During this time of year, many people will begin to enter the Coverage Gap or “Donut Hole” portion of their Medicare Part D coverage and find their coverage costs changing.
If you have already purchased medications with a retail value of $4,020 you are in the 2020 Donut Hole.
Question: I have purchased medications worth $3,930 so far this year, my next brand-name drug purchase has a retail cost of $400, bringing me into the Donut Hole (or Coverage Gap). Will I get a Donut Hole discount on the full $400 retail price or just the $90 that falls into the gap?
Your Donut Hole discount (which is 25%) only applies to the $90 portion of the retail drug price that falls into the Coverage Gap. Since your purchase “straddles” two phases of coverage, you pay your cost-sharing for the Initial Coverage phase (for example, $47 for a Tier 3 brand drug) and the brand-name Donut Hole discount applies to the remainder of the retail price falling into the Donut Hole.
Therefore, your total drug cost is the cost-sharing you paid in the Initial Coverage phase plus the discounted cost in Donut Hole. (Note: The combined cost of the Initial Coverage phase and the Donut Hole phase will never exceed your drugs total retail cost.)
Question: If I use only one brand drug that costs $347 and have a $47 co-pay, will I enter the 2020 Donut Hole?
Yes. If your retail drug costs average $347 you will exceed your Medicare plan’s Initial Coverage Limit of $4,020 and enter the 2020 Coverage Gap or Donut Hole sometime in November.
Only your plan’s retail drug costs count toward entering the Donut Hole. Your co-pay has no impact on entering the Donut Hole, but will impact when you exit the Donut Hole.
Question: I am in the Donut Hole and now have a new prescription that is not on my plan’s list of covered drugs. Do I get a discount on my new medication and will my costs count toward getting out of the Donut Hole?
No. Only Medicare Part D prescription medications found on your plan’s formulary receive the 75% discount. Non-formulary medications and medications excluded from the Medicare Part D program, do not qualify for the Donut Hole discount and your non-formulary drug purchases do not count toward meeting your 2020 total out-of-pocket drug spending (TrOOP) limit of $6,350 — the amount you need to spend to exit the Donut Hole.
If you are using a non-formulary medication, you can ask your Medicare plan for a Formulary Exception which is a type of Coverage Determination.
If your Medicare Part D plan denies your request, you have the right to appeal your plan’s decision. For more information, you can click here to read about Formulary Exceptions. https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Exceptions.html
If you would like help comparing your needs against the many Medicare plans out there or if you just want to ask a few questions, you can call me directly at 207-370-0143 or use my simple form on the CONTACT page of this site to send an email message.
The best part about working with me is that it will not cost you anything to talk with me to discuss your options and review the plans that are available. I am paid by the insurance companies in the form of a commission when you enroll in a plan. You will not pay anything to meet with me and you will pay the same price for your insurance that everyone pays whether they had my help or not.
“My goal is to help people and I have found great joy in being able to offer my services to people who need my help.”
Updated 2024 Medicare & You Handbook Available online at: https://www.medicare.gov/index.php/medicare-and-you
Summary: The Medicare & You 2023 handbook is available free of charge. It’s published by the Centers for Medicare & Medicaid Services (CMS). This is the official government guide explaining the Medicare program in detail. You can get Medicare & You in a variety of formats. You can get the handbook in an electronic, PDF form or paper form and in English, Spanish, large print, Braille, or audio.
Medicare & You 2023 Handbook
Medicare & You 2023 is an official government publication. Millions of people receive the Medicare & You handbook at their homes by mail each year. CMS usually mails the Medicare & You handbook in the fall of each year. This is to help prepare people for the Annual Election Period, which occurs October 15th to December 7th each year. During this time, Medicare beneficiaries can review their Medicare coverage and make changes, if they want.
Frequently Asked Questions (FAQ)
I’ve had Medicare for a number of years. Why is the Medicare & You 2023 Handbook important to me? Each year, the Centers for Medicare & Medicaid Services (CMS) publishes a revised Medicare & You Handbook. The purpose of the Medicare & You Handbook is to provide Medicare beneficiaries with up-to-date information about the Medicare program. If you’ve been enrolled in Medicare for a few years, you may want to use the Medicare & You 2023 as a reference guide to the current features of the Medicare program and your rights as a Medicare beneficiary.
What topics are included in the Medicare & You 2023 Handbook?
