• Beginning January 1, 2006, anyone who has Medicare may receive help paying for prescription drugs under a new program known as Medicare Part D.

• A large number of different plans are being offered under Part D, by private insurance companies and HMOs. There are complicated choices to be made.

• Medicare requires that certain types of drugs be covered by each plan – but the actual lists, known as "formularies," vary from plan to plan, as do the pharmacies each plan uses.

• For most Medicare members, the program involves a monthly fee ("premium") and pays only part of the cost of some prescriptions.

• People with equal or better prescription coverage through an employer, the VA or private insurance should usually keep that coverage and not enroll in a separate Part D plan.

• People whose Medicare comes through an HMO – "Medicare Advantage" plans – must usually get their part D through the same plan, if they want to keep it.

• People who now get their medicine through Medi-Cal and are also Medicare eligible will have to use a new Medicare Part D plan. They will have to pay part of the cost.

• Other very low-income Medicare members will be able to get their medicines at very low cost – though making the right choices is still very important.

• Once you choose a plan, you can switch to another only at certain times – but certain low-income people can switch at any time. Ask what rules apply for you.

Part D for people who now receive their prescriptions through Medi-Cal

If you are eligible for both Medicare and Medi-Cal with no share of cost (known as "dual eligible"), Medi-Cal will no longer cover your drugs. You are eligible for the Part D "low-income subsidy" (also called "extra help"), but you will now have to pay a little for each prescription. You will be automatically enrolled in a Medicare Part D plan if you do not choose one, but you can change to a different plan if you wish. It’s worth checking for a plan that includes the medicines you need and that works with drug stores convenient for you.

• Not all Part D plans are open to Medi-Cal recipients at no monthly charge. It is important to ask, as the information in the new "Medicare and You" book sent to California resi-dents contains an error: it says all plans are available. They’re not – unless you pay extra.

• If Medi-Cal has been paying your monthly premium for an HMO, it will no longer do so.

• Special arrangements will permit nursing home residents to receive their prescriptions through the facility, at no extra charge.

Some people who are not quite eligible for Medi-Cal (or have it but with a share of cost) due to excess income and/or assets can also receive the "low-income subsidy." Your monthly fee (called a "premium") will be reduced or zero, and you will have to pay only a small amount for each prescription – the exact costs vary, depending on your income and asssets.

• If your Medicare premiums (Part A or B) are paid for under the QMB, SLMB, or QI-1 programs, you will be automatically enrolled for the low-income subsidy.

• If your annual income is below $14,355 for a single person or $19,245 for a couple, you have less than $10,000 ($20,000 for a couple) in bank accounts and investments (figures as of January 1, 2006) and you are not already receiving Medi-Cal, you can receive the low-income subsidy. Apply at your Social Security office, your local welfare office, at www.ssa.gov or by calling the Senior Legal Hotline.

• Even if your income is above these amounts, if you have Medi-Cal with a share of cost, paying the full share of cost for one month will make you eligible for the low-income subsidy for the rest the year or the next year – depending in which month this occurs.

  • The "Medicare and You" error mentioned above also applies to you; the low-income subsidy does not cover the full premium for all plans.

Plans now being offered by private insurance companies and HMOs are of two types:

1. New prescription drug plans (PDPs) for people with traditional, fee-for-service Medicare.

2. Medicare Advantage prescription drug plans (MA-PDPs) for people who get their Medicare through health maintenance organizations (HMOs) or other "managed care."

If your Medicare Advantage program has a prescription drug plan that meets the new Part D requirements, you will be enrolled automatically and usually must use that plan if you want to keep your HMO membership. If you sign up for a separate PDP, you will likely lose your Medicare Advantage membership.

To decide whether to sign up and if so, for which plan, you need to look at the different plans’ monthly fees, whether the drugs you need are included, how much they will cost, which pharmacies participate with the plans – and what other coverage you have.

Medicare also sets maximum costs that plan members can be charged. But some plans offer better deals than the minimum required. Shop around. Standard coverage as of January 1, 2006, is:

• monthly premiums – an average of $25 to begin with in California.

• annual $250 deductible – you pay this before the plan pays anything.

• you pay 25% of your drug costs from $250 to $2,250 during a year – a "copayment."

• you pay 100% of your drug costs from $2,250 to $5,100.

• you pay about 5% of drug costs above $5,100 for the rest of the year.

• To sign up, contact an independent PDP directly or your HMO for its plan.