Ahip 2025 Module 3: Medicare Part D
Prescription Drug Coverage questions
and answers
Mrs. |Roswell |is |a |new |Medicare |beneficiary |who |has |just |retired |from |retail |work. |She |is |
interested |in |selecting |a |Medicare |Part |D |prescription |drug |plan. |She |takes |several |medications
|and |is |concerned |that |she |has |not |been |able |to |identify |a |plan |that |covers |all |of |her |
medications. |She |does |not |want |to |make |an |abrupt |change |to |new |drugs |that |would |be |
covered |and |asks |what |she |should |do. |What |should |you |tell |her? |- |ANS |-Every |Part |D |drug |
plan |is |required |to |cover |a |single |one-month |fill |of |her |existing |medications |sometime |during |a
|90-day |transition |period.
What |types |of |tools |can |Medicare |Part |D |prescription |drug |plans |use |that |affect |the |way |their |
enrollees |can |access |medications? |- |ANS |-INCORRECT |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.
Mr. |Hildalgo |complains |to |you |that |because |he |takes |multiple |expensive |drugs, |he |has |trouble |
paying |his |cost |sharing |for |his |prescription |drugs, |particularly |at |the |beginning |of |the |year |
during |the |deductible |phase. |He |is |happy |with |his |plan |and |does |not |want |to |change. |
However, |he |said |he |had |heard |about |a |new |program |called |the |Medicare |Prescription |
Payment |Plan |and |asked |whether |it |might |help. |What |do |you |tell |him? |- |ANS |-The |Medicare |
Prescription |Payment |Plan |helps |spread |out |beneficiary |cost-sharing |payments |but |does |not |
decrease |the |total |amount |owed.
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? |- |ANS |-If |the |drug |coverage |he |has |is |not |expected |to |pay, |on |average, |at |least |as
, much |as |Medicare's |standard |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.
One |of |your |clients, |Lauren |Nichols, |has |heard |about |a |Medicare |concept |from |one |of |her |
neighbors |called |TrOOP. |She |asks |you |to |explain |it. |What |do |you |say? |- |ANS |-
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? |- |ANS |-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.
b.
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.
Mr. |Rice |is |68, |actively |working, |and |has |coverage |for |medical |services |and |medications |
through |his |employer's |group |health |plan. |He |is |entitled |to |premium |free |Part |A |and |thinking |
of |enrolling |in |Part |B |and |switching |to |an |MA-PD |because |he |is |paying |a |very |large |part |of |his |
group |coverage |premium, |and |it |does |not |provide |coverage |for |a |number |of |his |medications. |
Which |of |the |following |is |NOT |a |consideration |when |making |the |change? |- |ANS |-b.
Mr. |Rice's |retiree |plan |is |required |to |take |him |back |if, |within |63 |days |of |having |voluntarily |quit |
the |employer's |plan, |he |decides |that |he |prefers |it |to |his |Medicare |Part |D |plan.
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? |- |ANS |-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.
Prescription Drug Coverage questions
and answers
Mrs. |Roswell |is |a |new |Medicare |beneficiary |who |has |just |retired |from |retail |work. |She |is |
interested |in |selecting |a |Medicare |Part |D |prescription |drug |plan. |She |takes |several |medications
|and |is |concerned |that |she |has |not |been |able |to |identify |a |plan |that |covers |all |of |her |
medications. |She |does |not |want |to |make |an |abrupt |change |to |new |drugs |that |would |be |
covered |and |asks |what |she |should |do. |What |should |you |tell |her? |- |ANS |-Every |Part |D |drug |
plan |is |required |to |cover |a |single |one-month |fill |of |her |existing |medications |sometime |during |a
|90-day |transition |period.
What |types |of |tools |can |Medicare |Part |D |prescription |drug |plans |use |that |affect |the |way |their |
enrollees |can |access |medications? |- |ANS |-INCORRECT |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.
Mr. |Hildalgo |complains |to |you |that |because |he |takes |multiple |expensive |drugs, |he |has |trouble |
paying |his |cost |sharing |for |his |prescription |drugs, |particularly |at |the |beginning |of |the |year |
during |the |deductible |phase. |He |is |happy |with |his |plan |and |does |not |want |to |change. |
However, |he |said |he |had |heard |about |a |new |program |called |the |Medicare |Prescription |
Payment |Plan |and |asked |whether |it |might |help. |What |do |you |tell |him? |- |ANS |-The |Medicare |
Prescription |Payment |Plan |helps |spread |out |beneficiary |cost-sharing |payments |but |does |not |
decrease |the |total |amount |owed.
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? |- |ANS |-If |the |drug |coverage |he |has |is |not |expected |to |pay, |on |average, |at |least |as
, much |as |Medicare's |standard |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.
One |of |your |clients, |Lauren |Nichols, |has |heard |about |a |Medicare |concept |from |one |of |her |
neighbors |called |TrOOP. |She |asks |you |to |explain |it. |What |do |you |say? |- |ANS |-
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? |- |ANS |-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.
b.
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.
Mr. |Rice |is |68, |actively |working, |and |has |coverage |for |medical |services |and |medications |
through |his |employer's |group |health |plan. |He |is |entitled |to |premium |free |Part |A |and |thinking |
of |enrolling |in |Part |B |and |switching |to |an |MA-PD |because |he |is |paying |a |very |large |part |of |his |
group |coverage |premium, |and |it |does |not |provide |coverage |for |a |number |of |his |medications. |
Which |of |the |following |is |NOT |a |consideration |when |making |the |change? |- |ANS |-b.
Mr. |Rice's |retiree |plan |is |required |to |take |him |back |if, |within |63 |days |of |having |voluntarily |quit |
the |employer's |plan, |he |decides |that |he |prefers |it |to |his |Medicare |Part |D |plan.
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? |- |ANS |-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.