The Medicare & You Handbook contains information on
Medicare Part A (hospital insurance)
Medicare Part B (outpatient/medical insurance)
Medicare Supplement (Medigap) insurance
Medicare Advantage plans
Medicare Part D prescription drug coverage and the “donut hole”
Medicare & You 2024 lists many Medicare-covered services. Also, the Medicare & You 2024 handbook has a chart comparing key features of
Medicare Part A and Part B under the federal Medicare program with Medicare Advantage. Inside Medicare & You 2024 you’ll also find information on such topics as getting help with the cost of Part D prescription drug coverage, and much more.
What topics are not included in the Medicare & You 2024 Handbook?
Medicare & You 2024 doesn’t include plan-specific information – for example, when it comes to Medicare Advantage plans or Medicare prescription drug plans. If you have a Medicare Advantage or Medicare prescription drug plan, you’ll find plan-specific information in your plan’s 2022 Evidence of Coverage and Summary of Benefits. The Annual Notice of Change (ANOC) explains changes in the 2023 plan and benefits.
What if I didn’t get a Medicare & You 2023 handbook in the mail?
You can call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. A Medicare representative can check your address on file and get a Medicare & You 2023 handbook mailed to your home.
Can I get the Medicare & You 2024 Handbook in other formats?
Yes. You can get an electronic version of Medicare & You 2024 from the Medicare website. In fact, if you want to “go green” as the kids say these days and inform Medicare you wish to receive communications electronically rather than by postal mail. You can download a PDF to your computer. Keep in mind Medicare & You is about 130 pages long. If you choose to keep it in an electronic format, you can find topics using key word searches and hyperlinks from the table of contents. You can get the Medicare & You 2024 handbook in English or Spanish. You can also download a copy of Medicare & You in large print or Braille. You can listen to audio podcasts of Medicare & You 2024 chapters. Finally, you can order paper or CD versions of Medicare & You by calling Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. You get Medicare & You free of charge.
Would you like to learn more about your Medicare coverage options? I can help. Give me a call at 207-370-0143 or email by clicking here.
Available online at: https://www.medicare.gov/index.php/medicare-and-you
Summary: The Medicare & You 2023 handbook is available free of charge. It’s published by the Centers for Medicare & Medicaid Services (CMS). This is the official government guide explaining the Medicare program in detail. You can get Medicare & You in a variety of formats. You can get the handbook in an electronic, PDF form or paper form and in English, Spanish, large print, Braille, or audio.
Medicare & You 2023 Handbook
Medicare & You 2023 is an official government publication. Millions of people receive the Medicare & You handbook at their homes by mail each year. CMS usually mails the Medicare & You handbook in the fall of each year. This is to help prepare people for the Annual Election Period, which occurs October 15th to December 7th each year. During this time, Medicare beneficiaries can review their Medicare coverage and make changes, if they want.
Frequently Asked Questions (FAQ)
I’ve had Medicare for a number of years. Why is the Medicare & You 2023 Handbook important to me?
Each year, the Centers for Medicare & Medicaid Services (CMS) publishes a revised Medicare & You Handbook. The purpose of the Medicare & You Handbook is to provide Medicare beneficiaries with up-to-date information about the Medicare program. If you’ve been enrolled in Medicare for a few years, you may want to use the Medicare & You 2023 as a reference guide to the current features of the Medicare program and your rights as a Medicare beneficiary.
What topics are included in the Medicare & You 2023 Handbook?
The Medicare & You Handbook contains information on
Medicare Part A (hospital insurance)
Medicare Part B (outpatient/medical insurance)
Medicare Supplement (Medigap) insurance
Medicare Advantage plans
Medicare Part D prescription drug coverage and the “donut hole”
Medicare & You 2021 lists many Medicare-covered services. Also, the Medicare & You 2021 handbook has a chart comparing key features of Medicare Part A and Part B under the federal Medicare program with Medicare Advantage. Inside Medicare & You 2021 you’ll also find information on such topics as getting help with the cost of Part D prescription drug coverage, and much more.
What topics are not included in the Medicare & You 2023 Handbook?
Medicare & You 2023 doesn’t include plan-specific information – for example, when it comes to Medicare Advantage plans or Medicare prescription drug plans. If you have a Medicare Advantage or Medicare prescription drug plan, you’ll find plan-specific information in your plan’s 2022 Evidence of Coverage and Summary of Benefits. The Annual Notice of Change (ANOC) explains changes in the 2022 plan and benefits.
