Questions About Medicare Part D

[tednlou2]

Today, I ran into someone I've met at our HIV doc.  He's on Social Security Disability after getting an AIDS diagnosis and having medical issues.  So, he gets Medicare and due to his income he gets the "extra help" where I guess he also get Medicaid.  So, that pays his Part D and B premiums, co-pays, deductibles, and the Medicaid part pays the 20% Medicare doesn't.

He's getting ready to start meds and thought that everything would be a go, since he pays $2.50 for generic and like $6-something for brand names.  However, he's been hearing about the donut-hole issue where (and I'm fuzzy here) once they pay out $4,000+ or whatever it is, you have to pay 80% of the drug price until you'd paid out a lot of money yourself and then I guess it kicks back in???

He was asking me what I knew about all this, and I didn't have the answers.  He was worried, because he said HIV meds would add up to hit that dollar amount pretty quickly and wondered what happens then.  Would he then have to pay out the 80% out of pocket himself after that, which would just not be possible?  Does the "extra help" change any of this?  He was signed up for ADAP, but they took him off the list, because he now has Medicare.  If it is true that he would have to pay out all the money himself, would ADAP help him? 

I just wanted to get some accurate info for him.  Oh, I guess one good thing that happened for him was that he contested the fee his lawyer got.  His lawyer got $6,000 of his backpay.  He wrote a letter explaining that he had done all the work--getting all his medical reports, etc, etc.  His lawyer didn't do anything, except for showing up at the hearing.  At the hearing, he did all the talking while the lawyer just sat there.  Anyway, the original judge considered this request and decided he should get $3,000 back from the lawyer.  I didn't know that was possible.  So, I guess he would have that money for meds, but he said he has so many past-due bills that it will be gone. 

[Mus1cl0V3R]

Greetings,
If he has both SSDI and Medicaid that would make him dual eligible.

Individuals identified as "dual eligible" by CMS are not subject to the donut hole, as their prescription coverage is fully subsidized.

http://en.wikipedia.org/wiki/Medicare_Part_D_coverage_gap

...dual eligibles have the right to switch plans every month in order to enroll in a plan that better meets their prescriptions needs...

http://en.wikipedia.org/wiki/Medicare_Part_D

Understanding the Medicare Part D Donut Hole:
http://healthinsurance.about.com/od/medicare/a/understanding_part_d.htm

HTH
Cheers

[Miss Philicia]

I am dual eligible and on both Medicare Part D and Medicaid. One becomes your primary insurance and one your secondary, so everything is actually covered. Somehow my donut hole is covered.

[denb45]

I am dual eligible and on both Medicare Part D and Medicaid. One becomes your primary insurance and one your secondary, so everything is actually covered. Somehow my donut hole is covered.

I used to be dual eligible up until about 2009 when my states medicaid office told me I was 1 dollars over the limit   so I cannot even use my Part D anymore, instead I had to sign-over my medicare part A, B & D to Blue Cross Blue Shield, and they actually pay my States ADAP-program ( only for H.A.R.R.T drugs ) all other non-HIV drugs I have to pay outta pocket for, I also have Co-pays for those Meds as well as doctors visits

LUCKY you Miss P, wish I was in your shoes