Understanding Medicare Part D

Understanding Medicare Part D

What Is Phases Extra Help/ Helpful Open Commonly Glossary Medicare? of Part D LIS Resources Enrollment Asked Questions 1 A resource for patients taking VYNDAMAX taking patients for A resource Understanding Medicare Part D Medicare 1 Cover 2 Introduction Medicare? Medicare? What Is What Introduction Health insurance coverage can be difficult to understand, especially when trying to figure out how much you will pay for prescription drugs. This guide pertains to Medicare Part D, which is the part of Medicare that covers prescription drugs. This guide explains: D of Part Phases Part D Extra Help/ Extra The basics of Medicare What is Medicare and Medicare Part D Extra Help? LIS Resources Resources Helpful Resources that can support you in navigating your Medicare coverage Enrollment Enrollment Open Commonly How to sign up or change asked questions your Medicare plan Asked Questions Asked Commonly Also, the Glossary at the end of this guide explains any terms that may be unfamiliar. Glossary 2 3 What Is Medicare? Medicare? Medicare? What Is What What Is Medicare? Medicare is a federal government health insurance program.1 It differs from private (or “commercial”) insurance in that it is run by the government instead of private insurance companies.1 of Part D of Part Original Medicare Phases An “Original Medicare” plan is one that includes Part A and Part B.2 Part B covers general healthcare Part A covers expenses services such as care from such as inpatient care healthcare providers, outpatient in hospitals, skilled care, infusion costs including the nursing facility care, Help/ Extra cost of infused drugs, preventive hospice care, and LIS services, some home healthcare, some home healthcare.2 and some medical equipment.2,3 Medicare Advantage Medicare Advantage, or Medicare Part C, is a government program run by private Resources Resources insurance. Medicare Advantage plans are “bundled” plans, meaning they include Helpful Part A, Part B, and usually Part D.2 In most cases, you’ll need to use healthcare providers who participate in the plan’s network.2 However, many plans offer out-of-network coverage, though sometimes at a higher cost.2 Medicare Advantage premiums may be higher, but sometimes total expected out-of-pocket Enrollment Enrollment 2,4 cost is lower compared to an Original Medicare plan. These plans may Open also include extra benefits like hearing, vision, and dental coverage.2 Prescription Drug Coverage Medicare helps cover the cost of prescription drugs. This Part D Questions Asked guide will Part D is offered as a stand-alone plan that can be added to your Commonly Medicare plan or included in a Medicare Advantage plan with specifically prescription drug coverage.2 discuss Part D These plans are run by private insurance companies that follow rules set by Medicare. The phases of Part D coverage and how much you pay in each phase are defined each year. You can sign up for a Part D plan if you have Part A, Part B, or both. If you decide to have a Medicare Advantage plan, it may include a Part D plan.2 Glossary 3 4 What Is Medicare? Medicare? Medicare? What Is What To qualify for Medicare, you must meet one of the following criteria1,5: of Part D of Part Phases Extra Help/ Extra Aged 65 years or older LIS Under 65 years of age and receive Social Security Disability Insurance Resources Resources (SSDI) for 24 months due to Helpful severe disability Have end-stage renal disease, regardless of age or income Enrollment Enrollment Open Receiving SSDI due to amyotrophic lateral sclerosis/ Lou Gehrig’s disease Questions Asked Commonly Glossary 4 5 Phase of Part D Medicare? Medicare? What Is What Understanding the Phases of Part D and Your Out-of-Pocket Costs There are 4 phases of Medicare Part D coverage.6 The limits of each phase are defined every year. During each phase, you’ll be responsible for a different of Part D of Part portion of the cost of your prescription drugs in addition to your plan’s monthly Phases premiums. These phases apply to all of your prescription drugs, including VYNDAMAX® (tafamidis). The limits below are the set amounts for 2020, and will change in 2021. Deductible Phase You will first need to meet a deductible. Help/ Extra Depending on which Part D plan you Patient pays 100% LIS choose, the deductible may be up to $435 or you may not have a deductible at all.6,7 Patient share = up to $435 Initial Coverage Phase After you meet your deductible, you and your Resources Resources insurance plan will split part of the prescription Helpful drug costs. Your part will be a co-pay or Patient pays 25% coinsurance. Most patients will pay a 25% Plan pays 75% coinsurance. The initial coverage phase lasts until total spending by you and your health plan equals $4020 (including deductible).6 Patient share = approximately $900 