What if I didn’t get a Medicare & You 2023 handbook in the mail?
You can call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. A Medicare representative can check your address on file and get a Medicare & You 2023 handbook mailed to your home.
Can I get the Medicare & You 2023 Handbook in other formats?
Yes. You can get an electronic version of Medicare & You 2021 from the Medicare website. In fact, if you want to “go green” as the kids say these days and inform Medicare you wish to receive communications electronically rather than by postal mail. You can download a PDF to your computer. Keep in mind Medicare & You is about 130 pages long. If you choose to keep it in an electronic format, you can find topics using key word searches and hyperlinks from the table of contents. You can get the Medicare & You 2021 handbook in English or Spanish. You can also download a copy of Medicare & You in large print or Braille. You can listen to audio podcasts of Medicare & You 2021 chapters. Finally, you can order paper or CD versions of Medicare & You by calling Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. You get Medicare & You free of charge.
Would you like to learn more about your Medicare coverage options?
If you use of the insulins listed above then there may be a plan that offers a $25-$35 copay this year!
Say “Good Bye” to the Donut Hole!
The opportunity to get insulin for $25 or $35 a month is a very good deal. However, this isn’t automatic and you may be stuck paying much higher copays in 2022 if you don’t have a plan that is participating in this new program.
That’s right. Not all Part D prescription drug plans will offer the $25-$35 copay.
It is important to understand that of the 14 insurance companies that offer Medicare plans in Maine and New Hampshire, only about half are participating in this lower copay scheme. And some companies only offer it on select plans.
How to get these new Medicare savings?
This is the important part. Getting these savings is not automatic, you have to have a plan that participates.
You will need to research all the plans to find which standalone Part D prescription drug plans or Medicare Advantage plans will offer the lower costs. Start by calling your current plan and asking what your costs will be next year. If they do not say $25 or $35 then you may want to shop around for a better plan.
Would you like some help?
If you would like help searching for a new plan or just have a question, call us at (207) 370-0143 or use the button below to send an e-mail.
Generally, the only time you can switch to another Medicare prescription drug plan is during the Annual Medicare Open Enrollment Period that begins October 15th and ends December 7th.
However, there are other times of the year you can change, depending on where you live and what plan you have. To find out if you qualify to change plans outside of the Open Enrollment window, give me a call. I am happy to help!
If you’re only paying $35 every month, who’s helping to pay the rest?
Currently, the insurance companies that offer Part D prescription drug coverage on their plans have the option to offer prescription drugs at lower copays during the donut hole coverage gap.
But the insurance companies have to pick up the costs that would normally be paid by the pharmaceutical companies. Often, they choose to pass these costs on to you, the Medicare beneficiaries in the form of much higher premiums.
This new program makes two significant changes:
Pharma companies (specifically, Eli Lilly, Novo Nordisk, and Sanofi as the participating insulin makers) can continue paying their full coverage gap discount for products, even if a Part D plan offers lower cost-sharing.
Participating Part C and Part D plans will be required to cap insulin costs at $35 for a month’s supply, by applying the manufacturer rebates. This will happen year-round, even if you enter the “donut hole.“
How long will this program last?
This is a pilot program, in a sense. Medicare says it will watch how this works starting in 2021 and determine whether any changes are needed as time goes on. Expectations are from 3 to 5 years.
Medicare Administrator Seema Verma also said during the announcement: “If it goes well, we’ll extend this to other drugs. We’re starting with insulin, but depending on the progress, we will consider offering this flexibility to manufacturers and plans with other drugs, depending on the results. We think this creates a foundation and a platform to fix some of the problems that we have in Medicare Part D.”
The good news is that if Medicare does decide to continue with this low-cost insulin, other insurance companies may sign on in 2022 or later.
Would you like more info?
If you would like to talk about this program or schedule a meeting, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.
The best part about working with me is that it w not cost you anything to discuss your options or to review the plans that are available. I am paid by the insurance companies in the form of a commission if you enroll in a plan, just like your car insurance agent.
You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me. My goal is to help you and I have found great joy in being able to offer my services to people who need my help.
If you are diabetic and using insulin, you may be able to save a lot of money.
Call me today and I will be happy to explain all your options and help you compare plans so you can choose the coverage you need for a price you can afford.
Schedule a quick phone call today.
I can answer all your questions over the phone and I can help you with everything you need to know. I have all the forms and applications you need and I can also help you complete them.
