CHOOSING A MEDICARE PRESCRIPTION DRUG PLAN  

What should a dual eligible do to ensure that they have access to Medicare prescription drug coverage that meets their needs?

Dual eligibles, their families, providers and/or advocates must select and enroll in a plan that meets their needs.  No one should assume that the PDP to which a dual eligible is randomly auto-assigned will meet their needs. Each year the plans change and formularies may change, so people must check to make sure their plan still meets their needs.  

What are the key things to think about when choosing a PDP?

·        Individuals or their caregivers will need to evaluate the drug formularies of the various plans to see if the formulary includes all the drugs they need, and to see if there are any restrictions on access to those drugs.

·        If the plans do not cover all their prescription drugs, a medical consultation may be necessary to see if their doctor will work with the person to appeal the decision or if the individual can safely be switched to other medications.

·        Individuals or their caregivers will need to look at the pharmacy network to make sure the pharmacy they use is part of the PDP’s network.

·        Individuals and their caregivers need to be aware that Medicare will reimburse only for premiums that are at or below a certain cost level, so choosing another plan may result in higher costs to the individual.  More information on premiums, premium benchmarks, and finding out if your plan's premium is at or under the regional benchmarks.

Be aware that different rules apply for individuals who reside in nursing facilities or ICFs/MR versus other group homes, at home or in supported living arrangements.

Who is authorized to enroll in a Medicare PDP on behalf of a dual eligible with a cognitive or intellectual disability? 

The federal Centers for Medicare and Medicaid Services (CMS) has stated that each state will decide who is considered a legally authorized representative for selecting and enrolling a person with a cognitive disability in a PDP.   Families and caregivers are urged to contact their State Medicaid agencies for more information.