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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 changes to Medicare drug coverage
All Part D plans use tiered cost sharing. Drugs in each tier have a different cost. A drug in a lower tier will generally cost less than a drug in a higher tier. In some cases, a flat copayment may be replaced with coinsurance (a percentage of the drug's cost). If your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug in a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
You do not have to pay all of the costs of your drugs while you are in the coverage gap. In 2016, you will pay 45 percent of the price for brand name prescription drugs on your plan's formulary while you are in the coverage gap. You will get this discount at the time you buy the drugs. You will pay 58 percent of the price for generic drugs on the plan's formulary during the coverage gap. These changes do not apply if you already receive extra help.
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
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.
Medicare Access for Patients-Rx (MAPRx) provides an explanation of the Part D benefit.
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