SPDAP & You
If your annual income is below $36,180 for a single person (or $48,720 if you are married and living with your spouse), you may qualify for extra help. Slightly higher income levels may apply if you provide ½ support to other family members living with you.
And if your resources (including your savings and stocks, but not counting your home or car) are under $13,820 (for a single person) or under $27,600 (for a married couple) you may qualify for extra help paying for your Medicare prescription drug costs.
You can apply for this extra help through the Social Security Administration or your State Medical Assistance Office. Social Security mails the application for extra help to those who may qualify. If you receive an application, fill it out and return it in the enclosed postage paid envelope. You can also complete an application on line at http://www.ssa.gov/prescriptionhelp
The amount of extra help you get depends on your income and resources.
You still need to join a Medicare prescription drug plan for Medicare to pay for your drug costs.
If you qualify for extra help, you will have continuous drug coverage and will pay only a small amount for your prescriptions.
- Liquid Resources (e.g., Bank accounts, cash on hand)
- Investments (e.g., Stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts, etc.)
- Life Insurance policy
- Pensions and Retirement Information (e.g., Railroad retirement, Veterans Pay, other pension or retirement)
- Real estate (not including an individual’s home)
- Social Security Number
Unless you have other drug coverage that is, on average, at least as good as standard Medicare prescription drug coverage, it’s important for you to join a Medicare prescription drug plan when you are first eligible. For most people, joining when you are first eligible means you will pay a lower monthly premium than if you wait to join later.
The Senior Prescription Drug Assistance Program will pay a subsidy up to $40 towards your monthly premium in a Maryland approved prescription drug plan or Medicare Advantage Plan.
Once you reach $3,700 in yearly drug costs, you will enter the coverage gap or “doughnut hole.” Information about a 2017 SPDAP Coverage Gap (Donut Hole) subsidy will be forthcoming
Yes. Certain drugs are excluded, which means they can not be provided as part of standard Medicare prescription drug coverage. Some examples of excluded drugs include benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for relief of colds. However, except for non-prescription over-the-counter drugs, a plan can choose to cover excluded drugs if the plan offers more than standard coverage. Non-prescription drugs can’t be included. However, under certain circumstances, they may be provided at no cost.
No. Joining a Medicare drug plan is your choice; however it is to your advantage to join when you are first eligible. Medicare imposes a penalty of at least 1% per month for every month that you wait to join. Like other insurance, you will have to pay this penalty as long as you have Medicare prescription drug coverage. If you are a SPDAP member and you do not enroll in a Medicare drug plan, you will not receive SPDAP assistance.
Yes. Medicare Part B will still cover drugs that it covers now (like some cancer drugs that are usually given out by a doctor in his or her office). Drugs that are not covered under Part A or Part B will, in most cases, be covered under Medicare prescription drug coverage.
A formulary is a list of specific drugs a Medicare drug plan will cover. Plans must cover all types of drugs required by Medicare, but within each type it can limit which specific drugs it will cover. It may also charge different cost-sharing amounts for different drugs within a type of drug.
If you need a drug that is not on the covered drug list, or that is on the list but you think it should be covered for a lower copayment, you can (1) Contact the plan and ask for an exception. You will probably have to provide information from your doctor about why you need the drug your plan will not cover. (2) If your plan denies the exception, you can appeal. Your plan must give you information on how to appeal.
Generally if you join a Medicare Prescription Drug Plan, you can only change plans under certain circumstances. You can choose to switch your current plan during the Annual Open Enrollment Period, usually occurring in the October/December time frame each year.
Enrollment is generally for the calendar year. In addition to the annual Open Enrollment Period, SPDAP members are allowed to change their prescription drug plan one additional time during the calendar year. In certain cases, such as if you move or enter a nursing home, you can switch your plan at other times.
If you have both Medicare and Medicaid, you can change plans at any time.
