Questions and answers about Medicare Part D

Questions and answers about the Medicare Part D prescription drug program:

Q: My question is about the "doughnut hole," where you pay 100 percent of the costs between $2,250 and $3,600. They say you reach the $2,250 level based on the total drug cost paid by both you and your plan. I know what my co-pay is, but I don't know what the insurance costs are.

- John in Boynton Beach, Fla.

A: You should use your Part D card for every drug purchase you make. Your plan is supposed to keep track of how much you spend out of pocket as well as the total cost of the drugs. Insurance companies are required to provide the information on request, and some voluntarily issue a monthly statement of those figures.

Q: I tried to fill a prescription for Niaspan under Part D and found that although the drug was listed in my insurance company's formulary, Medicare had removed the drug from its approved coverage just after the company published its list. The pharmacist informed me that the drug was not covered and I would have to pay full price rather than the much smaller co-pay. What can I do to get Medicare to reverse its action relative to this drug?

- Ted in Dayton, Ohio

A: Medicare made a mistake when it approved formulary lists that included Niaspan and a similar drug, Niacor, because they are not eligible drugs. They are a form of niacin and are considered a vitamin, not a medicine. Some plans have decided to continue covering those drugs on their own until June 1.

Q: I've fallen in a crack! I was on Medicare and Medicaid, and my drugs were quickly and efficiently paid by Medicaid. That stopped Dec. 31. The new plan is so complicated that none of us can get through. They seem to want us to "join their club" before they will pay for my medicines. Can you tell me how to get the new coverage started?

- Carol in Wimberley, Texas

A: You are what's known as a "dual eligible" because you are in both programs. You should have automatically been enrolled in a Medicare Part D plan last December. Any pharmacist should be able to tell you which plan you are in. If you have "fallen in a crack" and were not automatically enrolled, you can enroll at the pharmacy in the WellPoint(cq) plan and get immediate coverage, with a maximum co-pay of $5. Later, you could change to a different plan without penalty so long as you remain a dual eligible.

Q: If I am in an HMO, do I need to sign up for the new drug program? If I move to another state and am not able to get into another HMO, what should I do?

- Beverly in Lake Worth, Fla.

A: Many HMOs offered drug coverage last year, and if you were happy with your plan, you don't have to do anything. If your HMO didn't offer drugs last year but does now, you should have been automatically enrolled in the drug plan. If you move you may have to join a different plan, but they are available in every state, labeled as Medicare Advantage plans.

Q: Can you tell me if there is an interactive calculator tool on the Web where one may plug in the drugs, their strength and dosage, and compare one plan to another?

- Jane in Loganville, Ga.

A: The Medicare Web site has just such a calculator. Go to www.medicare.gov and click on the link that says "compare Medicare prescription drug plans," then the button that says "find a Medicare prescription drug plan." You enter your ZIP code and list your drugs and dosages, and the calculator will show the available plans in your area and how much you would pay for those specific drugs. You can compare up to three plans at a time. Once you've narrowed the choice down to one plan, you should double-check with the plan to make sure it covers the drugs you take.

Q: If a person signs up for a Part D plan, can he change his mind prior to the effective date? If so, would the Medicare-approved prescription discount card still be valid? If a person signs up for a Part D plan, how does the discount card insurer know that the card should no longer be valid?

- Leon in Central Texas

A: Yes, you could cancel the plan before its effective date. However, the Medicare-approved prescription drug card should no longer work. They were supposed to expire on Dec. 31.

Q: I am currently working and have creditable drug coverage through my employer. However, if I retire sometime other than the November-December open enrollment period, will I be able to switch to a Medicare plan at the retirement date without incurring any penalties? Are there any pre-existing condition clauses in the new Medicare plans?

- Tom in Smyrna, Ga.

A: So long as you maintain creditable coverage while working, you would not be subject to a penalty upon retirement, but you must enroll in a prescription drug plan within 60 days of your retirement. There are no pre-existing condition clauses in the Medicare plans.

Confused about the new Medicare Part D prescription drug program? Cox Newspapers Washington Bureau reporter Larry Lipman answers selected questions from readers on Saturdays. Send your question, with your name and city, to medicaremailbag@coxnews.com