# Presentation: 000993

## Medicare Prescription Drug CoverageRetiree Town Hall Presentation:Comparing Prescription Drug Coverage

**November 2005**

**Notes:**
I’d like to welcome all of you to our session today. Our session today is designed to discuss the introduction of Medicare Part D and how it affects Oak Ridge retirees, their dependents and other individuals who are eligible for Medicare.

I’m _______ from Towers Perrin. Towers Perrin is a human resources consulting firm and our company been asked by Oak Ridge Human Resources to conduct these sessions with you.

As you may know, this session is the first of two town hall meetings that Oak Ridge is offering to retirees. Today’s session will focus on Medicare and what Part D is, what it means to you and what you should consider when you receive materials from insurance companies and providers who will be encouraging you to enroll.  And let me assure you that you will be receiving materials in the near future if you haven’t already.

We’ll also be offering one more series of retiree meetings for you in early November.  During that session, we’re planning to provide you with a comparison of how your Oak Ridge retiree prescription drug coverage compares to the plans that are offered in this area.

Our goal here today will be to walk you through Medicare and the newest part of Medicare, prescription drug coverage.  I’ll be pausing for questions at various points throughout today’s session and we have some assistants from Oak Ridge HR who will be manning the roving mikes.

Now, let’s get started...

## Today’s Agenda

- What’s happening?
- Why we’re here today
- Considerations as you evaluate coverage
- Comparing your Oak Ridge retiree prescription drug coverage to local provider plans
- Considerations for limited income and resources individuals
- What happens next?

**Notes:**
Let’s review our agenda for today’s meeting.  We’ll talk about what’s happening to Medicare and what brings us here today.

We’ll get into some basics about Medicare, although I expect that we’ll be covering some topics that many of you are already experts on.  We’ll also talk about what’s changing.

We’ll spend some time discussing what the “standard Medicare Part D” coverage will look like.  We’ll also do a brief comparison of how that coverage compares to Oak Ridge coverage ... and I think that many of you will be pleasantly surprised to see how your Oak Ridge coverage compares to the standard Part D plan.

Finally, we’ll talk about what you can expect in the coming months, which we expect will involve a great deal of mail, phone calls and TV ads.

## 

What’s Happening?

**What’s Happening?**

**Notes:**
OK, let’s cover what information you can expect to receive in the coming months.

## What’s Happening?

- Medicare Prescription Drug, Improvement, and Modernization Act of 2003 — or the Medicare Modernization Act (**MMA**) — signed into law on December 8, 2003
- Effective January 1, 2006, Medicare will provide optional prescription drug coverage called **Medicare Part D**
- It replaces prescription drug discount card, which will phase out by May 15, 2006
- Beginning November 15, anyone with Medicare is eligible to enroll for this coverage
- Legislation encourages employers to continue to be the primary provider of prescription drug benefits for their Medicare-eligible population

## What’s Happening? (cont.)

- The benefits of this legislation include:
- Offers prescription drug coverage to Medicare beneficiaries who don’t have access to adequate prescription drug coverage today
- Provides enhanced benefits with lower out-of-pocket costs to limited-income beneficiaries, as defined by the government
- Gives employers the choice to continue to be the primary provider of prescription drug benefits ― not intended to replace employer-sponsored coverage that’s as generous or more generous

## What’s Happening? (cont.)

- Oak Ridge will continue to offer the current prescription drug coverage, which is *as generous as or more generous than* Medicare Part D for 2006
- Anyone who participates in an Oak Ridge retiree medical plan receives prescription drug coverage automatically
- Oak Ridge prescription drug coverage does **not** coordinate with Medicare Part D coverage
- This means, for most Medicare-eligible Oak Ridge employees and retirees, enrolling in Medicare Part D will **not** provide additional benefits
- If you are a Medicare-eligible retiree or LTD recipient enrolled in Oak Ridge coverage and you elect Medicare drug coverage, your Oak Ridge medical and prescription drug coverage will be cancelled

**Notes:**
Oak Ridge will continue to offer the current prescription drug coverage to retirees and the coverage retirees receive is clearly more generous than what Medicare Part D offers for 2006.

Let’s remember that anyone who’s enrolled for Oak Ridge retiree medical coverage already receives prescription drugs included in that coverage

Oak Ridge and Medicare Part D do not coordinate, which means that you wouldn’t be able to submit a claim that Medicare Part D has already paid and receive any additional benefit from your Oak Ridge coverage.

So, an Oak Ridge retiree who enrolls in Medicare Part D – and pays the premium for doing so – won’t be receiving any additional benefits.

What’s more, if you are an Oak Ridge retiree who’s enrolled in retiree medical coverage and you decide to enroll in Medicare Part D coverage, you will risk losing your Oak Ridge retiree medical coverage.

## Why We’re Here Today

- By now, you may have received mailings from a number of carriers who want to offer you prescription drug coverage
- These mailings will encourage you to enroll “just to be safe”
- The companies sending you these mailings do not know that you already have prescription drug coverage through Oak Ridge
- They are mailing to all Medicare-eligible individuals
- Oak Ridge wants you to understand:
- What Medicare drug coverage means to you as a Medicare-eligible Oak Ridge retiree or employee
- That your current prescription drug coverage is *as generous as or more generous than* the standard Medicare coverage
- Enrolling in Medicare Part D will not offer any additional benefits, although there are some exceptions
- Enrolling in private Medicare prescription drug coverage for 2006 will jeopardize your Oak Ridge-provided coverage

