Medicare Part D -- New Benefit

Today Medicare covers only a few drugs that are not given in a hospital or doctor’s office. Starting in January 2006, Medicare will begin paying for covered drugs for people with Part A or Part B or both who sign up for the new benefit. Medicare calls it Medicare Prescription Drug Coverage, but most people call it Medicare Part D. This benefit will be offered through private insurance companies. People with limited income and assets won’t have to pay a premium or deductibles and will pay a small copay per prescription. Others who don’t qualify for this extra help will pay a premium, deductible, and part of their drug costs.

You can read about this new coverage on the Medicare website ( To see what Part D may save you, use the calculator on the Kaiser Family Foundation website (

If you or someone you care about has kidney disease, talk with your doctor and review the list of medicines you are taking now, would be taking if you could afford them, and may need in the future as your health and treatments change. When the plans are posted in October on the Medicare website, compare what drugs each covers to see which plan is best for you. If you have other drug coverage now, find out whether it is at least as good as Medicare’s Part D. If it isn’t, you might want to sign up for Part D to save money and to avoid higher premiums later. Sign up starts November 15, 2005.

Hello, and thank you for the information. I had heard about this program and requested information from my social worker, but she had limited info. It is about time for this.

I do have a question, however. I have been unable to get on the transplant list because I only have medicare coverage. My husband is self-employed. Do you have any information on specific transplant medications being covered?

There is no change how drugs that were previously covered by Part B will be paid – they will still be covered by Part B. If you have Medicare Part A and B, your anti-rejection drugs would be covered by Part B. To protect your rights to have Medicare Part B pay for anti-rejection drugs, you must have Medicare A at the time of the transplant, the transplant must have taken place in a Medicare approved facility, and you must have Part B at the time you want Medicare to pay for the drugs

However, if you have a transplant and don’meet the requirements to get Part B coverage then you could use Part D to pay for anti-rejection drugs and any others on your plan’s list of covered drugs. Incidentally, Medicare is requiring that companies that sell Part D plans cover all anti-rejection medicines.

With the Part D premium, deductibles, coinsurance, and the donut hole, you may be better off with Part B coverage for your anti-rejection medicines and using Part D to pay for other drugs that you need.

I understand how you could be frustrated that you can’t get on the transplant list. However, if you have Medicare because of kidney failure, that coverage will end 36 months after the transplant and you’ll need expensive anti-rejection medicines as long as your transplant lasts. I’m sure you hope this will be much longer than 36 months.

I assume by what you say about your husband’s job status that you have no secondary coverage and he is uninsured or has no family coverage. I don’t know what your financial situation is or how long you’ve had Medicare, but you may qualify for a Medigap or other health coverage. Your social worker, state insurance department (see map at, or your State Health Insurance Assistance Program (call 1-800-MEDICARE to get their number) should be able to tell you what options you have for coverage.

Good luck!

Thank you very much for your information. I will research medi-gap to find out if I have any eligibility. I have had medicare since 2003 and have been on dialysis since 9/2000. I was on PD until a couple weeks ago and my membrane just stopped working and for no apparent reason. I have never has peritinitis or any issue with it. Both my doctor and nurses say they have never seen this before. Now, I have just had the perma-cath placed in my chest and go into the clinic 3X’s per week at 5:30am.

Just a recap on this, now that we’re here 2006…

Did it go smoothly for any of you dialysis patients at home? …I did read some problems for some patients throughout the nation…just curious…

So far it has been ok. But I don’t know what will happen when we have to get the IV Iron as it isn’t in any of the drug formularlys that I saw.

There are some drugs that Medicaid are still paying for, am not sure which ones they are but I think you can visit your states government website to get that information…for example, for California it …just change the ca part to your state’s initial…

I guess okay, but the costs are prohibitive, I have to cut way back on stuff until I reach somewhere around $5,000, they did us no favors going with this system, I had much better coverage before, although they now have to provide a few drugs they didn’t before.

Cathy (with Kaiser)

Cathy I agree with you. I don’t think they did us any favors either. It was definitely easier before the switch and the co-pays were less. By easier it seems like now I am always having to get the doctor to write something to get certain drugs whereas before it wasn’t questioned. For example protonix they want you to use over the counter medications instead.

I have been working with the National Kidney Foundation on Part D education. I have heard of various problems with Part D from social workers that are trying to help patients work through them.

The plan limits can definitely be a hassle–for patients, MDs, and social workers. Thank goodness all plans don’t require them. If your plan sets any limits (prior authorization, quantity limits, step therapy – using another drug first), once your doctor provides the medical justification (called an exception request) and the plan approves it (which hopefully it will), that approval is good for at least the plan year.

State Medicaid agencies pays for drugs that are excluded by Part D if they pay for these drugs for people with Medicaid only. There are a few classes or drugs that Part D excludes: drugs for weight gain/loss/anorexia, drugs for cosmetic purposes, drugs for cough and cold symptoms, over-the-counter drugs, barbiturates (mostly sleeping pills), benzodiazepines (anti-anxiety drugs and drugs for restless legs), vitamins. Vitamin D analogs are not excluded but plans don’t seem to always realize this. We’re trying to get CMS to clarify this to plans and pharmacies.

Check out An updated Compare Drug Plans packet will be available next week and again after the formularies (lists of covered drugs) change the first Monday in February. You’ll find many resources, including booklets and soon there will be 40 fact sheets for different stages/types of treatment and financial/insurance status on

Yes but you must be careful, with Kaiser Senior Advantage if you sign up for a drug coverage you will lose your Kaiser insurance, so we are stuck with their prescription plan which is essentially Medicare’s basic which should leave me out of pocket $3,600 before I then get substantial coverage. This is much more than I have been paying (by probably $3,000) but it is better than nothing, I’m sure I will meet the deductible in the first quarter of this year due to the cost of renagel alone, but it is keeping me healthy and alive and they are paying a small fortune to let me have daily dialysis (about $15,000 a month) so I can’t really feel too bad.


You’re right. If you’re in a Medicare Advantage plan (otherwise called a Medicare Health Plan), you must stick with that plan’s drug plan (called an MA-PD) if you’re on dialysis. If you have limited income and resources, you can get extra help to pay the premium and cost shares. Some people qualify automatically, but others must apply through Social Security.

People that have Medicare and Medicaid (Medi-Cal in CA) can get their drugs for $1 for generics or $3 for brand names. Those who have an income of at least 150% of the federal poverty level and/or resources of $11,500 (single) or $23,000 (couple) must pay the full premium and cost shares of $3,600 of the first $5,100 in drug costs and 5% for drug costs after that for the rest of the year. Some plans cover more drugs or cover generics and/or brand name drugs during the coverage gap. They’re usually the plans with the higher premiums.

In helping some people I’ve found that even people that have Medicare and Medicaid may be able to get more of their drugs covered if they pay a small premium. The cost of the premiums is way outweighed by not having to pay full price for some drugs that are not covered on the free premium plans.