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Medicare Part D Drug Benefit

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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.


Part D basics

See which Medicare national plans cover Alzheimer's drugs, and which plans require prior approval.

2013 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 typically begins in the fall.

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 2013 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 2013 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?

Learn more:
Things to Consider when Choosing a Medicare Drug Plan (PDF)

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Important Notes

Closing the "donut hole" for seniors
The "coverage gap" or "donut hole" is a certain point 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 2013, Medicare will pay 52.5% for brand drugs and 21% for generic drugs that are covered by the Part D plan. Some Part D plans provide additional payment in the coverage gap for drugs on its formulary.

Aricept and quantity limits
Most plans have either taken Aricept off their lists of covered drugs (formulary) or are only covering the high dose Aricept 23 mg. Plans are covering the generic form of 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. For example, a Quantity Limit could be 60 pills for a one month period. We have raised the issue with the Medicare agency and have been told that there should not be less than the upper amount of drugs approved by FDA.

Re-assignment for Medicare-Medicaid and "extra help" enrollees

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.

Compare plans.

Use the Medicare Plan Finder to find and compare drug plans and enroll.

If you received a blue letter: Beneficiaries were sent a blue letter because their current plan either: 1) is leaving the Medicare program in 2013 or 2) their current plan will charge a higher premium in 2013. The letter informs beneficiaries that CMS will automatically reassign them to another plan unless the individuals select new plans.

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: Medicare beneficiaries who receive "extra help" were sent a tan letter from CMS. These individuals are called "choosers" because they selected and joined their previous or current drug plan on their own. Their plans' premium is increasing in 2013, and this group will have to choose a new plan with a lower premium on their own or they will pay a portion of their monthly premium in 2013. CMS will not automatically assign "choosers" to new plans

In 2013, there has been a 2 percent decrease in plans (327 nationwide) for "extra help" beneficiaries (also called benchmark plans). The slight decrease in benchmark plans is primarily the result of the loss of benchmark status for most plans offered by UnitedHealth. However, beneficiaries receiving the "extra help" subsidy or on Medicaid will still have options of plans from which to choose in most states.

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Extra help paying for prescription drugs

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.

Medicare Access for Patients-Rx (MAPRx) provides links to a wide variety of resources to help people on Medicare find information on Medicare prescription drug coverage.

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.

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