## 

Considerations As You Evaluate Coverage

**Considerations As You Evaluate Coverage**

## Medicare Part D Terminology

- Terms and abbreviations:
**CMS** – Centers for Medicare and Medicaid Services
**Medicare Part D** – also refers to Medicare prescription drug coverage
- “**As generous as or more generous than**” – the Medicare phrase applied to employer-provided coverage that offers a benefit comparable to (or better than) the standard Medicare Part D coverage
**Creditable Coverage** – verification that an individual has coverage that is *as generous as or more generous than* standard Medicare Part D coverage
**Formulary **– a specific list of drugs that are considered “covered” by a health plan or prescription drug plan
**Limited Income and Resources** – individuals who meet specific criteria established by CMS that qualify them for extra assistance through CMS
**TrOOP **– True out-of-pocket maximum that is defined as the amount of out-of-pocket costs a retiree would expect to pay if enrolled in a Medicare Part D plan, not including monthly premiums or out-of-pocket costs for catastrophic coverage

**Notes:**
Now that we’re in the Medicare Part D discussion, it’s a good time to make sure we’re all speaking the same Medicare language.  Here are some terms you’ll hear me use – in fact, in a couple of instances, I’ve already used these terms.  But let’s go through each of these to make sure.  [Read slide]

## Considering Other Prescription Drug Coverage

- As mentioned, choosing Medicare prescription drug coverage will jeopardize your Oak Ridge retiree medical coverage
- However, we understand that you will receive mailings from many providers offering coverage and you may want to compare those plans with your Oak Ridge retiree medical coverage
- To help you, we’ll be comparing some of the plans offered in our area during today’s session
- In evaluating coverage, we’ll be asking these questions:
- Does the plan cover all my drugs?
- How much will this plan cost me?
- Does the plan have a coverage gap?
- How does the plan limit my out-of-pocket expenses?
- Is my pharmacy in the network?
- Does the plan offer mail order?

## Does The Plan Cover All Of My Drugs?

- Many plans have formularies, which limit the drugs that are covered under the plan
- All of the Medicare prescription drug plans include a formulary
- In most cases, these formularies limit the number of drugs offered under each class of drugs and may cover a generic rather than brand-name drug
- We will not cover specific formularies for each of the plans today
- Contact each provider if you’d like more information about their formulary
- Your Oak Ridge prescription drug coverage does ***not*** include a formulary

## How Much Will This Plan Cost Me?

- The first consideration will be the **premium or contribution** for joining the plan
- The national average cost of Medicare prescription drug plans is $32 per month, but prices will vary, depending on the level of coverage provided in each plan — increased coverage will generally cost more
- The next consideration is the **deductible** that must be met before coverage will begin
- Most plans require that you pay the full cost up to a certain dollar limit, after which the plan’s benefits begin
- The standard Medicare prescription drug plan includes a $250 annual deductible
- Your Oak Ridge prescription drug coverage requires a $150 deductible for retail pharmacy prescriptions

## How Much Will This Plan Cost Me? (continued)

- Finally, consider what you may pay, in coinsurance or copays, each time you obtain a prescription
**Coinsurance** is a percentage of the cost
- The standard Medicare prescription drug plan includes 25% coinsurance on total annual drug costs up to $2,250 and 5% of the cost after you have spent $3,600 out-of-pocket
- Your Oak Ridge prescription drug coverage includes coinsurance for prescription drugs obtained through a retail pharmacy
**Copays** are a fixed dollar amount
- For example, generic drug copays through a mail order program may cost $25 for a 90-day supply
- Your Oak Ridge prescription drug coverage includes copays for prescription drugs obtained through mail order

## Does The Plan Have A Coverage Gap?

- A **coverage gap** – or “doughnut hole” – is like a second deductible
- When your total prescription drug costs reach a certain level, you assume the full cost of prescription drugs
- You pay for prescription drugs up to another limit of out-of-pocket expenses, upon which the coverage gap closes
- The standard Medicare prescription drug coverage plan has a coverage gap that takes effect when your total prescription drug expenses reach $2,250
- The standard Medicare plan resumes paying benefits when you reach a total of $3,600 in out of pocket expenses
- Your Oak Ridge prescription drug coverage does ***not*** have a coverage gap

## How Does The Plan Limit My Out-of-Pocket Expenses?

- A plan may include an **out-of-pocket maximum **that will limit the amount you pay in coinsurance toward prescription drugs in a given year
- The standard Medicare prescription drug coverage has an out-of-pocket maximum of $3,600 each year, after which Medicare catastrophic coverage begins
- When you reach that threshold, your coinsurance is reduced from 25% to 5% for prescription drugs for the remainder of that calendar year
- Your Oak Ridge prescription drug coverage does not have an out-of-pocket maximum

## Is My Pharmacy In The Network?

- Participating pharmacies vary by plan
- You will need to refer to the materials you receive from the insurers offering Medicare prescription drug plans in your area
- You should also confirm participation with your local or preferred pharmacy

## Does The Plan Offer Mail Order?

- Mail order availability will vary by plan as well
- Confirm that mail order is an option and verify how you can submit prescriptions as well as how prescriptions are mailed to you
- In some cases, plans allow you to purchase up to a 90-day supply of your medication through a participating retail pharmacy in addition to mail order

## Let’s stop for a minute to see if there are any questions?

**Notes:**
I know we’ve covered a lot of material so let’s pause for a minute and give you a chance to ask questions.  

Just so you know, we’re going to be covering the standard Medicare Part D coverage and how it compares to your Oak Ridge retiree prescription drug coverage next, so if you have questions about that, let’s wait to see if we cover it during the next section.  If not, I’ll be pausing for questions again later.