Medicare Savings Programs, also known as the Medicare Buy-In or “Quimby” is a way to help reduce your costs with the Medicare Part B premium, copays and costs for prescription medications under Part D.
Depending on your income and assets, you may get help paying for Medicare co-pays, coinsurance, deductibles, premiums, and “extra help” with your Part D costs. There are two levels of MSP or Medicare Savings Program help that you may qualify for.
QMB pays ALL Medicare premiums, coinsurances, and deductibles, and lowers generic drug co-pays and eliminates the “donut hole.” There are also special plans with additional benefits like dental, vision, hearing and transportation that you will also qualify for. Click here to learn more.
Here are the income and asset guidelines for Maine:
Single
INCOME: $1,823 per month or less ASSETS: Liquid assets at or below $58,000 Note: Liquid assets include cash or other resources that can be changed into cash on demand like cash value of life insurance.
Married
INCOME: $2,465 per month or less ASSETS: Liquid assets at or below $87,000 Note: Liquid assets include cash or other resources that can be changed into cash on demand like cash value of life insurance.
Level 2—The SLMB or QI level with Maine Rx or DEL:
SLMB or QI pays Medicare Part B premium and Part D premium within a certain limit, pays your deductible, and lowers copays & eliminates the “donut hole.” It also lowers generic drug copays.
Here are the income and asset guidelines for Maine:
Single
SLMB INCOME: $2,066 per month or less QI INCOME: $2,248 per month or less ASSETS: Liquid assets at or below $58,000 Note: Liquid assets include cash or other resources that can be changed into cash on demand.
Married
SLMB INCOME: $2,794 per month or less QI INCOME: $3,041 per month or less ASSETS: Liquid assets at or below $87,000 Note: Liquid assets include cash or other resources that can be changed into cash on demand.
What Is Estate Recovery?
If you only have one of the MSP levels, QMB, SLMB or QI, the state cannot recover the cost of helping you from your estate when you die.
But if your income and assets are low enough and you get MaineCare plus an MSP, the state MAY try to recover some costs when you die if you are over 54 and have no surviving spouse or dependent child.
How Do I Apply?
Call toll Free: (866) 976-9038 for help or to find someone in your area to help you apply.
Or use My Maine Connection to apply online: www.Maine.gov/MyMaineConnection
If you have both Medicare AND MaineCare (Medicaid) then you may qualify.
Special Needs Plans (SNP) are plans that offer more benefits than you get with traditional Medicare like Dental, vision and hearing aids. These plans are under Part C of Medicare.
Good news! Some Medicare Advantage and Part D plans in 2021 will provide supplemental benefits for insulin, including during the coverage gap (or Donut hole) phase.
A new program in 2021 called, the Part D Senior Savings Model will weigh the effects of offering people who are enrolled in Medicare more choices of insurance plans that would lower your out-of-pocket costs of insulin to $35 for a one-month supply – and these costs will stay at $35, even when you hit the Donut hole!
High insulin costs, in the past, have been a huge burden on many of my clients, being detrimental to their health and their finances.
During Medicare’s Open Enrollment this year, if you are a diabetic, you should review which plans in Maine will participate in this new program and what that may mean to the cost of your insulin and other medications.
Who is Participating?
In 2021, there will be 1,635 prescription drug plans participating in the Part D Senior Savings Model, including both Medicare Advantage Plans and stand-alone Part D Prescription Drug Plans.
For a full list of the drugs effected, click here.
To see all the plans that are participating, click here.
To talk to a local expert about this program, click here.
The new Part D Senior Savings Model was created in response to President Trump’s plan to lower the cost of insulin. For carriers with products participating in this model, a one-month supply of insulin would not cost any more than $35.
The model also intends to decrease Medicare expenses by offering a variety of supplemental benefits to cover costs such as copays and initial coverage.
The Part D Senior Savings Model’s goal is to provide beneficiaries with higher quality care and will benefit those who have either a Part D Prescription Drug plan or a Medicare Advantage Plan.
When Will These Changes Take Place?
Beginning with the Annual Enrollment Period for the 2021 plan year, which runs from October 15th to December 7th, participating insurance companies will offer Mainers on Medicare beneficiaries these supplemental benefits for insulin. The drug companies will pay the 70 percent discount for your insulin, if it is included in the program.
Under the new program, Medicare plans in Maine will offer Mainers more choices that will allow them access to more types of insulin. With the maximum copay being $35, the model projects members saving an average of over 66 percent in annual out-of-pocket costs on insulin.
