Colorado Medicare Health/Drug Insurance Coverage Options

The Colorado SHIP (State Health Insurance Assistance Program) can help you with questions and can provide one-on-one assistance. Call the Colorado SHIP at 1-888-696-7213 to be directed to the SHIP office nearest you or visit the Colorado Senior Health Care & Medicare Assistance (Colorado SHIP & SMP) page for more information. SHIP assistance is free and confidential. We do not endorse or sell drug or
health plans.

The Social Security Administration takes applications and determines eligibility for the Extra Help program. Complete an
online application at the Administration's Extra Help with Medicare Prescription Drug Plan Costs page or call the Colorado SHIP at 1-888-696-7213 for help.

Medicare can provide information on how drug plans or Medicare
Health Plans with Drug Coverage cover your current prescriptions. Check Medicare.gov or call 1-800-MEDICARE
(1-800-633-4227) 24 hours a day, seven days a week.

Benefits Check Up has a website to help you find additional benefits through numerous local, state, and federal programs.
Go to benefitscheckup.org for more information.
For extensive general health insurance information, visit
doi.colorado.gov and click on Health Insurance.

If you have Medicare Part A, Part B, or both, you are eligible for Medicare Part D. Many people will first enroll in a Part D plan when they enroll in Medicare Part A and B: three months before, the month of, or three months after their 65th birthday (seven month Initial Enrollment Period).

Enrollment occurs when you review plans, pick a plan, and then call that plan, call Medicare, or enroll online to indicate which plan you have chosen.

There are additional Special Enrollment Periods for situations such as moving from one coverage area to another, moving in or out of a nursing home, or losing employer coverage. Some people have coverage from another source and might not need to get a Part D plan (see “Thinking About Skipping Part D?” below).

Contact Medicare (1-800-MEDICARE), or Colorado SHIP (State Health Insurance Assistance Program) at 1-888-696-7213, for additional information about the timelines for enrolling in Medicare Parts A, B, and D.

Medicare prescription drug coverage, known as “Part D,” is prescription drug insurance provided by private insurance companies. This prescription drug coverage can be purchased as a “Stand-Alone” Part D plan or can be included in a purchased “Medicare Health Plan with Drug Coverage” plan. All Part D plans sold in Colorado have been approved by Medicare. The plans change each year, so new information is summarized annually in this publication.

In Colorado for 2024 there are 21 Stand-Alone Part D plans. Each of those plans is sold throughout the state. There are 46 Medicare Health Plans (HMO, PPO, or PFFS with drug coverage) and 21 Medicare Health Plans for special populations (Special Needs Plans) that include Part D coverage. Medicare Health Plan availability varies by county, so not all Medicare Health Plans are available throughout the state.

Each plan has a different list of covered drugs, premiums, deductibles, copays, and pharmacy networks. Each company must offer a “Standard Plan,” but may also offer enhanced plans with additional coverage.

If your Stand-Alone Part D Plan or Medicare Health Plan with Drug Coverage is continuing into 2024, and if you want to keep that plan, you don’t need to take any action. You should have received an “Annual Notice of Change” from your insurance provider by September 30. This notice gives you information on the premiums and general changes, but it does not have to include changes about what drugs will be covered by the plan.

Plans often make changes annually - there may be new premiums, copays, and changes in the lists of drugs that are covered. We recommend you evaluate your prescription drug coverage each year to determine which plan best fits your needs for the coming year. You can compare plans yourself at www.Medicare.gov (see “Do-It-Yourself Plan Comparison Searches" below) or get help by calling Medicare (1-800-MEDICARE) or call Colorado SHIP (State Health Insurance Assistance Program) at (1-888-696-7213).

You can enroll or change your Part D plans and Medicare Health Plans from October 15 through December 7. The enrollment change will take effect on January 1, 2024. You can make this change by calling 1-800-MEDICARE, calling your new plan choice, or making your enrollment selection online at Medicare.gov.

Premiums and Deductibles

Premiums are the monthly cost of purchasing the Stand-Alone Part D coverage or the Medicare Health Plan. The deductible is the amount of money you have to pay out of your pocket before your insurance begins to pay its share.

Copays

Copays vary from plan to plan and within plans depending on the medication. Most insurers use a “tiered” system where copays are lowest for generics, and highest for brand-name drugs. Each plan may also have “preferred” and “non-preferred” drugs that will also affect the copays.

Medicare drug insurance plan premiums for 2024 vary from $0 to $132 for Stand-Alone Plans, and from $0 to $116 for Medicare Health Plans with drug coverage. Deductibles range from $0 to $545 for either Stand-Alone Plans or Medicare Health Plans with Drug Coverage.

The Coverage Gap (or "Donut Hole")

The Coverage Gap has been a feature of the Part D Standard Plan since its beginnin4 in 2006. It became known as the “Donut Hole” because it is a hole in coverage in the and in 2022, 75% of the cost of brand name covered drugs will be paid by the manufacturer and the plan. The consumer will pay 25% of the cost. 75% of the cost of generic drugs will be paid for by Medicare, and the other 25% will be paid for by the consumer.

