Key Facts for PAAD Participants
Medicare Part D, the prescription drug benefit offered by the federal Medicare program, is offered through private plans approved by Medicare and is available to anyone who has Medicare Part A and/or Part B.
As of January 1, 2006, PAAD participants who have Medicare must enroll in a Medicare prescription drug plan to use Medicare Part D benefits along with PAAD benefits. Medicare is the primary payer of prescriptions for PAAD participants who are eligible to enroll in Medicare Part D. PAAD participants who are eligible to enroll in Part D and who have limited income and resources must also apply for "Extra Help" from the federal government to help pay for Medicare Part D costs. If you are prohibited from joining Medicare Part D due to other coverage (such as retiree or union), please see the section on Creditable Coverage below.
Here are key facts you need to know:
- All PAAD participants who have Medicare Part A and/or Part B, have to enroll in Medicare Part D to use PAAD benefits. They also must apply, if eligible, for "Extra Help" from the federal government to help pay for Medicare Part D. The PAAD program will assist eligible PAAD participants in applying to the federal government for the "Extra Help."
- PAAD participants who have Medicare will use PAAD benefits together with Medicare Part D benefits. If a Medicare Part D plan is the primary payer for a medication covered on its formulary, PAAD will provide coverage as secondary payer if needed for that drug, and the PAAD beneficiary will pay up to the regular PAAD copayment for PAAD covered drugs. However, if a Medicare Part D plan does not pay for a medication because the drug is not on its formulary, PAAD beneficiaries will have to switch to a drug on the Part D plan's formulary, or their doctor will have to request an exception due to medical necessity directly to their Part D plan.
- Medicare Part D plans will cover medically necessary prescription medications under Medicare Part D. The PAAD program and/or the federal Medicare program will pay all prescription costs above the required $5 PAAD co-payment for generic drugs and $7 PAAD co-payment for brand name drugs, including premiums. However, if a Medicare Part D plan does not pay for a medication because the drug is not on its formulary, PAAD beneficiaries will have to switch to a drug on their Part D plan's formulary, or their doctor will have to request an exception due to medical necessity directly to their Part D plan.
- The State of New Jersey will pay the monthly premiums on behalf of PAAD participants for certain standard basic Medicare Part D prescription drug plans at or below the regional Part D benchmark premium (for 2013, the Medicare Part D benchmark premium for New Jersey equals $37.04), and for certain standard basic or enhanced Medicare Part D plans up to $5 above the regional benchmark that have no deductible. To find out which basic Part D plans in New Jersey for which PAAD pays the monthly premium, please call 1-800-792-9745
- If you are a new PAAD member and have already enrolled in a Part D prescription drug plan, you may opt to switch to a plan whose premium is paid for by PAAD by calling 1-800-792-9745.
- A PAAD participant may choose to enroll in a Medicare Part D prescription drug plan that is not a standard basic plan at or below the regional benchmark or up to $5 above the regional benchmark without a deductible. However, he/she will be responsible for paying the entire monthly directly to that Medicare Part D prescription drug plan.
Medicare Advantage Participants
- The PAAD program will pay up to the annual Medicare Part D benchmark premium for Medicare Advantage prescription drug plans (MAPDPs). For 2013, the Medicare Part D benchmark premium equals $37.04. The PAAD program will pay up to the benchmark premium for the prescription portion of the total premium only for MAPDPs. PAAD does not pay for any medical coverage premiums for MAPDPs.
- All PAAD participants must be enrolled in Medicare Part D to use their PAAD benefits. That means that PAAD participants who are enrolled in Medicare Advantage (MA) plans without a prescription drug plan component must contact their MA plan and ask about enrolling in a prescription drug plan component so they do not lose their PAAD benefits. PAAD will pay up to the annual Medicare Part D benchmark premium in New Jersey ($37.04 for 2013) for the MA plan’s prescription drug plan component.
PAAD participants who have “creditable coverage” for prescription drugs through a former employer or union and have been notified to not enroll in Medicare Part D do not have to enroll in order to use PAAD benefits. Creditable coverage means that the prescription drug coverage provided by an employer or union is, on average, at least as good as that which is provided by a basic Medicare prescription drug plan. Employers or unions are responsible for sending out notification regarding creditable coverage and whether or not to enroll in Medicare Part D to their employees/retirees.
- PAAD participants with creditable coverage from a former employer or union are asked to send a copy of the notice to the PAAD program.