Additional information on the 2021 Part D Senior Saving Model, including fact sheets and press releases, can be found linked at the bottom of the CMS report.
Would you like my help?
If you would like to talk about this program or schedule a meeting, you can reach me at 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.
The best part about working with me is that it w not cost you anything to discuss your options or to review the plans that are available. I am paid by the insurance companies in the form of a commission if you enroll in a plan, just like your car insurance agent.
You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me. My goal is to help you and I have found great joy in being able to offer my services to people who need my help.
If you are diabetic and using insulin, you may be able to save a lot of money.
Call me today and I will be happy to explain all your options and help you compare plans so you can choose the coverage you need for a price you can afford.
Schedule a phone call or meeting today.
I can answer all your questions over the phone or we can talk face-to-face and I can help you with everything you need to know. I have all the forms and applications you need and I can also help you complete them.
Not happy with your current Medicare Insurance Plan? Or just curious if there is a better plan?
Like the song says… “You better shop around!”
This is very good advice!
Whether it is groceries, heating oil, or anything else, everybody wants to get the best value for their money. And today’s options for health insurance can be pretty darn costly. That’s why it’s a good idea to shop around for the right Medicare Advantage or Prescription Drug Plan.
Cost is not the only thing to consider when comparing plans.
There are dozens of Medicare Supplemental plans available in Maine this year, all with different costs.
Keep the following things in mind when you compare plans to make sure you get the best plan!
What are the monthly premiums and deductible costs?
What will you pay for the benefits and services you’re likely to use?
Is there a limit on what you will have to pay out-of-pocket for the year?
Will you have to change pharmacies if you change plans?
What benefits are most important to you? Such as Dental, Vision, Chiropractic
Comparing costs of prescription drug coverage is another part of the cost puzzle.
Do you know how much your prescriptions will cost?
Does the plan cover the drugs you take?
What pharmacies will give you the best price?
Will the Part D coverage gap (“donut hole”) effect you? If so, when?
Only you can determine what mix of benefits and costs will work best with your needs and budget, but I can help.
I can help make it easy to compare plans so you can pick one that best meets your needs.
I can explain everything you need to know and after you’ve narrowed your choices to a few really good plans, together we will review those plans to get more details about their benefits and services.
I work with all the insurance companies and plans available and I have helped hundreds of people with this decision. I understand these plans and how they work and I can help you understand them too.
And the best part is – you pay nothing for my help!
That’s right. I help you review your plan options and answer all your questions and it won’t cost you a cent!
Why?
This is what agents do. Just like with your car insurance or home owners insurance, as your agent I work for you and I get paid by the insurance companies to help you. And not just now but throughout the year.
I am trained by each insurance company on how their plans work and what they offer plus I have clients who use these plans which gives me real experience helping them year after year. So, I know which plans are the most popular and why.
Another great thing about having someone on your side is that I am available throughout the year if you have any questions or need help! So, if you have a problem with the insurance company or if you don’t understand something you get in the mail, I will be here to help with that too!
No one plan is perfect for everyone. Each plan is different, just like each person is different. I will help you understand the differences so you can the right choice with confidence!
Would you like my help?
If you would like to talk to me or schedule a meeting at your home or a nearby meeting place, you can reach me by calling 207-370-0143 or use my simple form on the CONTACT ME page of this site to send an email message.
Again, the best part about working with me is that it will not cost you anything to meet with me to discuss your options or to review the plans that are available. I am paid by the insurance companies in the form of a commission if you enroll in a plan. You will not pay any more than anyone else and you are under no obligation whatsoever to enroll in any plans if you meet with me.
“My goal is to help you and I have found great joy in being able to offer my services to people who need my help.”
Here is how to read and use this helpful drug benefit summary.
You get a lot of mail from Medicare & your insurance. One document to watch for is your monthly Medicare prescription drug plan “Explanation of Benefits” (EOB).
Think of your EOB as a helpful tool for managing your Part D prescription drug claims and costs.
It’s important to review your Part D Explanation of Benefits!
This document provides a summary of the prescriptions you’ve filled in the previous month and information about your drug coverage, such as:
Whether you’ve met your deductible (if you have one) and, if not, how much more you need to spend before your plan begins to pay its share.
What you have paid “out-of-pocket” to date for your prescriptions.