Formularies

Formularies are the lists of drugs covered by the individual plans.
When drugs are not on the formulary, you pay full price. Each plan will pay for some brand-name and some generic drugs in each treatment category, but not all drugs. Check if your drugs will be covered in 2024 by your current plan, or by the new plan you are considering. Eliminate plan choices that don’t cover the majority of your prescriptions, especially more expensive brand-name drugs, or consider asking your doctor if you can switch to those drugs that are covered by your plan.

Certain types of drugs or categories of drugs are not covered by Part D plans, including over-the-counter drugs, drugs for weight management, fertility or sexual dysfunction, or cosmetic purposes. These are known as “exclusions.”

Which Pharmacies Can You Use?

Each insurer has a network of pharmacies where you can use your drug insurance. Check to ensure that the pharmacy you use is part of the network for the plan you choose. Drug purchases in out-of-network pharmacies cost more and may not count toward your true out-of-pocket expenses.

You can achieve the greatest cost savings with your prescription copayment or coinsurance amounts by checking the status of your pharmacy with your plan. Pharmacies listed with the plan as “Preferred Cost-Sharing” network pharmacies may offer even lower copayment or coinsurance amounts than “Standard Cost-Sharing” network pharmacies.

Most Medicare drug insurers also offer a mail order pharmacy option. It is important to compare how mail order costs compare to retail – they may be cheaper or more expensive, depending on the plan.

Each Part D insurer must offer a plan that is equivalent to this plan. They can also sell “enhanced” plans that have more generous coverage, usually for a higher premium. Few plans have the identical costs as described in the Standard Plan, but they can be sold because they are overall financially the same. The amounts shown below DO NOT INCLUDE monthly premiums. 

Yes, they can do the following. 

• Call their own clients, or someone who has given them permission to discuss new plan options.
• Conduct sales activities in appropriate common areas of healthcare settings.
• Provide refreshments and light snacks to potential enrollees at sales presentations.

No, they can't do these things.

• Solicit potential client’s door-to door.
• Say they’re from Medicare or use “Medicare” misleadingly.
• Market non-health related products to potential enrollees during Medicare Advantage Plan or Prescription Drug Plan sales activities or presentations.
• Provide meals to potential enrollees at sales presentations.

If you have questions, call the Colorado Senior Medicare Patrol at 1-800-503-5190.
 

If you have drug benefits through your or your spouse’s current employer plan or with a retiree plan, you may be able to keep your current coverage. If Medicare considers this coverage to be as good as or better than Medicare Part D (“creditable coverage”), you do not need to enroll in a Part D plan. If you later lose coverage, you’ll be able to enroll in a Part D plan without facing a penalty for late enrollment.

Each year you should receive a notice regarding your coverage and confirming if your coverage is “creditable.” Save this notice. If you have not received a notice by mid October, contact your benefits administrator to request one. It is important that you contact your benefits administrator before making ANY decisions regarding your prescription drug coverage. If you choose a Part D plan outside your employer coverage, you could lose your employer health coverage entirely – ASK FIRST!

If you have prescription drug benefits through the Federal Employees Health Benefits Program (FEHBP) or TRICARE for Life, you may enroll in Medicare prescription drug coverage, if you choose. However, the drug coverage through these plans is typically better than the Medicare prescription drug plan coverage.

You might want to enroll in a Medicare drug plan if you are eligible for Extra Help in paying your prescription drug costs (see “Extra Help for Part D Costs” below). Extra Help may provide lower drug copays than your retiree plan. You cannot receive the Extra Help through your FEHBP or TRICARE for Life.
If you have Veterans Affairs (VA) coverage, you have the option of getting your prescriptions through the VA and enrolling in a Medicare prescription drug plan. You cannot use both VA coverage and Medicare coverage at the same time. However, you can use your Medicare prescription drug coverage to receive Extra Help and to fill prescriptions at pharmacies outside the VA system.

If you currently have little or no drug costs, you may be thinking about not enrolling in Part D. Consider that, like any other insurance, Part D is designed to protect you now and in the future; most people can’t predict what their health care needs will be in six months.

The disadvantages of delaying enrollment include: 1) you risk not having the coverage if you need it; 2) after your first opportunity to enroll has passed, you will have only yearly opportunities to enroll during the Annual Enrollment Period October 15 –December 7, with an effective date of January 1 of the following year; or 3) if you do enroll at a later date, you will likely have to pay a penalty for late enrollment (see “Penalties for Late Enrollment” below).

If you still have drug coverage from a Medicare Supplement issued before 2006, it is not creditable coverage and your penalty for late enrollment into Part D will increase each year you postpone the coverage. If and when you enroll in a Part D plan, be sure to notify your Medicare Supplement company that you no longer want drug coverage as part of the Supplement; you cannot have both.