A Medicare drug plan is required to offer standard prescription drug coverage, and may choose to offer additional coverage. A standard plan can not cover benzodiazepines. However, a Medicare drug plan may cover benzodiazepines if it offers more than standard coverage. The premium for these plans will most often be higher than for standard plans.
Medicare has selected 10 different prescription drug plans for Maryland. These plans offer a total of 20 plan options. There are also 9 Medicare Advantage Plan sponsors that offer drug coverage combined with health benefits. These plans offer a total of 26 plan options. Medicare beneficiaries can choose drug coverage through the following options:
Standard Prescription Drug Plan
A standard Medicare drug plan provides you with an initial drug benefit of around $3,700 paid by the plan while receiving this benefit you will have to pay plan co-pays or coinsurance. After you use the initial benefit, you will have to pay 40% for brand name drugs and 51% for generic drugs, until you’ve spent a total of $7,425.00 out of pocket for drug deductibles, co-pays and costs. After you’ve spent $7,425.00 out of pocket, you receive a more generous catastrophic drug benefit in which you pay either $3.30 for generic or $8.25 for all other drugs, or 5% of the cost of the drug.
About 60% of the plans have an initial yearly deductible of $400, the other 40% have no deductible. Each plan has varying levels of co-pays and/or coinsurance depending on whether the drug is a generic, brand or non-preferred drug. Plan premiums vary amongst the plans and are usually lower if a deductible is required.
Enhanced Prescription Drug Plan
Enhanced prescription drug options have higher monthly premiums, but in return you get more extensive drug coverage. If you have significant drug needs, or want more generous coverage in case you need more prescriptions, enhanced drug coverage may be a good option for you. Some enhanced plans cover some or all generic drugs after the initial $3,700 drug benefit.
Medicare Advantage Drug Plans
Medicare Advantage Plans are health plans options under Medicare. Under Medicare Advantage you get all of your Medicare-covered health care through the plan, including extra benefits and lower co-payments than available under basic Medicare. You may have to see doctors or use hospitals that are in the plan’s network. We recommend you contact the Medicare Advantage plans to consider whether their medical coverage is right for you.
If you only want prescription drug coverage, you should choose a stand alone PDP. If you want additional health benefits to cover your Medicare medical co-payments and enhance your standard Medicare medical coverage, you can select an MAPD. Most of our members will be choosing between a Prescription Drug Plan or PDP and an Enhanced Prescription Drug Plan or EPDP. If you have a Medicare advantage plan, you will choose an MAPD.
Like other insurance, people who join a Medicare prescription drug plan will pay
- a monthly premium,
- a yearly deductible (up to $400 in 2017), and
- part of the cost of their prescriptions, including a co-payment or coinsurance.
Costs will vary depending on the drug plan. Some plans may offer more coverage and additional drugs. If the person you care for has limited income and resources and qualifies for extra help, he/she may not have to pay a premium or deductible.
If a drug is no longer covered by your Medicare drug plan for non-safety reasons, or if it is covered at a higher cost, your plan must let you know 60 days before the change. If you do not get a 60-day notice, the plan must let you get a 60-day supply when you get your next refill for the previous cost.
The Medicare & You book contains no information on SPDAP, since it is not a Medicare Drug Plan, but a state subsidy program.
Yes. You can enroll in Medicare Part D. However, you can only use one program or the other to pay for specific drugs.
For more information about Medicare prescription drug coverage, read the “Medicare & You” handbook. It includes more detailed information about Medicare prescription drug plans, including which plans are available in your area.
- Visit www.medicare.gov on the web. Select “Search Tools” to get personalized information. Or, select “Frequently Asked Questions” to get answers to common questions.
- Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486- 2048.
- Call the State Health Insurance Assistance Program for face to face assistance (see the “Medicare & You” handbook for the telephone number). You can also call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov on the web to get the telephone number.
- Look for local Medicare-related events.
Maryland – SPDAP
c/o Pool Administrators
628 Hebron Avenue, Suite 502
Glastonbury, CT 06033