Medicare Part D

Medicare Part D
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Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.[1]


Program specifics

Eligibility and enrollment

Individuals are eligible for prescription drug coverage under a Part D plan if they are entitled to benefits under Medicare Part A and/or enrolled in Part B. Beneficiaries can obtain the Part D drug benefit through two types of private plans: they can join a Prescription Drug Plan (PDP) for drug coverage only or they can join a Medicare Advantage plan (MA) that covers both medical services and prescription drugs (MA-PD).[2] The latter type of plan is actually part of Medicare Part C and has several other differences relative to original Medicare. About two-thirds of Part D beneficiaries are enrolled in a PDP option.[3] Not all drugs will be covered at the same level, giving participants incentives to choose certain drugs over others. This is often implemented via a system of tiered formularies in which lower-cost drugs are assigned to lower tiers and thus are easier to prescribe or cheaper.

Dual eligibles (those also eligible for Medicaid benefits) were transferred from Medicaid prescription drug coverage to a Medicare Part D plan on January 1, 2006. They are automatically enrolled in one of the less expensive PDPs in their area, chosen at random. If the dual-eligible person is already enrolled in an MA-PD plan, then they are automatically removed from the MA plan upon enrollment in a PDP.

Most Medicare beneficiaries must affirmatively enroll in a Part D plan to participate. Annual enrollment periods last from November 15 to December 31 of the prior plan year. This changes in 2011, when the enrollment period will last from October 15 to December 7.[2] Medicare beneficiaries who were eligible but did not enroll during the enrollment period must pay a late-enrollment penalty (LEP) to receive Part D benefits. This penalty is equal to 1% the national average premium times the number of full calender months that they were eligible but not enrolled in Part D. The penalty raises the premium of Part D for beneficiaries, when and if they should elect coverage.[4]

Enrollment in Part D as of April 2010 was 27.6 million beneficiaries.[2] In 2010, there were 1,576 stand-alone Part D plans available, down from 1,689 plans in 2009. The number of available plans varied by region. The lowest was 41 (Alaska & Hawaii) and the highest was 55 (Pennsylvania & West Virginia).[3] This allows participants to choose a plan that best meets their individual needs. Plans are required to offer the "standard" benefit or one actuarially equivalent, or they may offer more generous benefits. Medicare has made available an interactive online tool called the Medicare Plan Finder that allows for comparison of coverage and costs for all plans in a geographic area. The tool allows one to enter a list of medications along with pharmacy preferences. It can show the beneficiary's total annual costs for each plan along with a detailed breakdown of the plans' monthly premiums, deductibles, and prices for each drug during each phase of the benefit design. Plans are required to update this site with current prices and formulary information every other week throughout the year.

Costs to beneficiaries

Beneficiary cost sharing (deductibles, coinsurance, etc.)

The MMA establishes a standard drug benefit that Part D plans must offer. The standard benefit is defined in terms of the benefit structure and not in terms of the drugs that must be covered. In 2010, the standard benefit requires payment of a $310 deductible, then 25% coinsurance drug costs up to an initial coverage limit of $2,830. Once this initial coverage limit is reached, the beneficiary must pay the full cost of his/her prescription drugs up until the total out-of-pocket expenses reach $4,550 (excluding premiums). This coverage gap existing between the initial coverage limit and the catastrophic coverage limit is referred to more commonly as the "Donut Hole". Once the beneficiary reaches catastrophic coverage, he or she pays the greater of 5% coinsurance, or $2.50 for generic drugs and $6.30 for brand-named drugs. The catastrophic coverage amount is calculated on a yearly basis, and a beneficiary who reaches catastrophic coverage by December 31 of one year will start his or her deductible anew on January 1.[2]

The standard benefit is not the most common benefit offered by Part D plans. Only 11 percent of PDPs for 2010 offer the defined standard benefit. Plans vary widely in their formularies and cost-sharing requirements. Most eliminate the deductible and use tiered drug co-payments rather than coinsurance.[2] The only out-of-pocket costs that count toward getting out of the coverage gap and into catastrophic coverage are True Out-Of-Pocket (TrOOP) expenditures. TrOOP expenditures accrue only when drugs on plan's formulary are purchased in accordance with the restrictions on those drugs. Monthly premium payments do not count towards TrOOP.