Even though Medicare Part D coverage is voluntary in the sense that you have to choose to enroll in it and pick a plan, there is a penalty for enrolling late. The penalty is based on how many months have passed since you first became eligible for the benefit.

The penalty increases the longer you wait to enroll, begins when you finally do enroll, and continues to be assessed on top of your Part D premiums for as long as you have Part D. The number of months you didn’t elect coverage but were eligible is multiplied by 1% of the National Base Average premium ($34.70 for 2024) and applied monthly thereafter.

Extra Help is a program that is available for people with limited income and resources. If you qualify, you can have a plan with limited or no premium, low or no deductible, lower copays for your prescriptions, and a low or no coverage gap. You can also change plans during the year instead of waiting for the Annual Open Enrollment Period.

Who Will Qualify (may change in 2024)

Income Limits for 2023:

• Single $1,660/month ($19,920 annually)
• Couple $2,339/month ($28,068 annually)

Asset/Resource Limits for 2023

• Single $10,590
• Couple $16,630

How to Apply

If you are on Medicare and Medicaid and the state pays your Part B premium, you should automatically qualify for Extra Help without having to do anything.

Everyone else will need to apply for Extra Help. The easiest and quickest way to apply is online at www.ssa.gov (see the “Need More Information and Assistance?” section below).

If you qualify for Extra Help, the following Benchmark Plans will provide the lowest premiums and deductibles (highlighted in bold on the plan list).

• Clear Spring Health Value Rx (PDP)
• Cigna Secure Rx (PDP)
• Humana Basic Rx Plan (PDP)
• Wellcare Classic (PDP)

Your copays for your drugs depend on how well your chosen plan covers your list of drugs. You can compare plans yourself at Medicare.gov (see “Do-It-Yourself Plan Comparison Searches,” below), get help by calling Medicare (1-800-MEDICARE), or call Colorado SHIP (State Health Insurance Assistance Program) at (1-888-696-7213).

There are three MSPs, each with different income and resource limits. If you qualify for any MSP, the State will pay your Part B premium for you. One of the MSP programs even helps you with your Part A and B deductibles and copayments.

Generally, if you qualify for full benefits under the Extra Help program, you will qualify for MSP. For more information, contact Colorado SHIP (State Health Insurance Assistance Program) at 1-888-696-7213, or your local County Department of Human Services.

Many manufacturers of prescription drugs offer assistance for users of their products who need assistance. For information on whether help with costs is available for your prescriptions, go to the Medicare Pharmaceutical Assistance Program website or call Colorado SHIP (State Health Insurance Assistance Program) at 1-888-696-7213.

All of the Medicare Health Plans listed as "2024 Colorado Medicare Health Plans (with Drug Coverage)" have prescription drug coverage. Most people choose a Medicare Health Plan that includes drug coverage. People who have creditable drug coverage from another source, but want a Medicare Health Plan should call 1-800-MEDICARE or the Colorado SHIP (State Health Insurance Assistance Program) at 1-888-696-7213, to find out which plans can be combined with your drug plan, but not cause disenrollment from your original plan.

Medicare drug plans are allowed to place restrictions on drugs. Prior Authorization means that the doctor must ask the plan’s permission before prescribing the drug. Step Therapy means the doctor must demonstrate that a lower cost generic drug does not work for you  before prescribing a higher cost brand-name drug. Plans may also place Quantity Limits on the amount of any drug you can get in one month. The patient and his/her doctor must consider those restrictions when deciding on a drug therapy.

Sometimes it is better for an individual to choose a higher cost plan without drug restrictions than to choose a lower cost plan with multiple restrictions. There is a process to seek an exception to drug restrictions from the drug plan. Visit the Medicare website (Medicare.gov), call 1-800-MEDICARE, or call the Colorado SHIP (State Health Insurance Assistance Program) at 1-888-696-7213 for assistance.

At medicare.gov you can find that the Medicare Plan Finder actually performs more functions, despite its simpler look. You can log in for a personalized experience, or get more information without logging in, as well as qualifying for a Special Enrollment Period, learning more about Medicare, and getting information about Medigap plans.

The Medicare Plan Finder - 2024
1. Log in for a personalized experience
2. Search anonymously
3. Learn More about Medicare
4. Find Medigap plans

After creating and logging into your MyMedicare.gov account, you will be asked a few questions regarding the type of 2024 coverage you are looking for – either a Medicare Advantage plan, drug plan or Medigap policy.

On the prescription drug screen, you will get a list of all the prescription drugs you filled through Medicare last year. Just check the boxes of the drugs still prescribed. This personalization is only available to users who log-in to the Plan Finder with their MyMedicare user name and password.

Once the drug lists are finalized, and pharmacies are chosen, it’s time to compare plans (by scrolling down on the page).

Notice the “Live Chat” at the top of the page. Seniors often have questions when comparing plans. Once logged-in to your MyMedicare.gov account, you will be able to chat in real-time with a CSR at the 1-800 Medicare call center; from anywhere in the new Plan Finder.