## 

Comparing Your Oak Ridge Retiree Prescription Drug Coverage to Local Provider Plans

**Comparing Your Oak Ridge Retiree Prescription Drug Coverage to Local Provider Plans**

## 2006 Prescription Drug Coverage for Oak Ridge Retirees: Snapshot of Benefits under the Retiree Medical Plan

|  | Retail
(up to a 30 day supply) | Mail Order 
(up to a 90 day supply) |
| --- | --- | --- |
| Deductible: | $150 | $0 |
| For In-Network Pharmacy | COINSURANCE
Brand name: Plan pays 70%
Participant pays 30% (minimum $10)
Generic:
Plan pays 80%
Participant pays 20% (minimum $10) | COPAYMENT
Brand name: $35
Generic: $15
 |
| For Non-Network Pharmacy | COINSURANCE
Brand name: Plan pays 50%
Participant pays 50% 
Generic:
Plan pays 50%
Participant pays 50% |  |

**Notes:**
Our plan encourages you to obtain your prescriptions through an in-network pharmacy and to use generics whenever possible.  
After you meet a $150 deductible, you share in the cost of the prescriptions by paying 30% of the cost for a brand name and 20% of the cost for generic if you use an in-network pharmacy.  And when you use an in-network pharmacy, you’re purchasing drugs that are already discounted off the retail price.  If you use a non-network pharmacy, you’ll pay more for any prescription – not only through higher coinsurance but also because you’ll be paying for drugs that aren’t discounted through our network.
And while you have a deductible before coverage begins on the retail side, you can use the mail order throughout the year without meeting a deductible. If you haven’t used the mail order portion of the program and are on maintenance medications that you expect to use for three months or longer, you might want to give it a try.  You can minimize your out-of-pocket costs and get your prescriptions mailed to your home.

Let’s also spend a moment talking about the lifetime maximum of $75,000 for your retiree medical coverage.  An attempt was made to combine the plan’s medical and prescription drug costs and apply it to the $75,000 lifetime maximum.  However, it was not possible to include the prescription drugs to that maximum so those costs are not included your lifetime maximum.

## Standard Medicare Part D Drug Benefit: A Visual

- *TrOOP is “true out-of-pocket” maximum — amount retiree must pay before catastrophic (95%) benefit begins. Employer and insurance company payments do not count toward satisfaction of TrOOP.

**0%**

**25%**

**50%**

**75%**

**100%**

- $250

- $2,250

- $5,100

***Retiree pays 100% of first $250***

***Retiree pays 25% of ******next $2,000, ******up to $500 ***

- Deductible

**Coinsurance**

- Plan pays 75%

**Part D benefits**

**Retiree liability (counts toward $3,600 true out-of-pocket maximum (TrOOP)***

***Retiree pays 5% (no maximum)***

***Retiree pays 100% of next $2,850, up to $3,600******total out-of-pocket limit***

***Retiree out-of-pocket costs***

- $250

- $750

- $3,600

***Annual drug costs***

- Plan pays 95%

- Coinsurance

- Coverage Gap (“Donut Hole”)

- CatastrophicBenefit

**Notes:**
This is another way to look at what we’ve just described.  The light portion of the chart is what a retiree enrolled in this plan would expect to pay and the dark portion is what Medicare will pay.
You can also see at the bottom of the slide another abbreviation that comes to us via Medicare Part D:  TrOOP is true out-of-pocket maximum.

## Comparing Medicare Prescription Drug Plans 

- We’ll be comparing the following plans:
**Aetna Medicare Rx Essentials, Plus and Premium Plans**
**Community Care Rx Basic, Choice and Gold Plans**
**Coventry AdvantraRx Value, Premier and Premier Plus Plans**
**Humana PDP Standard, Enhanced and Complete Plans**
**AARP Medicare Rx by UnitedHealthcare**
- Please note that we have used each of the plan’s summary of benefits to create this comparison
- We cannot answer specific details about any of the plans, with the exception of your Oak Ridge coverage
- These comparisons were created using information that we believe to be current and accurate; however, you should contact each of the providers directly for the most up-to-date information on any of the plans discussed during today’s session

## Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans

|  | Oak Ridge | Aetna Medicare Rx Essentialssm | Aetna Medicare Rx Plussm | Aetna Medicare Rx Premiersm |
| --- | --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $38.86 | $50.45 | $66.75 |
| Annual Deductible | $150 (retail only) | $250(retail and mail order) | $0 | $0 |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Brand name:$25 copay
Generic:$5 copay | Brand name:$35 copay
Generic:$7 copay
 | Non-Preferred Brand name:$40 copay
Preferred Brand name:$20 copay
Generic:$2 copay |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere |  |  |

## Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans

|  | Oak Ridge | Aetna Medicare Rx Essentialssm | Aetna Medicare Rx Plussm | Aetna Medicare Rx Premiersm |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Brand name:$50 copay
Generic:$10 copay | Brand name:$70 copay
Generic:$14 copay
 | Non-Preferred Brand name:$80 copay
Preferred Brand name:$40 copay
Generic:$4 copay |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% for all drugs | Brand name:You pay 100% for all drugs
Generic:$7 copay – retail
$14 copay – mail
 | Brand name:You pay 100% for all drugs
Non-Preferred Generic:$40 copay – retail
$80 – mail
Preferred Generic:$2 copay – retail
$4 copay – mail |

## Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans

|  | Oak Ridge | Aetna Medicare Rx Essentialssm | Aetna Medicare Rx Plussm | Aetna Medicare Rx Premiersm |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted | The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost | The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost | The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost |

## Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan

|  | Oak Ridge | Community Care Rx Basic | Community Care Rx Choice | Community Care Rx Gold |
| --- | --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $33.31 | $41.41 | $45.23 |
| Annual Deductible | $150 (retail only) | $250(retail) | $250(retail) | $100(retail) |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Formulary Brand name:Plan pays 55%You pay 45%
Formulary Preferred Brand name:Plan pays 75%You pay 25%
Formulary Generic:$0 copay | Formulary Brand name:$40 copay
Formulary Preferred Brand name:$20 copay
Formulary Generic:$4 copay
 | Formulary Brand name:$50 copay
Formulary Preferred Brand name:$25 copay
Formulary Generic:$4 copay
 |

## Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan

|  | Oak Ridge | Community Care Rx Basic | Community Care Rx Choice | Community Care Rx Gold |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | In addition to paying the copayment/coinsurance listed on the prior page, you pay the difference between the cost of the drug if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug |  |  |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Formulary Brand name:Plan pays 55%You pay 45%
Formulary Preferred Brand name:Plan pays 75%You pay 25%
Formulary Generic:$0 copay | Formulary Brand name:$120 copay
Formulary Preferred Brand name:$60 copay
Formulary Generic:$12 copay | Formulary Brand name:$150 copay
Formulary Preferred Brand name:$75 copay
Formulary Generic:$12 copay |
|  |  | Mail order not available but 90-day supply can be obtained at participating pharmacies |  |  |

## Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan

|  | Oak Ridge | Community Care Rx Basic | Community Care Rx Choice | Community Care Rx Gold |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% of the cost of all prescription drugs through coverage gap
 |  |  |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |  |  |

## Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage

|  | Oak Ridge | AdvantraRx Value Plan | AdvantraRx Premier Plan | AdvantraRx Premier Plus |
| --- | --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $22.86 | $33.99 | $43.85 |
| Annual Deductible | $150 (retail only) | No deductible | No deductible | No deductible |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Non-Formulary Brand name:You pay 100%
Formulary Brand name:$36 copay
Formulary Generic:$15 copay
 | Non-Formulary Brand name:$53 copay
Formulary Brand name:$20 copay
Formulary Generic:$5 copay | Non-Formulary Brand name:$63 copay
Formulary Brand name:$20 copay
Formulary Generic:$0 copay
 |
|  |  | 90 day supply available at participating pharmacies – copay equals three times 30 day supply copay |  |  |

## Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage

|  | Oak Ridge | AdvantraRx Value Plan | AdvantraRx Premier Plan | AdvantraRx Premier Plus |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You pay the difference between what the plan would pay if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug
 |  |  |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Non-Formulary Brand name:You pay 100%
Formulary Brand name:$72 copay
Formulary Generic:$30 copay
 | Non-Formulary Brand name:$106 copay
Formulary Brand name:$40 copay
Formulary Generic:$10 copay | Non-Formulary Brand name:$126 copay
Formulary Brand name:$40 copay
Formulary Generic:$0 copay
 |

## Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage

|  | Oak Ridge | AdvantraRx Value Plan | AdvantraRx Premier Plan | AdvantraRx Premier Plus |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% of the cost of all prescription drugs through coverage gap |  |  |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |  |  |

## Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

|  | Oak Ridge | Humana PDP Standard | Humana PDP Enhanced | Humana PDP Complete |
| --- | --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $14.08 | $22.48 | $67.16 |
| Annual Deductible | $150 (retail only) | $250(retail only) | No deductible | No deductible |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Non-Preferred Brand name: Plan pays 75%
You pay 25% 
Preferred Brand name:Plan pays 75%
You pay 25% 
Preferred Generic:Plan pays 75%
You pay 25%  | Non-Preferred Brand name:$60 copay
Preferred Brand name:$30 copay
Preferred Generic:$7 copay ($0 copay until total drug costs reach $250) | Non-Preferred Brand name:$60 copay
Preferred Brand name:$30 copay
Preferred Generic:$7 copay($0 copay until total drug costs reach $250) |
|  |  | 90 day supply available at participating pharmacies – copay equals three times 30 day supply copay |  |  |

## Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

|  | Oak Ridge | Humana PDP Standard | Humana PDP Enhanced | Humana PDP Complete |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You pay the difference between what the plan would pay if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug
 |  |  |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Non-Preferred Brand name: Plan pays 75%
You pay 25% 
Preferred Brand name:Plan pays 75%
You pay 25% 
Preferred Generic:Plan pays 75%
You pay 25%  | Non-Preferred Brand name:$150 copay
Preferred Brand name:$75 copay
Preferred Generic:$17.50 copay ($0 copay until total drug costs reach $250) | Non-Preferred Brand name: $150 copay
Preferred Brand name:$75 copay
Preferred Generic:$17.50 copay ($0 copay until total drug costs reach $250) |

## Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

|  | Oak Ridge | Humana PDP Standard | Humana PDP Enhanced | Humana PDP Complete |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% for all drugs
 |  | Retail and mail order copays apply through coverage gap |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted
 | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |  |  |

## Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage

|  | Oak Ridge | AARP Medicare Rx by UnitedHealthcare |
| --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $27.28 |
| Annual Deductible | $150 (retail only) | No deductible |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Non-Preferred Brand name:$55 copay
Preferred Brand name:$28 copay
Preferred Generic:$5 copay  |
|  |  | 90 day supply available at participating pharmacies – copay equals three times 30 day supply copay |

## Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage

|  | Oak Ridge | AARP Medicare Rx by UnitedHealthcare |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You will generally pay more for prescriptions filled at a non-participating retail pharmacy. |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Non-Preferred Brand name:$165 copay
Preferred Brand name:$84 copay
Preferred Generic:$15 copay  |

## Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage

|  | Oak Ridge | AARP Medicare Rx by UnitedHealthcare |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% for all drugs
 |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted
 | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |

## An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

- Let’s review an example of how the costs might play out for a retiree.
- Joe has a few medical conditions that require regular medication;
- 3 of them are brand-name
- Joe fills these three times at his pharmacy and then uses mail order for the rest of the year (three 90-day supplies)  Each of these drugs costs $100 for a 30-day supply or $300 for a 90-day supply
-  2 of those are on Humana’s Preferred Brand name list.
- He also takes one drug that is a generic but does not take this regularly – he expects to refill that drug five times during the year at his pharmacy.  The retail cost for this drug is $30 for a 30-day supply.
- We’ll assume that Joe only uses participating pharmacies.
- If Joe did not have any coverage, his total prescription drug costs would be $3,750.

## An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

|  | Oak Ridge | Joe Pays | Total Drug Cost | Humana PDP Enhanced | Joe Pays |
| --- | --- | --- | --- | --- | --- |
| Annual Deductible | $150 (retail only) | $150 |  | No deductible | $0 |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)

Generic:
Plan pays 80%
You pay 20% (minimum $10) |  30% x {$900 Minus $150 deductible} =
30% X $750 = $225

1 Generic ($10) X 5 refills = $50 | 3 Brand names ($100) X 3 refills = $900

1 Generic ($30) X 5 refills = $150

 | Non-Preferred Brand name:$60 copay
Preferred Brand name:$30 copay
Preferred Generic:$7 copay ($0 copay until total drug costs reach $250) | 1 Non-Preferred Brand name ($60) X 3 refills = $180
2 Preferred Brand name ($30) X 3 refills = $180 
1 Generic ($7) X 5 refills = $35 |
| Subtotal |  | $425 | $1,050 |  | $395 |

## An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage

|  | Oak Ridge | Joe Pays | Total Drug Cost | Humana PDP Enhanced | Joe Pays |
| --- | --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | 3 Brand name X 3 refills ($35) = $315 | 3 Brand name ($300) X 3 refills = $2,700
Joe hits Coverage Gap when Total Drug Costs reach $2,250 | Non-Preferred Brand name:$150 copay
Preferred Brand name:$75 copay
Preferred Generic:$17.50 copay ($0 copay until total drug costs reach $250) | 1 Non-Preferred Brand name ($150) X 3 refills = $450
1 Preferred Brand name ($75) X 1 refill = $75
Coverage Gap Hit – Joe pays for remaining $1,500 in drug costs |
| Subtotal this page
Subtotal prior page |  | $315
$425 | $2,700
$1,050 |  | $2,025
   $395 |
| Grand total
Premium Cost |  | $740
Included | $3,750 |  | $2,420
   $270 |

## Let’s stop for a minute to see if there are any questions?

**Notes:**
I know we’ve covered a lot of material so let’s pause for a minute and give you a chance to ask questions.  

Just so you know, we’re going to be covering the standard Medicare Part D coverage and how it compares to your Oak Ridge retiree prescription drug coverage next, so if you have questions about that, let’s wait to see if we cover it during the next section.  If not, I’ll be pausing for questions again later.

## Medicare Part C

- Originally known as Medicare+Choice plans, now called Medicare Advantage or Medicare Health plans
- These plans deliver Medicare benefits through coordinated care plans (HMOs, PPOs) or private fee-for-service plans
- May include additional benefits such as dental, vision, hearing screenings and prescription drugs
- Must live in the geographic service area where the plan provides service
- Premiums vary by plan
- Available to:
- Individuals entitled to Part A and enrolled in Part B
- 65 and older
- Disabled Medicare beneficiaries
- Except new enrollees with ESRD
- We’ll discuss the Medicare prescription drug coverage offered by some of the local Medicare Advantage plans
- The premium we note for each is for the prescription drug coverage only – however, many of these plans require additional premiums for medical coverage

## Comparing Medicare Advantage Prescription Drug Coverage

- There are several providers who offer Medicare Advantage plans in the Oak Ridge area
- These plans include Medicare prescription drug coverage as part of their overall medical coverage
- We’ll be comparing prescription drug coverage for the following Medicare Advantage plans:
**BlueCross BlueShield of Tennessee’s BlueAdvantagePlus**
**Cariten Senior Health **
**John Deere SecurePlus**

## Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage

|  | Oak Ridge | BlueAdvantagePlus |
| --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $37.98 |
| Annual Deductible | $150 (retail only) | No deductible |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Formulary Non-Preferred Brand name:$64 copay
Formulary Preferred Brand name:$32 copay
Formulary Generic:$8 copay |
|  |  | 90 day supply available at participating pharmacies – copay equals three times 30 day supply copay |

**Notes:**
Medicare Advantage plans charge one premium for medical coverage and a separate premium for the Medicare prescription drug coverage.  Many Medicare Advantage plans allow participants to elect medical only or medical plus prescription drug coverage.
On the other hand, your Oak Ridge medical and prescription drug coverage is integrated and neither the premium nor the coverage can be separated.

## Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage

|  | Oak Ridge | BlueAdvantagePlus |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Only covered in special circumstances: in case of emergency, traveling outside network or drug unavailable elsewhere. 10-day supply only at the following copays:
Formulary Non-Preferred Brand name:$64 copay
Formulary Preferred Brand name:$32 copay
Formulary Generic:$8 copay |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Formulary Non-Preferred Brand name:$128 copay
Formulary Preferred Brand name:$64 copay
Formulary Generic:$16 copay |

## Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage

|  | Oak Ridge | BlueAdvantagePlus |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% of the cost of all prescription drugs through coverage gap
 |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |

## Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage

|  | Oak Ridge | Cariten Senior Health (PPO & HMO) |
| --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $39.24 – PPO or HMO |
| Annual Deductible | $150 (retail only) | $100(retail) |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Multi-source Brand name, Non-Preferred Brand name and Non-Preferred Injectables:$50 copay
Other Preferred Brand name and Preferred Injectables:$30 copay
Preferred Brand name:$15 copay
All Generics except omeprazole:$5 copay |

## Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage

|  | Oak Ridge | Cariten Senior Health (PPO & HMO) |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | Multi-source Brand name, Non-Preferred Brand name and Non-Preferred Injectables:$150 copay
Other Preferred Brand name and Preferred Injectables:$90 copay
Preferred Brand name:$45 copay
All Generics:$15 copay |
|  |  | 90-day supply can be obtained at participating pharmacies or through mail-order pharmacy |

## Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage

|  | Oak Ridge | Cariten Senior Health (PPO & HMO) |
| --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pockets covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | You pay 100% of the cost of all prescription drugs through coverage gap
 |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted
 | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |

## Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage

|  | Oak Ridge | John Deere’s SecurePlus Medicare Part D Basic Alternative | John Deere’s SecurePlus Medicare Part D Enhanced Alternative |
| --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $29.29 | $43.90 |
| Annual Deductible | $150 (retail only) | No deductible | No deductible |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Non-Formulary Brand name, Formulary Brand name and Generic:$10 copay | All drugs: Plan pays 75%
You pay 25%  |

## Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage

|  | Oak Ridge | John Deere’s SecurePlus Medicare Part D Basic Alternative | John Deere’s SecurePlus Medicare Part D Enhanced Alternative |
| --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply) | Brand name: Plan pays 50%
You pay 50%
Generic:
Plan pays 50%
You pay 50%  | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere. You can obtain a 30 day supply:
Non-Formulary Brand name, Formulary Brand name and Generic:$10 copay | Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere. You can obtain a 30 day supply:
Non-Formulary Brand name, Formulary Brand name and Generic: Plan pays 75%
You pay 25%  |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | One month (30-day supply) available at mail order:
Non-Formulary Brand name, Formulary Brand name and Generic:$10 copay
 | One month (30-day supply) available at mail order:
Non-Formulary Brand name, Formulary Brand name and Generic:Plan pays 75%
You pay 25%  |

## Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage

|  | Oak Ridge | John Deere’s SecurePlus Medicare Part D Basic Alternative | John Deere’s SecurePlus Medicare Part D Enhanced Alternative |
| --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pockets covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | Coverage gap begins at $1,825 and you pay 100% of the cost of all prescription drugs through coverage gap | Coverage gap begins at $2,250 and you pay 100% of the cost of all prescription drugs through coverage gap |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted
 | The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost |  |

## An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage Prescription Drug Coverage

- Let’s review an example of how the costs might play out for a retiree.
- Joe has a few medical conditions that require regular medication;
- 3 of them are brand-name
- Joe fills these three times at his pharmacy and then uses mail order for the rest of the year (three 90-day supplies)  Each of these drugs costs $100 for a 30-day supply or $300 for a 90-day supply
-  2 of those are on Cariten’s Preferred Brand name list.
- He also takes one drug that is a generic but does not take this regularly – he expects to refill that drug five times during the year at his pharmacy.  The retail cost for this drug is $30 for a 30-day supply.
- We’ll assume that Joe only uses participating pharmacies.
- If Joe did not have any coverage, his total prescription drug costs would be $3,750.

## An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage

|  | Oak Ridge | Joe Pays | Total Drug Costs | Cariten Senior Health (PPO & HMO) | Joe Pays |
| --- | --- | --- | --- | --- | --- |
| Annual Deductible | $150 (retail only) | $150 |  | $100(retail) | $100 |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)

Generic:
Plan pays 80%
You pay 20% (minimum $10) |  30% x {$900 Minus $150 deductible} =
30% X $750 = $225

1 Generic ($10) X 5 refills = $50 | 3  Brand names ($100) X 3 refills = $900

1 Generic ($30) X 5 refills = $150

 | Other Preferred Brand name and Preferred Injectables:$30 copay
Preferred Brand name:$15 copay
All Generics:$5 copay | 1 Other Preferred Brand name ($30) X 3 refills = $90
2 Preferred Brand name ($15) X 3 refills = $90 
= $180
1 Generic ($5) X 5 refills = $25 |
| Subtotal |  | $425 | $1,050 |  | $305 |

## An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage

|  | Oak Ridge | Joe Pays | Total Drug Costs | Cariten Senior Health (PPO & HMO) | Joe Pays |
| --- | --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply) | Brand name: $35 copay
Generic:
$15 copay | 3 Brand name X 3 refills ($35) = $315 | 3 Brand name ($300) X 3 refills = $2,700
Joe hits Coverage Gap when Total Drug Costs reach $2,250 | Other Preferred Brand name and Preferred Injectables:$90 copay
Preferred Brand name:$45 copay
All Generics:$15 copay | 1 Other Preferred Brand name ($90) X 3 refills = $270
1 Preferred Brand name ($45) X 1 refill = $45 
Coverage Gap Hit – Joe pays for remaining $1,500 in drug costs |
| Subtotal this page
Subtotal prior page |  | $315
$425 | $2,700
$1,050 |  |  $1,815
 $275 |
| Grand Total
Premium Cost |  | $740
included |  |  | $2,210
$471 |

## Let’s stop for a minute to see if there are any questions?

**Notes:**
I know we’ve covered a lot of material so let’s pause for a minute and give you a chance to ask questions.  

Just so you know, we’re going to be covering the standard Medicare Part D coverage and how it compares to your Oak Ridge retiree prescription drug coverage next, so if you have questions about that, let’s wait to see if we cover it during the next section.  If not, I’ll be pausing for questions again later.