Among Medicare Part D enrollees in 2007 who were not eligible for low-income subsidies, 26% had spending high enough to reach the coverage gap. Fifteen percent of those reaching the coverage gap (4% overall) had spending high enough to reach the catastrophic coverage level. Enrollees reaching the coverage gap stayed in the gap for just over four months on average.[5] In 2010, 80% of PDPs offered no coverage within the Donut Hole, and almost all the remaining 20% of plans limited gap coverage to generic drugs.[3]

Under the Patient Protection and Affordable Care Act of 2010, the "Donut Hole" coverage gap will be gradually eliminated through a combination of measures including brand-name prescription drug discounts, generic drug discounts, and a gradual decrease in the "catastrophic coverage" threshold. The "Donut Hole" coverage gap is due to be completely eliminated by 2020.[6]

Most plans use specialty drug tiers, and some have a separate benefit tier for injectable drugs. Beneficiary cost sharing can be higher for drugs in these tiers.[7]

Beneficiary premiums

The average (weighted) monthly premium for PDPs was $35.09 in 2009, which is an increase from $29.89 in 2008. Premiums are projected to increase to $38.94 for 2010 as well.[3] In 2007, eight percent of beneficiaries enrolled in a PDP chose one with some gap coverage. Among beneficiaries in MA-PD plans, enrollment in plans offering gap coverage was 33% (up from 27% in 2006).[8] Premiums are significantly higher for plans with gap coverage. Major Part D plan sponsors are dropping their more expensive options, and developing lower cost ones.[9]

Low-income subsidies

One option for those struggling with drug costs is the low-income subsidy. Beneficiaries with income below 150% poverty are eligible for the low-income subsidy, which helps pay for all or part of the monthly premium, annual deductible, and drug co-payments. The Centers for Medicare and Medicaid Services (CMS) estimated that 12.5 million Part D beneficiaries were eligible for low-income subsidies in 2009.[2]

The subsidy award is given a level with the following effects:[citation needed]

Level Deductible Generic Copay Brand Copay Catastrophic Coverage
1 $0 $2.50 $6.30 $0 copays on all meds
2 $0 $1.10 $3.30 $0 copays on all meds
3 $0 $0 $0 $0 copays on all meds
4 $63 max 15% 15% $2.50 Generic & $6.30 Brand copays

Note: A common source of confusion; When the award letters were sent out for 2006 and 2007 subsidies the wording referred to a plan’s premium being paid for 100%. In actuality the amount paid is usually matched to the amount charged for the basic plan offered by the carrier. If this is the plan the customer has then, as expected, the premium is paid for. If the member has selected other than the most basic level of coverage then the premium will likely be higher than the amount paid for by the subsidy. This may result in the member being charged a monthly amount while thinking they have no monthly bill.

Excluded drugs

While CMS does not have an established formulary, Part D drug coverage excludes drugs not approved by the Food and Drug Administration, those prescribed for off-label use, drugs not available by prescription for purchase in the United States, and drugs for which payments would be available under Parts A or B of Medicare.[10]

Part D coverage excludes drugs or classes of drugs which may be excluded from Medicaid coverage. These may include:

  • Drugs used for anorexia, weight loss, or weight gain
  • Drugs used to promote fertility
  • Drugs used for erectile dysfunction
  • Drugs used for cosmetic purposes (hair growth, etc.)
  • Drugs used for the symptomatic relief of cough and colds
  • Barbiturates
  • Benzodiazepines
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Drugs where the manufacturer requires as a condition of sale any associated tests or monitoring services to be purchased exclusively from that manufacturer or its designee

While these drugs are excluded from basic Part D coverage, drug plans can include them as a supplemental benefit, provided they otherwise meet the definition of a Part D drug. However plans that cover excluded drugs are not allowed to pass on those costs to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.[11]

Plan formularies

Part D plans are not required to pay for all covered Part D drugs.[12] They establish their own formularies, or list of covered drugs for which they will make payment, as long as the formulary and benefit structure are not found by CMS to discourage enrollment by certain Medicare beneficiaries. Part D plans that follow the formulary classes and categories established by the United States Pharmacopoeia will pass the first discrimination test. Plans can change the drugs on their formulary during the course of the year with 60 days notice to affected parties.

Typically, each Plan's formulary is organized into tiers, and each tier is associated with a set copay amount. Most formularies have between 3 and 5 tiers. The lower the tier, the lower the copay amount. For example, Tier 1 might include all of the Plan's preferred generic drugs, and each drug within this tier might have a copay of $5–10 per prescription. Tier 2 might include the Plan's preferred brand drugs with a copay of $20–$30, while Tier 3 may be reserved for non-preferred brand drugs which are covered by the plan at a higher copay level - perhaps $40–$100. Tiers 4 and higher typically contain specialty drugs, which have the highest copays because they are generally quite expensive.

The Plan's tiered copay amounts for each drug only apply during the initial period before the coverage gap. Once in the coverage gap, also known as the Donut Hole, the person must pay for 100% of the prescription costs, based on prices established by the Plan. In 2008, 4% of Medicare beneficiaries spent enough to qualify for catastrophic coverage at which point the beneficiary pays 5% of the total drug cost or a co-payment of $2 for generics/preferred drugs and $5 for brand-name drugs, whichever is greater. In 2009, Plans reach catastrophic coverage when the beneficiary reaches $6,154 in total drug costs.[13]

The primary differences between the formularies of different Part D plans relate to the coverage of brand-name drugs. Nine out of the ten plans with the highest enrollment increased the number of drugs on their formularies in 2007. Plans have generally made fewer changes for 2008. One exception is Silverscript (Caremark Rx), which significantly increased the number of drugs on its 2008 formulary.[14]

Number of participants

At the start of the program in January 2006, it was expected that eleven million people would be covered by Medicare Part D; of those, six million would be dual eligible. About two million people who were covered by employers would likely lose their employee benefits.

