AHIP: Medicare Prescription Drug Plan Guide: How to Choose Your 2007 Plan
Stand-Alone Drug Plan
Getting Started Quick Facts Worksheet
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Worksheet

Fill in your information, then print out this page for your records. This will be helpful when you prepare to sign up for a plan.

IMPORTANT!
1) The information in the worksheet is completely private and will not be stored. Its only purpose is to help you understand your own priorities.
2) None of the fields are required. If you don't know an answer, feel free to leave it blank.


Step 1: Figure Out What is Best for You

As with many consumer decisions, you may need to make tradeoffs to get a plan that provides you with the best overall value. Answering the questions below will help you set your own priorities and make decisions that are right for you.

The Three C's: Coverage, Cost, and Convenience

Look over the questions under the coverage, cost, and convenience headings below. Check ONE item under each question based on how important it is to you.

1. Coverage
How important is it for my exact prescription drugs to be on the formulary?

Very important
Somewhat important (I am willing to discuss alternative drugs with my doctor.)
Not at all important (I will ask my doctor for alternative drugs if they are available.)

How important is it that I have prescription drug coverage in the coverage gap?
Very important (I have high drug costs.)
Somewhat important
Not at all important (I do not expect to reach the coverage gap this year.)

How important is it that I have prescription drug coverage for drugs not covered by Medicare (known as excluded drugs)?
Very important
Somewhat important
Not at all important


2. Cost
To pay for my prescription drugs, I prefer to pay most of my costs:
Through a predictable but higher monthly premium, combined with a lower coinsurance or copay at the point that I have a prescription filled
Through a higher coinsurance or copay at the point that I have a prescription filled, combined with a lower monthly premium

Tip
A predictable but higher monthly premium combined with lower coinsurance or copays may be best if you have high drug costs.
A higher coinsurance or copay combined with a lower monthly premium may be best if you have fewer prescriptions and lower drug costs.

How important is the total amount that I must pay each year for prescription drugs?
Very important
Somewhat important
Not at all important

What level of monthly prescription drug premium am I willing to/able to pay?
$0 per month (I do not want to pay a premium.)
$1 – $15 per month
$16 – $30 per month
More than $30 per month

What level of annual deductible am I willing to pay before I begin to receive my Medicare prescription drug benefit?
$0 (I do not want to pay a deductible.)
$1 – $150
$151 – $265

Would I prefer to pay a flat copay or a percentage coinsurance on each prescription?
A flat copay (such as $10 or $20)
A percentage coinsurance based on the price of the prescription drug


3. Convenience
How important is it that I keep my same pharmacy?
Very important (I am not willing to change my pharmacy.)
Somewhat important
Not at all important (I am willing to change my pharmacy.)

How important is it that I have access to network pharmacies in other cities and towns?
Very important (I need a national pharmacy network so I can use a pharmacy if I travel.)
Somewhat important
Not at all important

How important is it that I be able to get an extended supply of my medication(s) (e.g., a 90-day supply) at a reduced cost either from my local pharmacy or by mail order?
Very important
Somewhat important
Not at all important


Step 2: Determine Your Priorities

I want to:

Pay a higher monthly premium, but a lower copay or coinsurance on each prescription
Pay a higher copay or coinsurance on each prescription, but a lower monthly premium

Check the 3 options that are MOST important to you and also the 3 that are LEAST important to you.

IMPORTANCE
  
MOST
LEAST
  
 My exact drugs are on the formulary
 Coverage in the coverage gap
 Coverage for excluded drugs
 Total amount I must pay each year for prescriptions
 My monthly prescription drug premium
 My annual prescription drug deductible
 Paying a flat copay on each drug instead of a percentage coinsurance
 Keeping my same pharmacy
 Having access to network pharmacies when I travel
 Having access to extended supplies of my prescription drugs


Step 3: Plan Comparison Worksheet
ABOUT ME

Please check the boxes that apply to you:
I am eligible for or enrolled in Medicare now. OR
I will be eligible for Medicare in the coming year.
I qualify for extra help for my Medicare prescription drug costs. OR
I do not qualify for extra help for my Medicare prescription drug costs.

Name(s) of current health and prescription drug insurance. (If you are not certain, look at the card(s) you use when you go to the doctor and pharmacy.)


I currently spend $ per month OR $ per year on prescription drugs.

Tip If you do not know all your drugs and how much you spend, ask your pharmacy if it can give you this information. Ask for your drug history and costs for the last 12 months.


What am I willing to/able to pay for my Medicare drug benefit?

Monthly Prescription Drug Premium
$0 per month (I will pay higher copays for my drugs)
$1 – $15 per month
$16 – $30 per month
More than $30 per month

Annual Deductible
$0 per year (I do not want to pay an annual deductible)
$1 – $150 per year
$151 – $265 per year

Copay or Coinsurance
Flat copay for each prescription
Percentage coinsurance for each prescription, based on the price of the drug

My Other Priorities


My Pharmacy (Name):


My Stand-Alone Drug Plan Choices

For this section, you will need your red, white, and blue Medicare card, and any other current health insurance card you may have.

Go to medicare.gov to find information on the Stand-Alone Medicare Prescription Drug Plans (PDPs) in your community. Click on the “Compare Medicare Prescription Drug Plans” link. From there, follow the instructions to find up to four prescription drug plans that suit your needs based on your coverage, cost, and convenience priorities. Record what you want or are able to pay and then how much you would pay with each of the plans in the spaces below.

IMPORTANT!
None of the fields below is required, so if you don't have all of the information, don't worry! You'll be able to print out the form and fill in the rest of it later.


   Plan 1  Plan 2  Plan 3  Plan 4
Stand-Alone Drug Plan Name
Monthly Drug Premium
$ $ $ $
Annual Deductible
 $ $ $ $
Copay/Coinsurance
My Other Priorities        
Is my pharmacy in the plan network?


Finally, enter the prescription drugs you are currently taking, and calculate the cost of a 30-day supply under each plan.

 My Prescription Drugs  Plan 1  Plan 2  Plan 3  Plan 4
 
Cost for a 30-day Supply
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $
Drug Name
Dosage
How Often
$ $ $ $

Click the print button below to print out this page for your records. This will be helpful when you prepare to sign up for a plan.

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Once you have printed this page, click on the ‘next' button to learn about “How to Enroll”.
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