COST SHARING

Is a dual eligible required to pay a monthly premium for Medicare prescription drug coverage?

No, Medicare will cover the premium cost up to the average premium level for each state as determined by CMS.   

How will I know if a PDP’s premium is at or below the average for my state?

This information will be available at the CMS/Medicare website (www.medicare.gov).

What happens if the PDP that the person wants to switch to has a premium above the average?

If a dual eligible selects a plan with a higher than average premium, he or she will have to pay the entire amount over the average premium. In some states, state funding may be available to pay for the difference in premium cost. 

Will dual eligibles be required to pay an annual deductible for their Medicare prescription drug coverage?

No, dual eligibles will not be required to pay an annual deductible.

Will dual eligibles be required to pay a co-pay?

·        A dual eligible residing in an ICFs/MR or nursing facility will not be required to pay co-pays. 

·        If the dual eligible’s income is under 100 percent of the federal poverty level ($9,570 annually for an individual) he or she must pay $1 for preferred (usually generic) medications or $3 for non-preferred (usually brand name) medications as described by the PDP. 

·        If the individual’s annual income is above 100 percent of the federal poverty level ($9,570 annually) then the co-pay is $2 for the preferred medication and $5 for the non-preferred.

 Are States providing additional coverage to fill in the gaps for dual eligibles?

The MMA prohibits states from using federal Medicaid funds to fill in the gaps (e.g. co-pays).  However states can use state funds to fill in any gaps. Some states may use their State Pharmacy Prescription Assistance Program to supplement coverage.  Others states have passed separate legislation (sometimes using state Medicaid funds) to wrap around Medicare prescription drug coverage so that dual eligibles will not have to pay co-pays.