Which Part D coverage stage you are in
How to Read Your EOB
The first page contains a list of the six sections of information it provides. Let’s take a look at the first three sections in detail.
SECTION 1: Your prescriptions in the last month
Chart 1 shows a list of your prescriptions filled by date in the past month and which pharmacy you used. Be sure to check the accuracy of this list.
The chart displays three columns that show the amount the plan paid, what you paid, and any other payments from an organization or a program like a State Pharmaceutical Assistance Program (SPAP).
Near the bottom of the chart, you’ll see the monthly totals paid for your prescriptions. This total will include what was paid by the plan, by you, and by other programs on your behalf, if any.
The information will be identified as “total drug costs”. The section will also provide your monthly out-of-pocket costs. At the bottom, you can view the year-to-date total for what you’ve spent out of pocket on prescriptions. Finally, a total of the three columns indicates what you, your plan, and other organizations, if any, have spent since January 1. This information will be identified as “year-to-date total drug costs”.
SECTION 2: The Part D drug payment stages
In this view, the stage you’re in is identified by a shaded outline—for more information on the stages of coverage, please go here. Here you will see a description of the dollar amount you and/or your plan need to reach before moving to the next stage of coverage. This information will be identified as “total drug costs”. It will also show your current year-to-date “total drug costs,” which indicate how close you are to moving to the next stage of coverage.
The bottom section of the shaded box “What happens next?” gives you the additional amount that you, your plan and others on your behalf (if any) need to spend in “total drug costs” to move to the next payment stage.
This is especially important if you are in the Initial Coverage stage, because you will see how close you are to entering the Coverage Gap (aka Donut Hole), when you will pay more for your prescriptions.
Before you get too close to the gap, you might want to review your medications with your insurance agent or broker to see what you will pay Ask if there are ways to delay entering this stage, such as by switching to a generic medication or using a coupon or Patient Assistance Program.
SECTION 3:“Out-of-pocket” and “total drug costs” amounts and definitions This section provides your monthly and yearly“out-of-pocket costs” and “total drug costs” along with definitions of what these costs include or do not include.
Additional Information
The last three sections provide information on various topics.
Section four may include changes to your Drug List that affect drugs you take, such as a change to the coverage or cost of a drug.
Section five tells you what to do if you find a mistake in the EOB or have questions.
Additionally, you can find information about protecting yourself from fraud and how to contact the plan or Medicare with your concerns. Section six discusses the plan’s Evidence of Coverage, the benefits booklet that explains the plan and the rules you need to follow to obtain drug coverage. Certain chapters and topics are highlighted that will provide you with instructions if you have issues related to your drug coverage or difficulty paying for your drugs
Want to know more? I can help!
If you would like help finding answers to your questions, you can call me directly at 207-370-0143 or use my simple form on the CONTACT page of this site to send an email message. I am always happy to help!
The best part about working with me is that it costs you nothing! I am paid by the insurance companies in the form of a commission when I enroll someone in a plan. This is the same way it works when you buy car insurance or your home owners insurance. You do not pay anything to the agent and you will pay the same price for your insurance that everyone pays whether they had my help or not.
“My goal is to help people and I have found great joy in being able to offer my services to people who need my help.”
Mainers who cannot afford their medications should know that many public and private programs are available to provide free or low-cost prescription medicines if you qualify.
Tell your insurance agent if you can’t afford your medicines.
Your agent can help you access these programs. As an agent I have a lot of experience helping people find Medicare and individual health insurance coverage for expensive drugs.
And because I deal with this issue almost every day, I know what programs may be best suited to help. Your insurance agent or broker that helps you review your coverage every year also should have a good idea how to help.
I put together the following list of resources that I use every day to help my clients. I hope you find it helpful. If you want my help or just want to ask a question fill out the form at the bottom of this page to send me an e-mail or call me anytime at 207-370-0143 and I will do mt best to help you!
Talk to your doctor
Your doctor’s office can help you apply to these programs themselves or refer you to one of Maine’s 15 hospital-based prescription assistance programs. Don’t put yourself at increased risk of getting sicker by skipping the medicines you need because it’s too expensive.
Whether or not you have a Medicare Supplement plan with a separate Part D prescription plan or an all-in-one type Medicare Advantage plan that includes prescription drug coverage, your cost for prescriptions can increase when you hit the donut hole.
