2022 AHIP UNIT 3 MEDICARE PDP

2022 AHIP UNIT 3 MEDICARE PDP Question 1 Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? a.Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. b.Mr. Vaughn’s hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. Incorrect: Even if Mr. Vaughn’s balding wasthe result of illness or a side effect of chemotherapy, by law Part D plans are not permitted to provide coverage for cosmetic purposes. c.The vitaminsthe Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss medication cannot be covered. d.Medicare prescription drug plans are not permitted to cover the prescription medicationsthe Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility. Source: Module 3, Slide - Drugs Excluded from Part D Coverage Question 2 Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? a.Mr. Carlini can keep Original Medicare, but if he does not sign up for an MA plan that includes prescription drug coverage, he will only be able to obtain prescription drug coverage through a Medigap plan. b.To obtain prescription drug coverage, Mr. Carlini must enroll in an MA plan. The plan will cover his Part A and Part B services, as well as provide him with the desired prescription drug coverage. c.Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. d.Mr. Carlini can obtain drug coverage through the Federal government’sfallback plans, which are designed to provide an alternative to privately sponsored Medicare Advantage plans. Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basic and Slide - Medicare Prescription Drug Eligibility Question 3 Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her? a.When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. b.Medicare prescription drug plans are required to cover drugsin each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she needs. c.Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. Incorrect: Medicare drug plans are not required to limit the percentage of brand name drugs they cover. Part D formularies must include at least two drugs in each therapeutic category whether generic versions are available or not. d.Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. Source: Module 3, Slide - Covered Part D Drugs Question 4 Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him? a.The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. b.The government bases its payments to Part D plans on the standard benefit model. For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. c.The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. d.Medicare Part D drug plans may have different benefitstructures, but on average, they must all be at least as good as the standard model established by the government. Source: Module 3, Slide - Part D Plan Benefits. Question 5 Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he hasfor obtaining help with his considerable drug costs. What should you tell him? a.The only option available is to reduce hisincome so that he can qualify for the Part D extra help or wait until next year to see if the annual limits change. b.He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited meansto obtain the medications they need. Alternatively, he could check to see whether hisstate has a pharmacy assistance program to help him with his expenses. c.He should contact his neighbors and family members and let them know that any contributions they make toward his drug expenses will be tax deductible. d.He should look into the possibility of purchasing his medications through the internet from off-shore pharmacies. Source: Module 3, Slide - Other Help for Low Income - Pharmaceutical Assistance Programs. Question 6 Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her? a.An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. b.As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is not dependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. c.Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in a Medicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. d.To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy must be entitled to Part A and enrolled under Part B. She should contact her local Social Security office and decide to enroll in Part B prior to selecting a prescription drug plan. Source: Module 3, Slide - Medicare Part D Eligibility Question 7 Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? a.Thisis not a possibility. If Mrs. Berkowitz wants health coverage and drug coverage through a plan, she must purchase an MA-PD plan. b. Mrs. Berkowitz can enroll in any Medicare Advantage plan, regardless of whether it offers drug coverage, and enroll in any stand-alone Medicare prescription drug plan. c.If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Berkowitz can do this. d.Mrs. Berkowitz can apply for any Medicare Advantage plan and, if it offers drug coverage, ask to have that element of the coverage eliminated, after which she can enroll in a stand-alone Medicare prescription drug plan in her service area. Source: Module 3, Slide - Medicare Part D Prescription Drug Eligibility. Question 8 Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She hasrecently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? a.If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. b.If a Part D benefit is offered through her plan she must enroll in this plan. c.Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. d.Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics Question 9 All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage? a.Standard Part D coverage would require payment of only fixed per-prescription co-payments. b.Standard Part D coverage would require payment of an annual deductible, fixed per-prescription copayments, and once catastrophic coverage begins, the plan covers 100% of all costs. c.Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-paysfor generic and brand name drugs or coinsurance of 5%. d.Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. Source: Module 3, Slide - Part D Plan Benefits, Slide - Part D Benefits: The Standard Benefits for 2022 and Catastrophic Coverage. Question 10 Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan’s formulary. What could you tell him to do? a.Mr. Zachow will need to enroll in a Special Needs Plan to obtain coverage for his medication. b.Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan’s website, fill it out, and submit it to his plan. c.Mr. Zachow will have to wait until the Annual Election Period when he can switch Part D plans. In the meantime, he will have to pay for his drug out of pocket. d.Mr. Zachow could immediately disenroll from the Part D plan and select a new Part D plan that covers the drug that works for him. Source: Module 3, Slide - Enrollee Rights: Requesting Exceptions for Drugs. Question 11 Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she haslost. How would you advise her? a.She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network. b.She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. c.She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. Incorrect: In-network pricing depends on whether a pharmacy has contracted with a Part D plan to be considered within their network. The fact that Ms. Edwards is traveling does not alter the pharmacy’s network status. d.She may fill prescriptionsfor covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Source: Module 3, Slide - Part D Pharmacy Networks. Question 12 Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan’s formulary he takes several other medications. These include a prescription drug not on his plan’s formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say? a.The cost of the prescription drugs that are not on his plan’s formulary as well as the cost of the drug(s) to reduce joint swelling from the Canadian pharmacy will count toward TrOOP but the other medications in question will not count toward TrOOP. b.None of the costs of Mr. Wingate’s other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. c.The cost of the prescription drug that is not on his plan’s formulary will count toward TrOOP but the other medications in question will not count toward TrOOP. Incorrect: Some costs do not count toward TrOOP. These include costs for drugs not on a Part D plan’s formulary unless the beneficiary receives an exception under which the plan covers the drug. d.The cost of all medications bought within the United States not covered by his plan would count toward TrOOP. The cost of the Canadian bought medications would not count toward TrOOP. Source: Module 3, Slide - True Out-of-Pocket Costs? (TrOOP): What Counts and Slice - True Out-of-Pocket Costs (TrOOP): What is Excluded? Question 13 Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. a.I, II, and III only B.I only c.I, II, III, and IV d.I and II only Source: Module 3, Slide - Medicare Part D Prescription Drug Program Basics, Slide - Medicare Part D Drug eligibility and Slide - Medicare Part D Pharmacy Network. Question 14 Mr. Hutchinson has drug coverage through his former employer’s retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? a.He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. b.If the drug coverage he has is not expected to pay, on average, at least as much as Medicare’sstandard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. c.If he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. Incorrect: A penalty will be incurred if the employer coverage is not “creditable.” Prescription drug coverage is “creditable” if on average it equals at least as much as Medicare’sstandard Part D coverage expects to pay. d.He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. Source: Module 3, Slide - Employer/Union Coverage of Drugs and Slide - Part D Late Enrollment Penalty. Question 15 Mrs. McIntire is enrolled in her state’s Medicaid plan and hasjust become eligible for Medicare as well. What can she expect will happen to her drug coverage? a.She can expect that all her prescriptions will be automatically delivered on a mail-order basis as a requirement of the Medicare Part D program. b.Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. c.Unless she chooses a Medicare Part D prescription drug plan on her own,she will be automatically enrolled in one available in her area. d.She will continue to obtain her drug coverage through Medicaid. Source: Module 3, Slide - Medicaid Drug Coverage. Question 16 Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz haslost his employer group coverage within the last two weeks. How would you advise him? a.Mr. Schultz should immediately enroll in a Part D plan but he can expect to pay a premium penalty because he failed to enroll when first eligible. b.Mr. Schultz can wait up to 180 days after the loss of his creditable employer group coverage before enrolling in a Part D plan without worrying payment a premium penalty. c.Mr. Schultzshould seek to continue employer group coverage through COBRA because it is likely to have superior benefits at a more permanent solution. d.Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. Source: Module 3, Slide - Employer Coverage of Drugs. Question 17 Mr. Torres has a smallsavings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? a.In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. Incorrect: Part D beneficiaries have the option to pay their monthly premiums, not only through automatic payments from a checking account, but also from a savings account or automatic charges against their credit or debit card. b.In general, he must select a single Part D premium payment mechanism that will be used throughout the year. c.During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments. d.As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. Source: Module 3, Slide - Part D Premiums Question 18 Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? a.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will have to pay a one-time penalty equal to 10% of the annual premium amount. b.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. c.If she does not sign up for a Medicare prescription drug plan, she will incur no penalty, as long as she can demonstrate that she was in good health and did not take any medications. d.If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, she will be required to pay a higher premium during the first year that she is enrolled in the Medicare prescription drug program. After that point, her premium will return to the normal amount. Source: Module 3, Slide - Part D Late Enrollment Penalty. Question 19 What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? a.Part D plans may use varying co-payments, but they are required to cover all prescription medications on the market. b.Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization. c.The Federal government establishes a set formulary, or list of covered drugs, each year that the Part Dplans must use. Beneficiaries should consult the government’s list prior to deciding whether they wish toenroll in a Part D plan during that year. d.Part D plans may use varying co-payments for brand name and generic drugs, but they may not restrictaccess through prior authorization. Source: Module 3, Slide - Part D Drug Management Tools. Question 20 Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? a.Betsy, a grandmother from overseas who has overstayed her visa. b.Guy, who hasillegally crossed the Canadian border. c.Jose, a grandfather who was granted asylum and has worked in the United States for many years. d.Helena, an overseas college student who has overstayed her visa. Source: Module 3, Slide - Medicare Part D Eligibility.