eligibles”) - need to learn about this new program, how to enroll, and about their rights and responsibilities. A Web site, www.MentalHealthPartD.org, has been created by the American Psychiatric Association and other organizations to help people understand more about the benefit.

Who will the new Medicare Part D program affect?

All people who receive Medicare are eligible to enroll in the new program. You should have received information about your local plan choices in October 2005.

Dually-eligible patients will see a change in how they get their medications: they will no longer get their medicine through Medicaid, but now through Medicare Part D. If you are dually eligible, you will be automatically enrolled into a lowest cost plan in your area in the fall of 2005, but may choose another plan before January 1, 2006.

Other people with Medicare can voluntarily enroll by choosing a plan beginning on November 15, 2005.

You can also log onto the Center for Medicare & Medicaid Services (CMS) web site for more information at www.cms.hhs.gov.

Will this new Medicare Part D program cost me anything?

Most people in a prescription drug plan will pay a monthly premium, co-payments for each medication, an annual deductible and co-insurance. People with Medicare and Medicaid and some people with limited incomes will have lower costs.

How will this affect getting my prescriptions?

All Medicare Prescription Drug Plans must provide a “formulary,” a list of drugs covered by the plan, including both generic and brand name medicines. CMS requires that the plans include medications in a wide range of therapeutic categories. The process for filling your prescriptions might change under the new Medicare prescription drug program.

It is important to review the plans available in your region to see which drugs they will pay for since plans can choose to cover different medications. If possible, you should choose a plan that covers all of your medications. A Plan Comparison Web Tool is available at http://www.medicare.gov. The tool will help you pick the drug plan that’s right for you.

Where can I get my prescriptions filled?

Find your “network pharmacy,” listed on your plan materials or call the plan customer service line. A “network pharmacy” is a pharmacy that is under contract with a Medicare prescription drug plan. Plan members must get their prescriptions filled at a network pharmacy. Make sure the pharmacy you use now is part of the network for the prescription drug plan you joined.

Ask your doctor to call your prescription in and check that the medication is covered by your plan or bring in a paper prescription to the network pharmacy. Remember to bring your Medicare prescription drug plan card with you. If you do not have your card, you can give the pharmacist your Medicaid participant number or your Social Security number to check which plan you are enrolled in.

If I need help, where can I find out more information?

The new Medicare Part D program can be overwhelming, but fortunately there are a number of free, informational tools that are available to help you navigate the changes. A great site is www.MentalHealthPartD.org, which has been created coalition of mental health advocacy organizations, including the American Psychiatric Association.

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