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Senior PHARMAssist heading up local effort to improve Medicare assistance

The North Carolina General Assembly recently allocated $250,000 in non-recurring funds to increase community-based outreach and education concerning Medicare-approved drug benefits and the state’s pharmacy assistance program, NCRx. The Seniors’ Health Insurance Information Program (SHIIP), which is a part of the North Carolina Department of Insurance, is administering the grant statewide. Senior PHARMAssist was selected to receive one of the $10,000 community-based grants and will be the lead agency for the creation of the Durham Medicare Rx Network.

In addition to Senior PHARMAssist, this local effort includes the two local SHIIP coordinating agencies (the Council for Senior Citizens and the Durham County Cooperative Extension), the Department of Social Services, the local Social Security Administration, Lincoln Community Health Center, the Durham Center Pharmacy program, and other interested stakeholders.

The focus of the Durham Medicare Rx Network is to develop a more accurate and efficient way to handle all of the changes and options that seniors and people with disabilities face when choosing their Medicare-approved drug benefits. Every year, the private plans that administer the drug benefits change what medicines they cover and the cost of these medications. In addition, there has been tremendous confusion about Medicare drug benefits versus the new Medicare Advantage plans, which are privately administered medical plans that can include medication benefits as well.

For more information, please call Senior PHARMAssist at 688-4772 or one of the other Durham Medicare Rx Network agencies.

That time of year again

It’s critical that seniors and people with disabilities who have Medicare drug benefits understand that these privately administered plans will change EVERY YEAR. The best plan for a Medicare beneficiary in 2007 may be one of the most expensive plans in 2008 – even if the beneficiary’s medications have not changed. Thus, IT PAYS TO COMPARE, and sometimes, it pays to change plans. Important Note: If you decide to change your Medicare drug coverage for 2008, DO NOT disenroll from your current plan first. Simply enroll in your new plan and you should be automatically disenrolled from your old policy.

In North Carolina, there are 52 Medicare Part D or “stand-alone” drug plans to choose from for 2008. Most Medicare beneficiaries will add this medication benefit to their traditional Medicare A (primarily hospital coverage) and Medicare B (primarily doctor visits). You may opt, instead, to leave traditional Medicare and join a Medicare Advantage plan (Part C) to obtain your drug benefit. These plans (HMOs, PPOs, or Private Fee for Service) include services provided under Medicare Part A and B and even some extras, such as drug benefits. However, you should check with your healthcare providers, including hospitals, to ensure that they accept a specific Medicare Advantage plan. Many providers and healthcare institutions in Durham DO NOT contract with many of the Medicare Advantage plans. You will also want to know how enrolling in Medicare Part C affects your decision about drug coverage. For more information about Medicare Advantage plans in Durham, contact Lynne Chamblee (919-688-8247) or Deborah McGiffin (919-560-0521). They are the local co-coordinators for the North Carolina Seniors’ Health Insurance Information Program.

Medicare’s Web site (www.medicare.gov) has a “drug plan finder tool” that helps beneficiaries sort all the drug plans to select the best option available and also helps individuals enroll. You can obtain this same information by calling Medicare (1-800-633-4227), contacting NC SHIIP (1-800-443-9354), or in Durham, by setting up an appointment with Senior PHARMAssist (919-688-4772). The best plan for you depends on the medications that you take. When comparing plans, note that the pharmacy you choose also affects cost. Make sure your pharmacy is preferred by the plan. If it isn’t preferred, but you would rather stay with your pharmacy than switch, compare the plans that your pharmacy does accept. For guidance on how to use Medicare’s drug plan finder tool, please consult Senior PHARMAssist’s Medicare Drug Plan “Cheat Sheet.”

Further reducing your medication costs
If you have gross annual income at or below $15,552/individual or $20,772/couple, and cash assets at or below $11,710/individual or $23,410/couple, you may be eligible for financial assistance from Social Security (income amounts may be higher if beneficiaries work and/or financially support a relative other than a spouse who lives with them). You can apply for this subsidy on-line at the Social Security Administration Web site or by calling Social Security (1-800-772-1213) or the NC Seniors’ Health Insurance Information Program (1-800-443-9354). In Durham, you may also call Senior PHARMAssist (919-688-4772). If you think you may qualify, IT PAYS TO ACT IMMEDIATELY. If you do not qualify for full low-income subsidy (LIS) assistance, you may be eligible for other help with your out-of-pocket medication expenses.

