Assemblyman Englebright
An important message from Assemblyman Englebright

Englebright says:
Know your
Part D facts.

Dear Neighbor:

Seniors will soon have important decisions to make about the new Medicare prescription drug benefit that goes into effect on January 1, 2006. Enrollment started November 15, 2005 and goes through May 15, 2006.

Making a decision on whether or not you should enroll in the Medicare Part D benefit, remain in your EPIC plan, or keep your current retiree prescription drug coverage are all very serious considerations. This newsletter is designed to offer you basic information about the benefit, but more importantly, to stress that the decision to join is optional and personal. Before you consider doing anything, please be sure to contact the resource numbers provided and have a one-on-one counselor look at your personal information and circumstances so you have the information you need to make the best choice possible.


Assemblyman Steven Englebright

Should I enroll in Medicare’s prescription drug benefit?

If you currently have drug coverage that is at least as good as or better than Medicare’s basic drug benefit, you should probably keep it. You can join a Medicare plan later without the penalty if you need it. Your current benefit company should notify you to confirm whether or not its benefit is as good as or better. If you have not received that notice, call them and ask.

Will Medicare private drug plans offer uniform Medicare drug coverage?

No, they will not. The Medicare law outlined a plan that will be used as the standard for the overall value a plan must offer to be approved as a Medicare plan. Many of the plans will no doubt be different so long as the overall value is at least as good as the Medicare basic plan. According to the Basic Plan you would pay:

  • The first $250 of your drug costs for covered drugs each year (the deductible)
  • Coinsurance worth 25% of the cost of covered drugs between $251 and $2,250
  • 100% of the cost of covered drugs between $2,251 and $5,100
  • 5% of the cost of covered drugs above $5,101. This is called "catastrophic coverage" (or a co-payment of $2 for covered generics/preferred drugs and $5 for covered brand-name drugs, whichever is greater)
  • You will have to reach $3,600 in out-of-pocket costs in 2006 before you can receive catastrophic coverage


Questions to ask BEFORE you join or consider joining ANY PLAN!

  1. COST - How much are the co-pays/co-insurance for each drug on my list?

    • If a drug I take has high co-insurance, is there a substitute I can take?
    • Will I have to pay the full cost of my drug(s) at some point?
    • How much will I pay in monthly premiums and annual deductible?
  2. Covered Drugs - Will the plan cover all the drugs I take?

    • Will it cover the most expensive drugs I take and the most important?
    • If it doesn’t cover my most expensive and important drugs, will it cover an acceptable alternative?
    • Does the plan require that I get permission before it will cover any medications that I take (i.e. prior authorization)?
  3. Pharmacy - Is the pharmacy I use a regular pharmacy in the plan“s network? If not, what happens if I fill a prescription there?

    • Can I access prescriptions through mail order?
    • What happens if I travel or go out of state for long periods of time (i.e. Florida)?
  4. Coordination - Will the Medicare plan work with my current drug coverage?

What you need to know:

  • The new Medicare drug program is voluntary. Seniors may choose to enroll - or not. There are a couple of important things to know about this, though. (1) If you have both Medicaid and Medicare, and if you do not pick a plan and enroll before December 31, 2005 you will be enrolled in one of the new drug plans automatically, because your Medicaid drug benefit will end on December 31, 2005. (2) If you have drug coverage now, you will need to find out if Medicare considers this coverage to be "as good as or better" than the new Medicare drug benefit. This will affect your decisions about enrolling in the Medicare drug benefit. You might have to pay a late enrollment penalty if you don’t enroll until after May 15, 2006. You won’t have to pay the late penalty if the benefit you have is not "as good as or better than" the Medicare standard benefit.

  • The new Medicare prescription drug program works with New York’s EPIC program. Seniors with EPIC can keep their EPIC coverage. For some, particularly those eligible for extra help for low-income beneficiaries, enrolling in a Medicare drug program will mean more savings.

  • The new Medicare drug program has extra help to pay for drug costs for beneficiaries with lower incomes. The Social Security Administration has been mailing applications for this "extra help" (or low income subsidy) to those who may be eligible. You may have gotten this application already. Those already in Medicaid or one of the Medicare Savings Programs (QMB, SLMB, and QI-1) will be eligible automatically for the "extra help."

    Keep in mind that applying for the "extra help" is a separate step from enrolling in the new drug benefit.

  • This new Medicare benefit will only be available through private plans. This means that in order to get prescription drugs covered through Medicare, New Yorkers must enroll in one of the plans offering the benefit in New York. HMOs and other Medicare Advantage plans will also be offering the new prescription drug benefit.

How to Protect Yourself from Unscrupulous or False Marketing

Be an alert and informed consumer. Plans will be competing to get the most people enrolled as quickly as possible, so take care before making any decisions.

  1. Don’t give personal information over the phone, including to the "marketing representatives" of plans. Marketing representatives cannot request personal information as part of their marketing activities (however, other representatives from the same plans, such as enrollment representatives, will be asking for this information. Be sure to verify if they are legitimate).

  2. Meet plan representatives in a public place - not in your home. Verify the credentials and identification of whomever you speak with.

  3. Just Say "Stop." Plans must honor your request if you ask them not to call back. No legitimate plan requires personal information over the phone or needs to use pressure tactics.

  4. The Do-Not-Call Registry toll-free number is (888) 382-1222 (TTY (866) 290-4236), or Plans must honor "do not call" requests.

  5. Be Alert for Scams and Identity Theft. Unfortunately, the massive marketing that will take place also provides opportunities for fraud and abuse. Check and double-check the credentials of those you are dealing with before taking any action. Report any suspicious contacts.


For more information and counseling call:

StateWide’s Medicare/EPIC Project at:
(800) 333-4374

State Health Insurance Assistance Program (SHIP):
(800) 333-4114

Suffolk County Office for the Aging HIICAP Program:
(631) 853-8200

Ask for HIICAP

Steve Englebright
149 Main Street
East Setauket, NY 11733
(631) 751-3094