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| North Carolina Physician Medicare Part D Primer |
During the presidential campaign before the 2004 election there was pressure on both
parties to address rising prescription drug costs. The final bill involved controversy,
compromise and closed-door meetings. {Iglehart, NEJM 2004}
The final Medicare Modernization Act of 2003 made many changes to existing Medicare
policy, but the most significant was the Prescription Drug Benefit, also known as Part
D. This benefit involves private organizations (insurance companies sometimes
collaborating with pharmacies) contracting with the Centers for Medicare and Medicaid
Services (CMS) to offer prescription drug insurance to all Medicare beneficiaries.
Prescription drug plans are being offered as stand-alone prescription drug plans (PDPs)
or as part of a managed care (aka Medicare + Choice or Medicare Advantage or
Medicare Health Plan) package (MA PDP) through collaborating organizations of private
companies that have contracted with CMS. Organizations are required to offer a
formulary with at least 2 drugs in each therapeutic class, but there are some
exceptions. (No Medicare plan shall cover benzodiazepines, barbiturates, cough & cold
relief, vitamins & minerals, weight loss or gain, fertility drugs, cosmetic or hair growth
drugs, or non-prescription drugs.) Enrollees can expect to see lower prices at
“preferred" or "in-network” pharmacies once they have joined a plan.
For more details on Prescription Drug plans offered in NC, click here.
For more details on Medicare Advantage plans offered in NC, click here.
These plans have a deductible no higher than $250 and the threshold of out-of-pocket
prescription drug cost (before reaching the catastrophic 95% coverage level) is held at
$3600 regardless of how the coverage gap, or "doughnut hole," is handled by the plan.
(See the video presentation to understand how the standard plan, and the coverage gap
work with real cases, but note that a couple of the more expensive plans offer generic or
full coverage during the coverage gap.) The average monthly premium in North Carolina
will be about $37 in 2006 (range $13.27 to $65.03 per month for PDPs in NC). See links
above for more details.
North Carolina is a region all by itself (Region 8) for PDPs, which means that the same
standalone drug plans will not necessarily be offered in other states but in all parts of
North Carolina the choices of PDPs should be the same. North Carolina is paired with
Virginia (see map) for Medicare Advantage plans, so a Medicare managed care plan
offered in NC may be offered in VA as well, but access to these plans is not guaranteed
in all counties. Use the general Prescription Drug Plan Finder tool with a patient's zip
code to determine which MA PDP plans are available in their area.
In North Carolina 16 organizations are offering a total of 38 stand-alone PDPs and 5
organizations are offering a total of 15 MA PDPs. There are also 3 "Special Needs
plans" for Medicare beneficiaries with multiple chronic illnesses or living in long term
care facilities. (See Medicare Personal Plan Finder and click on "North Carolina" to see
organizations' contact information for all 56 plans in NC.)
People with both Medicare and Medicaid ("Dual beneficiaries") have been randomly
assigned to and enrolled in one of 13 PDPs (plans with **) with premiums at or below
$36.30. (Anyone already enrolled in a MA plan was assigned to the corresponding MA
PDP.) Dual beneficiaries may opt to change plans during any month if they are not
satisfied with the formulary or services provided by their plan. (Whereas others may
only switch plans during the open enrollment period.) Dual beneficiaries may also
choose to join a more expensive plan if they pay the difference out of their own pocket
monthly for the higher premium.
The Medicare Part D Prescription Drug Benefit represents a tremendous benefit
to many, and complicated decisions to all Medicare Beneficiaries.
See the "Decisions to Make" page for more information about how patients can
make decisions about Part D plans and deadlines for these decisions.
parties to address rising prescription drug costs. The final bill involved controversy,
compromise and closed-door meetings. {Iglehart, NEJM 2004}
The final Medicare Modernization Act of 2003 made many changes to existing Medicare
policy, but the most significant was the Prescription Drug Benefit, also known as Part
D. This benefit involves private organizations (insurance companies sometimes
collaborating with pharmacies) contracting with the Centers for Medicare and Medicaid
Services (CMS) to offer prescription drug insurance to all Medicare beneficiaries.
Prescription drug plans are being offered as stand-alone prescription drug plans (PDPs)
or as part of a managed care (aka Medicare + Choice or Medicare Advantage or
Medicare Health Plan) package (MA PDP) through collaborating organizations of private
companies that have contracted with CMS. Organizations are required to offer a
formulary with at least 2 drugs in each therapeutic class, but there are some
exceptions. (No Medicare plan shall cover benzodiazepines, barbiturates, cough & cold
relief, vitamins & minerals, weight loss or gain, fertility drugs, cosmetic or hair growth
drugs, or non-prescription drugs.) Enrollees can expect to see lower prices at
“preferred" or "in-network” pharmacies once they have joined a plan.
For more details on Prescription Drug plans offered in NC, click here.
For more details on Medicare Advantage plans offered in NC, click here.
These plans have a deductible no higher than $250 and the threshold of out-of-pocket
prescription drug cost (before reaching the catastrophic 95% coverage level) is held at
$3600 regardless of how the coverage gap, or "doughnut hole," is handled by the plan.
(See the video presentation to understand how the standard plan, and the coverage gap
work with real cases, but note that a couple of the more expensive plans offer generic or
full coverage during the coverage gap.) The average monthly premium in North Carolina
will be about $37 in 2006 (range $13.27 to $65.03 per month for PDPs in NC). See links
above for more details.
North Carolina is a region all by itself (Region 8) for PDPs, which means that the same
standalone drug plans will not necessarily be offered in other states but in all parts of
North Carolina the choices of PDPs should be the same. North Carolina is paired with
Virginia (see map) for Medicare Advantage plans, so a Medicare managed care plan
offered in NC may be offered in VA as well, but access to these plans is not guaranteed
in all counties. Use the general Prescription Drug Plan Finder tool with a patient's zip
code to determine which MA PDP plans are available in their area.
In North Carolina 16 organizations are offering a total of 38 stand-alone PDPs and 5
organizations are offering a total of 15 MA PDPs. There are also 3 "Special Needs
plans" for Medicare beneficiaries with multiple chronic illnesses or living in long term
care facilities. (See Medicare Personal Plan Finder and click on "North Carolina" to see
organizations' contact information for all 56 plans in NC.)
People with both Medicare and Medicaid ("Dual beneficiaries") have been randomly
assigned to and enrolled in one of 13 PDPs (plans with **) with premiums at or below
$36.30. (Anyone already enrolled in a MA plan was assigned to the corresponding MA
PDP.) Dual beneficiaries may opt to change plans during any month if they are not
satisfied with the formulary or services provided by their plan. (Whereas others may
only switch plans during the open enrollment period.) Dual beneficiaries may also
choose to join a more expensive plan if they pay the difference out of their own pocket
monthly for the higher premium.
The Medicare Part D Prescription Drug Benefit represents a tremendous benefit
to many, and complicated decisions to all Medicare Beneficiaries.
See the "Decisions to Make" page for more information about how patients can
make decisions about Part D plans and deadlines for these decisions.
Email holly.biola@gmail.com for updated
info. This site will be taken down 12/31/08.
info. This site will be taken down 12/31/08.
Email holly.biola@gmail.com for updated
info. This site will be taken down 12/31/08.
info. This site will be taken down 12/31/08.
Email holly.biola@gmail.com for updated
info. This site will be taken down 12/31/08.
info. This site will be taken down 12/31/08.
Email holly.biola@gmail.com for updated
info. This site will be taken down 12/31/08.
info. This site will be taken down 12/31/08.