Medicare Savings Programs (MSP, QMB, SLMB, QI)
If you have Medicare but need help with prescription drug costs, the MSP can be a huge help. Depending on what level you qualify for, you could get help paying for Part B and Part D premiums, copays, coinsurance, and deductibles. [READ MORE]
DEL PROGRAM (Low Cost Drugs for the Elderly or Disabled)
Many people who are either disabled or 62 and older who do not qualify for MaineCare, can get this help. DEL provides an 80% discount off the cost of many commonly used drugs. Some people with high medication costs may be able to get coverage of less commonly used drugs. If you are over 65 and already have Medicare, DEL does not take the place of Part D (Medicare prescription coverage). But, it may help to “wrap around” the Part D coverage in some cases. If you are eligible, it is good to apply for DEL.
Maine Rx Plus
Maine Rx Plus provides a 60% discount off the cost of many commonly used generic drugs at many pharmacies across Maine (only 15% off brand-name drugs). There may be other programs that can help pay more of your drug costs, but if not, it is good to apply for MaineRx Plus.
State prescription assistance programs like Maine Rx Plus can be helpful, but sometimes those programs don’t help enough. Community-based Prescription Assistance Programs (CPAPs) can search through their database to find other programs to help with the cost of medications. The CPAPs keep the latest information on a large number of drug company discount cards and discount programs for specific drugs. Staff can provide you with free information and help you to apply for discounts. For more information, see this flyer: Help with Prescriptions.
$4 Generics List Available at Most Pharmacies
Another way to save on prescriptions is by switching to generic. Generic medications can sometimes be less expensive than brand name drugs and may make it easier to find discounts.
Many pharmacies have started providing generic medications for only $4, regardless of your income or insurance status. Smaller, local pharmacies sometimes have generous discount programs as well. It’s a good idea to call the pharmacies nearest to you and ask about any discount programs that they offer.
Each Pharmacy will have a list of drugs they offer at $4. If your drug is not on the list call around. Each pharmacy has a different list so if you don’t find your generic drug on one list it may be on another. [READ MORE ABOUT HOW THESE $4 COPAY LISTS WORK]
Free Samples
Sometimes Health Centers, Hospitals, and Free Clinics are given free samples of certain medications that they can share with their patients. This assistance is usually not a long-term solution, but can definitely help! Whenever you are prescribed a medication, it never hurts to ask if there are free samples available.
Safely Ordering Drugs from Canada
For information about mail-ordering drugs from Canada, visit the Health Canada website to learn how to protect yourself from fraudulent companies.
Help with Private Insurance Co-pays
Even if you have health insurance through the Maine Health Insurance Marketplace, cost may still be an issue. Some people may be able to get help paying their co-pays if they meet certain income and medical guidelines. For more information visit the Patient Advocate Foundation’s Co-pay Relief website or call us toll free at 866-976-9038 for more details.
TRICARE
Military retirees, and some family members or former spouses age 65 and older may be eligible for two programs provided by the Department of Defense: TRICARE for Life and the TRICARE Senior Pharmacy Program. For more information and complete eligibility requirements for the TRICARE for Life and TRICARE Senior Pharmacy Program, contact Sierra Military Health Services (the Northeast Regional Contractor) toll free at 888-999-5195.
Veterans Benefits
CHAMPVA is a health care benefits program through the Department of Veterans Affairs (VA). For the spouse or widow(er) and for the children of a veteran who: is rated permanently and totally disabled due to a service-connected disability; was rated permanently and totally disabled due to a service-connected condition at the time of death; died of a service-connected disability; died on active duty and the dependents are not otherwise eligible for DoD TRICARE benefits. Under CHAMPVA, VA shares the cost of covered health care services and supplies with eligible beneficiaries.
VA and Medicare
As a Medicare-eligible Veteran, you have more options when it comes to healthcare and costs savings programs. To confirm your options call the Veterans Administration directly at 1-877-222-VETS (8387). [READ MORE ABOUT HO MEDICARE WORKS WITH VA BENEFITS]
HIV/AIDS Assistance
If you have been diagnosed with HIV and you are a resident of Maine, you could get assistance from the State of Maine to get HIV-related medications free of charge. The Aids Drug Assistance Program (ADAP) is a program of the Maine Center for Disease Control and Prevention (Maine CDC), HIV/STD Division. If you are interested in ADAP contact the Maine CDC at (207) 287-2899. You can also contact one of the HIV/AIDS organizations in the state or contact the AIDS Hotline at 1-800-851-2437.