Coverage Gap or “Donut Hole” Enrollment Open After the $4020 limit is met, you enter the coverage gap, also known as the donut hole. Patient pays 25% During this phase, most patients are still responsible for a 25% coinsurance. This phase lasts Manufacturer pays 70% until your out-of-pocket costs (including costs in Plan pays 5% the deductible and initial coverage phases) and the 6,8 manufacturer’s payments add up to $6350. Patient share = Questions Asked approximately Commonly $1300 Catastrophic Coverage Phase Patient pays After you have exited the coverage gap, you will 5% be in a final phase called catastrophic coverage. Government pays 80% During this final phase, you will pay 5% of the cost of covered drugs unless it is a generic drug.6,9 Plan pays 15% Until January 1 of Glossary the following The phases of Part D reset at the start of a new benefit year, January 1. year 5 6 Phase of Part D Medicare? Medicare? What Is What Understanding the Phases of Part D and Your Out-of-Pocket Costs With some prescription drugs, you can go through of Part D of Part Phases MULTIPLE Part D phases with one prescription. 1 1 2 3 4 Extra Help/ Extra This will happen with VYNDAMAX® (tafamidis). LIS MONTH Therefore, your first month of taking VYNDAMAX 1 will likely cost more than the following months. Resources Resources Helpful ...it is best to communicate with While you can find your specialty pharmacy to cost estimates online understand the monthly cost using tools like of VYNDAMAX specific to your Medicare.gov/PlanFinder... insurance coverage. Enrollment Enrollment Open Asked Questions Asked Commonly If you are concerned about the cost of your medication, VyndaLink™ may be able to help you find support to manage the costs of your medicine. You can call VyndaLink at 1-888-222-8475 (Monday-Friday, 8 AM-8 PM ET) or visit www.vyndalink.com/patient for more information. Glossary 6 7 Extra Help/LIS Medicare? Medicare? What Is What What Is Medicare Extra Help? Medicare Extra Help, also called the Medicare Part D Low-Income Subsidy (LIS) program, is a federal program that will pay part of the costs for prescription medications to lower the out-of-pocket costs for eligible Medicare Part D patients who have limited income and resources. To receive Extra Help benefits, you must of Part D of Part use prescriptions that are on your plan’s formulary (a list of drugs covered under Phases the plan) and pharmacies that are in your plan’s network.10 If you qualify for Extra Help, you can potentially pay a lower price for your prescription drugs Extra Help/ Extra Extra Help/LIS and Dual Eligible* beneficiary costs11† LIS $3.90 $0 to $0 Prescription Catastrophic Resources $8.95 Helpful deductible Brand drugs coverage The coverage gap is eliminated for patients receiving Extra Help.12 Full LIS Medicare patients pay no more than Enrollment $8.95 Open per VYNDAMAX® (tafamidis) prescription. Asked Questions Asked For more information on Extra Help and other resources Commonly that could potentially help with your out-of-pocket costs, visit www.medicare.gov/your-medicare-costs/get-help-paying-costs *Dual Eligible = patients who have both Medicare and Medicaid. †2020 prices listed, prices and limits are subject to change each year. Glossary 7 8 Extra Help/LIS Medicare? Medicare? What Is What Who Is Eligible? Some patients are automatically eligible, while others need to enroll. Automatic Enroll Through Enrollment Application of Part D of Part For patients who match For patients who meet Phases any of the below criteria2: all of the below criteria2: • Have both Medicare and Medicaid— • Have income and assets below in which case, you are considered the limits (detailed below) Dual Eligible • Live in the 50 states or District • Receive Supplemental Security of Columbia (if you are a resident Help/ Extra Income benefits of a US territory, separate Extra LIS • Receive help paying Medicare Help options are available) Part B premiums from a state Medicaid program (in a Medicare Savings Program) Extra Help Income Requirements and Benefits Resources (subject to change annually) Helpful 13,14 Dual Eligible * Medicare Part D (eligible for Medicaid Full Subsidy13† Partial Subsidy13 and Medicare) Single ≤$12,760 Single ≤$17,226 Single ≤$19,140 Yearly Income‡ Married ≤$17,240 Married ≤$23,274 Married ≤$25,860 Enrollment Open Co-pay§ $3.90 (brands) $8.95 (brands) $8.95 (brands)11 Coverage gap12 NONE15 NONE NONE Premium $0 $0 Sliding Scale|| Deductible $0 $0 $89.00 Questions Asked Commonly * Full-benefit dual eligible beneficiaries who receive a full range of Medicaid assistance, and Qualified Medicare Beneficiaries (QMBs) who are part of the Medicare Savings Program (MSP), with incomes≤ 100% Federal Poverty Limit (FPL), are required under Medicare Part D to pay a $3.90 co-pay for brand name drugs.

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