MEDICARE PRESCRIPTION DRUG COVERAGE

Cost-Sharing: Medicare Prescription Drug Plans Compared to

MaineCare and DEL

 

 

MaineCare: 45,000

DEL: 42,000

Other Medicare:  136, 696

 

Full MaineCare

Income 100% FPL

 

                                                                

DEL 

Income < 150 % FPL

Assets  < $10,000 (1 person), $20,000 (couple)

 

Basic Medicare Prescription Plan

Income >150% FPL

* Includes DEL with assets > $10,000 (1 person), $20,000(couple)

Monthly Premium

0                           

 

 

No Change

$0 to $35 depending on income

 

 

NOW: no premium

Estimate - $35/mo

 

 

 

NOW: no premium for DEL

 

Annual

Deductible

0

0 to $50 depending on income

$250

No Change

NOW: no deductible

NOW: no deductible for DEL

Co-Payment

Co-Insurance

(see notes)

$1-$2 generic $3-$5 brand

From $2 generic / $5 brand to 15% of cost of covered drug depending on income

25% of cost of covered drug between $250 & $2,250 of drug expenses

NOW: 2.50/prescription up to $25/month

NOW: 20% of DEL drug cost + $2

NOW: DEL = 20% of DEL drug cost + $2

Coverage Gap

None

 

NOW: no coverage gap
None

 

NOW: no coverage gap

No benefit between $2,250 & $5,100

 

NOW: No coverage gap for DEL

Catastrophic

Benefit

No cost after out of pocket drug expenses total $3,600. 

 

NOW: no catastrophic benefit

Depending on income:

No cost after out of pocket drug expenses total $3,600 or

 

$2 generic/$5 brand after out of pocket expenses total  $3,600

NOW: no catastrophic benefit

 

5% co-pay or $2 generic/$5 brand after out of pocket expenses total $5,100

 

NOW: off formulary drug covered after spending $1000 out of pocket annually between 8/1 and 7/31 on that drug

 

 

 

NOTES:

 

  1. 7,000 DEL Enrollees are also enrolled in the Medicare Savings Program.  They will have the same costs as MaineCare.
  2. Under Medicare there is no co-pay for residents of nursing facilities but there is a co-pay for residents of some Residential Care Facilities who are now exempt because most of they income is used to help pay for the cost of their care.
  3. All drugs now covered under MaineCare or DEL will not be covered under Medicare.
  4. 2005 Federal Poverty Level:

 

Monthly Income:

100 %

135%

150%

185%

1 person

$798

$1,077

$1,197

$1,476

2 people

$1,070 

$1,445

$1,605

$1,980

 

 

 

Maine Department of Health and Human Services

April 7, 2005