## 

Special Considerations for Limited Income and Resources Individuals

**Special Considerations for Limited Income and Resources Individuals**

**Notes:**
OK, let’s cover what information you can expect to receive in the coming months.

## Who Should Enroll in a Medicare Prescription Drug Plan?

**Those without drug coverage**
- For people without the benefit of employer-sponsored coverage

**Those who qualify for “extra help”**
- The Social Security Administration has identified people who may qualify for assistance in paying for drugs based on their income and assets ― applications were mailed directly to people in May 2005

- Medicare prescription drug plans are designed for people who need them most...

- ...but it’s completely up to each individual to decide what prescription drug coverage option makes the best financial sense for his or her family.

**Notes:**
So who should be considering enrolling in a Medicare prescription drug plan?  Really the plans are designed for two groups of individuals:  those who currently don’t have drug coverage now or those who qualify for extra help, due to limited income and resources.

## Who’s Eligible for Extra Help?

- “Limited income and resources” defined as:
- Income less than 150% of federal poverty level
- $14,355 for individuals in 2006
- $19,245 for couples in 2006
- Limited liquid assets
- $11,500 for individuals
- $23,000 for couples in 2006
- The Social Security Administration is sending applications to those who may qualify for the extra benefit
- If you receive an application, you should complete it.  Submitting this application does **not** enroll you for Medicare drug coverage
- However, according to the *Medicare and You 2006* Handbook, if you apply and qualify for assistance, you will automatically be enrolled in the plan for which you are considered eligible

**Notes:**
We’ve talk a lot about individuals who are described as having limited income and resources.  Let’s discuss how that definition is determined.  The income level is noted on the screen and I understand that CMS is comparing last year’s tax returns to determine who might qualify, based on those numbers.  However, another determination is how much in liquid assets an individual has – this doesn’t include a house or car but might be a savings account, a 401(k) balance or some other asset that conceivably could be turned into cash if need be.
Social Security has already started mailing applications to individuals who they believe might qualify.  If you receive the application, you should go ahead and complete it.  It will help you determine whether or not you might be considered as eligible.  Completing and submitting the application does not enroll you for 2006 Medicare prescription drug coverage.
If you think you might be eligible and have not received an application, you can contact your local Social Security office and request an application.  Again, completing and submitting the application does not enroll you for Medicare prescription drug coverage.

## What Does “Extra Help” Cover?

|  | Oak Ridge | <100%* | <135%** | <150%*** |
| --- | --- | --- | --- | --- |
| Monthly Premium Per Person | Included in your Retiree Medical contributions | $0 | $0 | Subsidy phased out at 150% |
| Annual Deductible | $150 (retail only) | $0 | $0 | $50 |
| Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply) | Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:
Plan pays 80%
You pay 20% (minimum $10) | Formulary Brand name:$3 copay
Formulary Generic:$1 copay | Formulary Brand name:$5 copay
Formulary Generic:$2 copay
 | Formulary Brand name:Plan pays 85%You pay 15%
Formulary Generic: Plan pays 85%You pay 15% |

*******	****Income must be less than $9,570 for individuals/$12,830 for a couple. Must also be eligible for Medicaid.**
********	****Income must be less than $12,920 for individuals/$17,321 for a couple. Liquid assets <$6,000 ind; $9,000 couple**
*********	****Income must be less than $14,355 for individuals/$19,245 for a couple. Liquid assets <$11,500 ind; $23,000 couple**

## What Does “Extra Help” Cover?

|  | Oak Ridge | <100% | <135% | <150% |
| --- | --- | --- | --- | --- |
| Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs) | Coverage gap does not apply

Coverage for retail and mail as noted | Formulary Brand name:$3 copay
Formulary Generic:$1 copay | Formulary Brand name:$5 copay
Formulary Generic:$2 copay
 | Formulary Brand name:Plan pays 85%You pay 15%
Formulary Generic: Plan pays 85%You pay 15% |
| Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses | Out of pocket limit does not apply

Coverage for retail and mail as noted | Formulary Brand name:$3 copay
Formulary Generic:$1 copay | Formulary Brand name:$5 copay
Formulary Generic:$2 copay
 | Formulary Brand name:$5 copay
Formulary Generic:$2 copay
 |

## But Keep in Mind...

- If you become enrolled in a plan offered to individuals with limited income and resources, you will lose your Oak Ridge retiree medical coverage
- Medicare or, if you are eligible, Medicaid will be your sole source of medical coverage
- Weigh the potential out-of-pocket costs — both your medical ***and*** prescription drug coverage — before filing your application
- For example, consider your Medicare inpatient deductible if you anticipate being hospitalized in the coming year
- You may also want to discuss this with your local Social Security office

## 

What’s Happens Next?

**What’s Happens Next?**

**Notes:**
OK, let’s cover what information you can expect to receive in the coming months.

## What’s Next?

- For 2006, a special Medicare Part D enrollment period will be held
- For individuals eligible by November 15: November 15, 2005 – May 15, 2006
- Individuals eligible later: If an individual becomes eligible for Medicare after May 15, 2006, there will be an initial open enrollment period for both Parts B & D
- In later years, from November 15 to December 31 for next benefit year (January 1 – December 31)

**Notes:**
As we’ve discussed, there will be a special enrollment period this year that will start in November and carry through May of next year.

