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Prescription
Advantage: is it right for me?
Prescription Advantage: is it right for me?
By Margie Ware, Regional SHINE Director
Consumers are hearing a lot of information about the Commonwealth’s new Prescription Advantage program. For many individuals, it will be most beneficial; for others there are better alternatives. How can a person decide?
Q. I guess I don’t qualify for this program. My income is over $20,000.
A. EVERYONE 65 and older in the Commonwealth is eligible to purchase prescription coverage under this program. The full cost of the program is $82 per month for single individuals; $66 per month for married individuals (whether one’s spouse joins or not) with a deductible of $500 annually. Individuals with incomes over $42,961 and married persons with household incomes over $58,057 pay the full cost. Below this figure, there is a fee subsidy. If one wants to pay a lower fee, you must submit a copy of your 2000 income tax return and/or your Social Security statement. Below $16,152 ($21,828 for two person households) the Commonwealth pays all monthly fees and deductibles.
Q. My friend said that she’s paying higher copays now. Why?
A. The former Pharmacy Program charged copays of $3 for generic drugs and $10 for brand name drugs. Under Prescription Advantage, Individuals with incomes below $17,184 ($23,220 for married individuals) will pay $5 for a generic drug and $12 for a brand name drug. Individuals in higher income brackets will pay $10 for generic prescriptions and $25 for brand name prescriptions.
Q. Twenty-five dollars per prescription! I take ten different prescriptions! That’s going to be expensive!
A. First of all, not all your prescriptions will be brand names. Second, Prescription Advantage has a "cap" on out-of-pocket expenses (not including one’s monthly fee). When the total of your annual deductible and your copays equal $2000 or 10% of your income (whichever is less) you will no longer pay copays during the plan year (April 1 - March 31.) You will only be billed your monthly fee if you are in a bracket which pays that fee.
Q. I presently have a Supplement #2 health insurance policy that includes prescription drugs. Should I stay with what I have or sign up for Prescription Advantage?
A. For married individuals, the total cost of Prescription Advantage will never be more than the differential one would pay between a Supplement #1 and Supplement #2 Medigap policy. If you presently have a Supplement #2 policy (sometimes referred to as "Gold"), check with your insurer to see if they will allow you to "downgrade" your policy before the open enrollment period next February. And don’t assume that Supplement #1 is the kind of policy you should buy instead – you should probably speak with a SHINE counselor to discuss what each policy covers and what makes the most sense for you. Any single individual with a Supplement #2 policy will save money with Prescription Advantage if they pay copays in their present plan over $200/year.
Q. I used to belong to the Pharmacy Program. I never paid a monthly fee or a deductible. Now I have to pay a $450 deductible and a $52 monthly fee! I think this is really unfair!
A. Your frustration is understandable. There are two things to remember. First, the
former Pharmacy Program was a benefit program. It was based on individual income. It was highly advantageous to married individuals who each had an income under $15,708. Prescription Advantage is an insurance-based program. It is designed to support itself financially, with specific public support for individuals and households below 188% of the poverty level. The copays and deductibles are calculated to make the program succeed. The second thing to remember is that under the previous program, many individuals with incomes just slightly over the $15,708 level were not eligible for ANY assistance. Now they have access to fairly-priced prescription insurance. Massachusetts is the ONLY state in the nation providing this level of coverage. So while some individuals will be paying more, many thousands more will have a new opportunity.
Q. I don’t really take that many medications. Should I join Prescription Advantage?
A. The best way to determine whether you should join the program is to speak to a SHINE Counselor. The following is a worksheet which SHINE Counselors use to assist clients in making that decision:
Prescription Advantage
Beginning next April, Prescription Advantage may begin charging surcharges to people who do not join when they are initially eligible (similar to the process involved in signing up for Medicare Part B). But for the time being, persons interested in Prescription Advantage will not be penalized if they choose not to join the program this year because they have fewer expenses being self-insured.
Again, please do not hesitate to call your local Council on Aging or Elder Services to speak to a SHINE Counselor. Everyone’s situation is different, and it’s important to think carefully about what method of prescription coverage is best for you.