AHIP Module 3
Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies
under a program known as Medicare Advantage (MA), not by the government. He likes Original
Medicare and does not want to sign up for an MA product, but he also wants prescription drug
coverage. What should you tell him? - ANSWERb. Mr. Carlini can stay with Original Medicare and also
enroll in a Medicare prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage to eligible Medicare beneficiaries. Correct
Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan
because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you
tell her? - ANSWERd. Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a
Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to
enroll under Part B before enrolling in a prescription drug plan. Correct
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage
previously available through her husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - ANSWERa. If a Part D benefit is offered through
her plan she may choose in enroll in that plan or a standalone PDP. Correct
Which of the following statements about Medicare Part D are correct?
I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in
limited circumstances.
II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to
have one.
III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits
through a standalone PDP.
IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through
their plan. - ANSWERb. I, II, and III only Correct
, All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a
beneficiary incur for prescription drugs in 2019 under the standard coverage? - ANSWERc. Standard Part
D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a
portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-
insurance after the coverage gap. Correct
Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs,
she will reach the coverage gap, and wants to be sure she has enough money set aside for those
months. She received assistance calculating her projected expenses from her daughter who is a
pharmacist, but she doesn't think the calculations are correct because her out-of-pocket expenses
would be lower than last year. She calls to ask if you can help. What might you tell her? - ANSWERd. It
would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up
the date for closing the so-called "donut hole" for brand name drugs to 2019. Correct
Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he
looks at information on various plans available in his area, he sees a wide range in what they charge for
deductibles, premiums and cost sharing. How can you explain this to him? - ANSWERa. Medicare Part D
drug plans may have different benefit structures, but on average, they must all be at least as good as the
standard model established by the government. Correct
Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP)
coverage. She is traveling and wishes to fill two of her prescriptions that she has lost. How would you
advise her? - ANSWERd. She may fill prescriptions for covered drugs at non-network pharmacies, but
likely at a higher cost than paid at an in-network pharmacy. Correct
What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees
can access medications? - ANSWERc. Part D plans do not have to cover all medications. As a result, their
formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost
containment techniques such as tiered co-payments and prior authorization. Correct
Mrs. Allen has a rare condition for which two different brand name drugs are the only available
treatment. She is concerned that since no generic prescription drug is available and these drugs are very
high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of
Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies
under a program known as Medicare Advantage (MA), not by the government. He likes Original
Medicare and does not want to sign up for an MA product, but he also wants prescription drug
coverage. What should you tell him? - ANSWERb. Mr. Carlini can stay with Original Medicare and also
enroll in a Medicare prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage to eligible Medicare beneficiaries. Correct
Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare prescription drug plan
because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you
tell her? - ANSWERd. Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a
Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to
enroll under Part B before enrolling in a prescription drug plan. Correct
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage
previously available through her husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - ANSWERa. If a Part D benefit is offered through
her plan she may choose in enroll in that plan or a standalone PDP. Correct
Which of the following statements about Medicare Part D are correct?
I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in
limited circumstances.
II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to
have one.
III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits
through a standalone PDP.
IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through
their plan. - ANSWERb. I, II, and III only Correct
, All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a
beneficiary incur for prescription drugs in 2019 under the standard coverage? - ANSWERc. Standard Part
D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a
portion of costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-
insurance after the coverage gap. Correct
Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs,
she will reach the coverage gap, and wants to be sure she has enough money set aside for those
months. She received assistance calculating her projected expenses from her daughter who is a
pharmacist, but she doesn't think the calculations are correct because her out-of-pocket expenses
would be lower than last year. She calls to ask if you can help. What might you tell her? - ANSWERd. It
would not be unusual for her costs to be a bit less because the Bipartisan Budget Act of 2018 moved up
the date for closing the so-called "donut hole" for brand name drugs to 2019. Correct
Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he
looks at information on various plans available in his area, he sees a wide range in what they charge for
deductibles, premiums and cost sharing. How can you explain this to him? - ANSWERa. Medicare Part D
drug plans may have different benefit structures, but on average, they must all be at least as good as the
standard model established by the government. Correct
Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP)
coverage. She is traveling and wishes to fill two of her prescriptions that she has lost. How would you
advise her? - ANSWERd. She may fill prescriptions for covered drugs at non-network pharmacies, but
likely at a higher cost than paid at an in-network pharmacy. Correct
What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees
can access medications? - ANSWERc. Part D plans do not have to cover all medications. As a result, their
formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost
containment techniques such as tiered co-payments and prior authorization. Correct
Mrs. Allen has a rare condition for which two different brand name drugs are the only available
treatment. She is concerned that since no generic prescription drug is available and these drugs are very
high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of
