2022 OVERVIEW of MEDICARE PROGRAM BASICS: CHOICE, ELIGIBILTY, AND BENEFITS MEDICARE PART D: PRESCRIPTION DRUG COVERAGE

2022 OVERVIEW of MEDICARE PROGRAM BASICS: CHOICE, ELIGIBILTY, AND BENEFITS MEDICARE PART D: PRESCRIPTION DRUG COVERAGE PART 3 1.Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends hastold her that she needs to be aware of something called TrOOP. What should you tell her when she asks you about TrOOP? a. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include, in addition to the annual deductible, costsfor drugs not on the Part D plan's formulary and drugs purchased outside the United States. Incorrect b. TrOOP is calculated on a cumulative basis and consists of the sum of an enrollee's out-of-pocket deductibles from the date of his or her enrollment in Part D plus outlays for over-the-counter drugs. Incorrect c. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. Correct d. TrOOP is calculated on an annual basis and consists of an enrollee's out-of-pocket deductible plus any amounts paid on behalf of an enrollee by Medicaid. Incorrect 2. Mr. Jacob understandsthat 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 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. Incorrect b. 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. Incorrect c. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Correct d. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. Incorrect 3. Mrs. McIntire is enrolled in her state’s Medicaid plan and hasjust become eligible for Medicare as well. What can she expect will happen with respect to her drug coverage? a. She will continue to obtain her drug coverage through Medicaid. Incorrect b. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. Incorrect c. She can change Medicare Part D prescription drug plans only during the annual election period. Incorrect d. Unless she chooses a Medicare Part D prescription drug plan on her own,she will be automatically enrolled in one available in her area. Correct 4. 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 prescriptionsthat she has lost. 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. Incorrect b. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct c. 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. Incorrect d. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. Incorrect 5. Mr. Rice has coverage for medical services and medications through his employer’s retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does not cover two important medications. What should he consider before making a change? a. If his drug coverage through the retiree plan is “creditable” he should not switch, even though it is possible to do so. Incorrect b. Mr. Rice can only receive his prescription drug coverage through a Medicare Advantage prescription drug plan so he should drop his employer coverage. Incorrect c. If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage. Correct d. Mr. Rice’sretiree 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. Incorrect 6. All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2020 under the standard coverage? a. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription copayments, 35% of the costsin the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. Incorrect b. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. Incorrect c. Standard Part D coverage would require payment of only fixed per-prescription co-payments. Incorrect 7. 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 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. Incorrect b. 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. Incorrect c. As long as 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 d. If the drug coverage he hasis 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. Correct 8. 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. 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. Incorrect be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct between $435 and $4,020, and once through the catastrophic coverage threshold the beneficiary pays either co-paysfor generic and brand name drugs or co-insurance of 5%, whichever is greater. Correct d. Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing b. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should c. 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 medicationsin a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. 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 9. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughntakes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescriptiondrug plan cover these drug needs. What should you tell them? a. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmeticpurposes. Incorrect b. Medicare prescription drug plans are not permitted to cover the prescription medicationsthe Vaughnsare interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughn’s could look into that possibility. Correct c. The vitaminsthe Vaughns are taking will be covered under Part D because their physician suggestedthey should take vitamins, but the hair loss medication cannot be covered. Incorrect d. Mr. Vaughn’s hair growth medication would only be covered under Part D if his balding resulted froman illness or was a side effect of a treatment such as chemotherapy. Incorrect 10. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She isinterested in enrolling ina Medicare Part D prescription drug plan (PDP). What should you tell her? a. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part Dcoverage. Incorrect b. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part Dcoverage. Incorrect c. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalonePDP. Correct d. If a Part D benefit is offered through her plan she must enroll in this plan. Incorrect