Hospital Programs
Many hospitals in Maine provide free or reduced-cost emergency services to people at certain income levels. Some hospitals go above and beyond just the emergency services and will also provide help with medications and other services. If you have questions about free care in Maine you can call the Maine Consumer Assistance Helpline at 1-800-965-7476.
MedAccess
MedAccess works with individuals and health care providers to identify ways patients can save money on prescription medications. The free program, administered by MaineHealth, helps patients and health care providers evaluate options such as pharmaceutical companies’ patient assistance programs, low-cost generic programs, and Medicare Part D and state and local prescription programs that can help save on prescription medication costs. For more information, see the MaineHealth MedAccess Program. MedAccess is part of the MaineHealth CarePartners Program.
Drug Safety, Effectiveness, and Cost
Consumer Reports Health Best Buy Drugs offers free, trusted educational resources to help you access the safest, most effective, and most affordable prescription drugs available. This resource is a grant-funded project providing independent, evidence-based reports on prescription drugs based on research conducted at the Drug Effectiveness Review Project,
Consumer Reports Health “translates” findings into consumer-friendly reports that are available for free. These reports identify drugs that are as effective and safe as others in its class but often available at a lower cost, as well as provide information about the underlying condition. These recommended drugs are often generic drugs, but in the case that a brand-name drug is superior to a lower-cost drug in safety or efficacy, it is recommended regardless of price. The reports are freely accessible at Consumer Reports Best Buy Drugs, and also available in a printed booklet. Fill out the form below to request a free booklet get mailed to you. Remember to include your address! 😊
The Centers for Medicare and Medicaid Services (CMS) has released the 2020 costs for a standard Part D prescription drug plans.
Here are the highlights for the CMS defined Standard Benefit Plan changes from 2019 to 2020. This “Standard Benefit Plan” is the minimum allowable plan to be offered by insurance company who has a contract with Medicare to offer Part D prescription drug insurance.
Initial Deductible: will be increased by $20 to $435 in 2020.
Initial Coverage Limit (ICL): will increase from $3,820 in 2019 to $4,020 in 2020.
Out-of-Pocket Threshold: will increase from $5,100 in 2019 to $6,350 in 2020.
Coverage Gap (donut hole): begins once you reach your Medicare Part D plan’s initial coverage limit ($4,020 in 2020) and ends when you spend a total of $6,350 in 2020.
2020 Donut Hole Discount:
Part D enrollees will receive a 75% Donut Hole discount on the total cost of their brand-name drugs purchased while in the Donut Hole. The discount includes, a 70% discount paid by the brand-name drug manufacturer and a 5% discount paid by your Medicare Part D plan. The 70% paid by the drug manufacturer combined with the 25% you pay counts toward your TrOOP or Donut Hole exit point.
For example: If you reach the Donut Hole and purchase a brand-name medication with a retail cost of $400, you will pay $100 for the medication, and receive $380 credit toward meeting your 2020 total out-of-pocket spending limit.
Medicare Part D beneficiaries who reach the Donut Hole will also pay a maximum of 25% co-pay on generic drugs purchased while in the Coverage Gap (receiving a 75% discount). For example: If you reach the 2020 Donut Hole, and your generic medication has a retail cost of $40, you will pay $10. The $10 that you spend will count toward your TrOOP or Donut Hole exit point.
Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit
You will be charged $3.60 for those generic or preferred multisource drugs with a retail price under $72 and 5% for those with a retail price greater than $72.
For brand-name drugs, You would pay $8.95 for those drugs with a retail price under $179 and 5% for those with a retail price over $179.
Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $3.60 for generic or preferred drug that is a multi-source drug and $8.95 for all other drugs in 2020. [Read more about these programs]
If you live in Maine or New Hampshire and would like to learn more about the new Medicare plans for 2020 or to go over the changes in your plan, you can call me at (207) 370-0143 or CLICK HERE to send me an email message.
You can also use the BOOK APPOINTMENT button below to set up a time to speak with me on the phone or in person. I can also send you information in the mail if you choose.
Have a question that needs to be answered right away? You can talk to a licensed insurance agent by calling (207) 370-0143 or toll free 866-976-9038.
Question: I have purchased medications worth $3,930 so far this year, my next brand-name drug purchase has a retail cost of $400, bringing me into the Donut Hole (or Coverage Gap). Will I get a Donut Hole discount on the full $400 retail price or just the $90 that falls into the gap?