North Carolina is now offering “premium assistance” of up to $29/month for seniors who are 65 or older, have a Medicare Part D plan, and do not qualify for full LIS assistance, provided they have:

  • gross annual income at or below $17,856/individual or $23,952/couple
  • cash resources at or below $20,000/individual or $30,000/couple
  • and a Medicare-approved drug plan that will accept payments from the state; most plans are participating

For more information on this program, called NCRx, visit www.ncrx.gov or call 1-888-488-NCRx. Though the original deadline to apply for NCRx has been extended indefinitely, don’t delay. Seniors who live in Durham County should contact Senior PHARMAssist because we can help you enroll in NCRx. Also, if you are eligible for NCRx, you are eligible for Senior PHARMAssist’s supplemental drug coverage.

Participants in our supplemental program use their Medicare card first and then our card as a “back up.” For medications on our geriatric formulary (safer, more effective, and more cost-effective medications for older adults), our participants don’t pay more than $3 for generics or $6 for brand-name medications. In other words, Senior PHARMAssist picks up the cost of covered medications whenever the Medicare plan does not - before, during, and after the “doughnut hole.” And THERE IS NO DEADLINE TO ENROLL in Senior PHARMAssist’s supplemental program. Our participants also receive hands-on assistance to help them better manage their medicines and access other community resources, which can further enhance their well-being.

Message to those in the doughnut hole
If you have Medicare drug coverage but lapse into your plan’s period of non-coverage - triggered in 2008 when total annual drug costs (yours plus the insurance company’s) reach $2,510 - you still may be able to minimize your out-of-pocket expenses:

  • First, make sure that your plan itself doesn’t offer extra assistance during the coverage gap. Some policies will continue to cover medications - generally generics only - during the so-called doughnut hole.
  • Ask your prescriber if he or she would consider switching you from brand-name medications to generic equivalents, when appropriate. It’s also good to periodically review all the medications you’re taking with your prescribers to see if any medicines can or should be removed from your drug regimen.
  • Finally, you may be eligible for drug company patient assistance programs that will help you during the period of non-coverage. Ask your prescriber. In Durham, you may also call Senior PHARMAssist.

A number of drug companies are providing needed medications to Medicare beneficiaries who have not enrolled in a Medicare drug plan. For more information in Durham, please call Senior PHARMAssist. Just a reminder: If you’re a Medicare beneficiary and did not enroll in a Medicare drug plan when first eligible and you did not have comparable (also called “creditable”) prescription coverage, you will incur a permanent 1% premium penalty for every month that lapses before you do enroll. With federal, state (NCRx), and local (Senior PHARMAssist) financial assistance available, Medicare beneficiaries in Durham – especially seniors – owe it to themselves to enroll.

Senior PHARMAssist and others are here for you
The annual enrollment period for Medicare’s prescription drug benefit is Nov. 15th – Dec. 31st, with coverage beginning on Jan. 1st. Senior PHARMAssist and other agencies mentioned above will continue to offer assistance with navigating Medicare-approved drug plans. This will be critical for beneficiaries of all income levels, as prices and policies will change each year – not to mention the medication needs of many of those enrolled.

Seniors, people with disabilities, and caregivers should remain vigilant. The NC Department of Insurance has confirmed that confusion related to Medicare changes is creating an environment for financial abuse and fraud. Beneficiaries should be certain whether a new health plan is truly offering benefits as advertised, without limiting access to needed services. There are also individuals who are posing as insurance agents simply to obtain personal information. Marketing of private plans is ongoing, and some companies may be “cold calling” seniors, though unsolicited door-to-door sales are not permitted.

In order for these Medicare changes to be most beneficial, many seniors are going to need one-on-one assistance from a trusted, reliable source. Senior PHARMAssist continues to be that source for hundreds of older adults in Durham. If you live in Durham County and need help obtaining and/or better managing your medicines, please call us at 919-688-4772.

Other sources of valuable Medicare information:

Access to Benefits Coalition and National Council on the Aging

Centers for Medicare and Medicaid

Families USA

Kaiser Family Foundation

Medicare Rights Center

Medicare Rx Education Network

Medicare Web site for Clinicians

National Consumers League

NC Department of Health and Human Services

NC Seniors’ Health Insurance Information Program

Senior PHARMAssist

Helpful links for prescribers, community pharmacists, and Medicare beneficiaries

To access Senior PHARMAssist’s formulary click here. To review the formularies of private companies sponsoring Medicare-approved prescription drug plans, click on the links below:












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