If someone becomes eligible later, there will be the same initial open enrollment period that exists for Part B.

In the future, enrollment periods for Medicare Part D will occur from November 15 to December 31 for coverage the following year.

## The Key Question...

- If I already have coverage through Oak Ridge, does it makes sense for me to enroll in a private Medicare prescription drug plan in 2006?

- The answer...

- In most cases, no! Remember the reason ― Oak Ridge already provides drug coverage that is expected to pay out at least as much as — and in most cases more than —  a standard Medicare prescription drug plan

- Most retirees are better off under Oak Ridge’s plan, unless:
- You are eligible for “extra help” or on Tricare (the plan for military retirees and spouses),
- Remember, if you are Medicare-eligible and elect Medicare Part D coverage, your continued coverage through Oak Ridge will be dropped

**Notes:**
Time for another question that I’ll answer for you.  If I already have coverage through Oak Ridge, should I enroll in a prescription drug plan through Medicare?
And the answer is no.  As we’ve discussed, you already have coverage – generous coverage – through Oak Ridge that provides more than the standard Medicare prescription drug coverage.
Only two exceptions to this one word answer – if you’re eligible for extra help as we just discussed or if you’re already enrolled in the Tricare plan.  If you’re in Tricare, I won’t be covering your coverage through that plan in today’s session.  We’ll be covering the prescription drug coverage through the MMMSP plan that I believe covers many of today’s attendees.
And remember, if you enroll in a Medicare Part D coverage, you risk losing your Oak Ridge retiree medical coverage.

## Oak Ridge Retiree Prescription Drug Coverage: Overview

- Your Oak Ridge retiree medical plan includes prescription drug coverage
- Anyone enrolled in the Oak Ridge retiree medical plan receives prescription drug coverage automatically
- Medical and prescription drug coverage is integrated; you cannot enroll in one without the other
- Oak Ridge prescription drug coverage is “creditable coverage,” which is defined by CMS as being “on average” at least as generous as the standard benefit
- Protects your right to leave the Oak Ridge retiree medical plan and join another “certified” plan or Medicare prescription drug plan within 63 days without incurring a penalty on the Medicare Part D premium for coverage
- Those without “creditable coverage” are penalized 1% of the monthly Medicare Part D premium for each month enrollment is delayed past their initial enrollment period

**Notes:**
The prescription drug coverage you have through Oak Ridge is included with the medical coverage that you receive.  The two coverages can’t be separated and you can’t enroll in one without the other.
The coverage you have through Oak Ridge is considered creditable coverage.  This verification gives you the option, down the road, to leave your Oak Ridge retiree medical plan and join a private Medicare Part D plan without having to pay a penalty – or increased premium.
If you don’t have creditable coverage and are considered a “late enrollee” in a Medicare Part D plan, you’ll pay a 1% penalty for each month that has passed since you were first eligible to enroll.  So if you enroll 19 months after you first became eligible and don’t have proof of creditable coverage, your premium will be 19% greater and will stay that at that level for the entire duration of your coverage with that plan.

## Key Points to Remember

- The Oak Ridge retiree medical plan includes prescription drug coverage. This means anyone who’s enrolled in an Oak Ridge retiree medical plan receives prescription drug coverage automatically
- Medical and prescription drug coverage are combined and a person can’t enroll in one without the other
- For 2006, your Oak Ridge coverage is at least as generous as private Medicare prescription drug coverage
- Your Oak Ridge prescription drug coverage does not coordinate with private Medicare prescription drug coverage
- This means you do not need to enroll in Medicare Part D to keep your Oak Ridge coverage
- In fact, if you enroll in Medicare Part D, you will lose your Oak Ridge retiree medical coverage

**Notes:**
So I’d like to leave you with a couple points that we’d like you to keep in mind as you’re receiving and reviewing the materials from other vendors.
First, you already have prescription drug coverage through Oak Ridge, which provides coverage that is as generous, if not more so, than the Medicare prescription drug coverage.
If you decide to enroll in a Medicare prescription drug plan, keep these points in mind – that coverage will not coordinate with your Oak Ridge coverage.  In other words, Oak Ridge coverage won’t pay what Medicare doesn’t and vice versa.  In addition, if you do enroll in a Medicare prescription drug plan, you’ll lose your Oak Ridge coverage.
However, if you qualify for extra help as a limited income and resources individual, you should enroll in the Medicare prescription drug plan since the benefits you’ll receive will provide you with the coverage you need at a significantly lower cost.

## Let’s stop for a minute to see if there are any questions?

**Notes:**
We’re near the end of our presentation today but I want to pause again to see if anyone has any questions.  

I know there may be some questions that you might not want to ask during the session so let me assure you that I’ll be here after our session, along with some of our helpers, to speak with you.

## Where to Get More Information

- OneCall
- By phone at **574-1500** or **1-877-861-2255**
- CSRs available Monday through Friday, 7:00 a.m. to 5:00 p.m. ET
- Via the internet at _**http://www.y12.doe.gov**_
- Employee & Retiree Benefits

## 

Thanks for Coming!

**Thanks for Coming!**

**Notes:**
So that wraps up our discussion today.  We can take a few more questions before we close our session and don’t forget that I’ll be available after our session, along with my colleagues, to answer any specific questions related to your personal situation.

I’d like to thank you for participating in our session today and being so attentive.  Hope you’ll join us in November for the next series of town hall meetings.

Take care and please get home safely.