As of January 30, 2007, nearly 24 million individuals were receiving prescription drug coverage through Medicare Part D (PDPs and MA-PDs combined), according to CMS.[15] There are other methods of receiving drug coverage when enrolled in Medicare, including the Retiree Drug Subsidy (RDS), Federal retiree programs such as TRICARE and Federal Employees Health Benefits Program (FEHBP) or alternative sources, such as the Department of Veterans Affairs. Including people in these categories, more than 39 million Americans are covered for prescriptions.

As of April 2006, the primary private insurance plans providing Medicare Part D coverage were UnitedHealth with 3.8 million subscribers, or 27 percent of the total, Humana with 2.4 million, or 18 percent, and WellPoint with 1 million, or 7 percent. Companies with the next largest shares were MemberHealth, with 924,100 subscribers (7 percent); WellCare Health Plans, with 849,700 (6 percent); and Coventry Health Care, with 596,100 (4 percent).[16] CMS offers updated enrollment numbers on their website.[17]

Program costs

As of the end of year 2008, the average annual per beneficiary cost spending for Part D, reported by the Department of Health and Human Services, was $1,517,[18] making the total expenditures of the program for 2008 $49.3 (billions). Projected net expenditures from 2009 through 2018 are estimated to be $727.3 billion.[19]

Implementation issues

  • Plan and Health Care Provider goals are not aligned: PDP's and MA's are rewarded for focusing on low cost drugs to all beneficiaries, while Providers are rewarded for quality of care – sometimes involving expensive technologies.
  • Conflicting goals: Plans are required to have a tiered exemptions process for beneficiaries to get a higher-tier drug at a lower cost, but plans must grant exception when medically necessary. However, the rule denies beneficiaries the right to request a tiering exception for certain high-cost drugs.[citation needed]
  • Lack of standardization: Drugs appearing on Tier 2 in one plan may be on Tier 3 in another. Tier 2 drugs may have a different co-pay with different plans. There are plans with no deductibles and the coinsurance for the most expensive drugs varies widely. Some plans may insist on step therapy, which means that the patient must use generics first before the company will pay for higher priced drugs. There is an appeal process, but the burden is on the beneficiary, as the insurer will not pay for the desired drug during the appeal process.
  • Standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.[20]

Impact on beneficiaries

One study published in April 2008 found that the percentage of Medicare beneficiaries who reported forgoing medications due to cost dropped after the implementation of Medicare Part D, from 15.2 percent in 2004 and 14.1 percent in 2005 to 11.5 percent in 2006. The percentage who reported skipping other basic necessities to pay for drugs also dropped, from 10.6 percent in 2004 and 11.1 in 2005 to 7.6 percent in 2006. Among the very sickest beneficiaries there was no reduction in the percentage who reported skipping medications, but fewer reported forgoing other necessities to pay for their medicines.[21][22] A second study appearing in the same issue of JAMA found that not only did Medicare beneficiaries enrolled in Part D still skip doses or switch to cheaper drugs, many do not understand the program.[21] Another study found that the Medicare Part D prescription benefit resulted in modest increases in average drug utilization and decreases in average out-of-pocket expenditures among Part D beneficiaries [23] Further studies by the same group of researchers indicate that the net impact of Medicare Part D among beneficiaries is a decrease in the use of generic drugs, which is consistent with economic theory, and shows how assessing Medicare Part D is complex [24]. A further study concludes that although there was a substantial reduction in out-of-pocket costs and a moderate increase in medication utilization among Medicare beneficiaries during the first year after Part D, there was no evidence of improvement in emergency department use, hospitalizations, or preference-based health utility for those eligible for Part D during its first year of implementation.[25] It was also found that there were no significant changes in trends in the dual eligibles' out-of-pocket expenditures, total monthly expenditures, pill-days, or total number of prescriptions due to Part D.[26]


By the design of the program, the federal government is not permitted to negotiate prices of drugs with the drug companies, as federal agencies do in other programs. The Department of Veterans Affairs, which is allowed to negotiate drug prices and establish a formulary, pays 58% less for drugs, on average, than Medicare Part D[not in citation given].[27] For example, Medicare pays $785 for a year's supply of Lipitor (atorvastatin), while the VA pays $520.

Former Congressman Billy Tauzin, R-La., who steered the bill through the House, retired soon after and took a $2 million a year job as president of Pharmaceutical Research and Manufacturers of America (PhRMA), the main industry lobbying group. Medicare boss Thomas Scully, who threatened to fire Medicare Chief Actuary Richard Foster if he reported how much the bill would actually cost, was negotiating for a new job as a pharmaceutical lobbyist as the bill was working through Congress.[28][29] A total of 14 congressional aides quit their jobs to work for the drug and medical lobbies immediately after the bill's passage.

In response, the Manhattan Institute, a free-market think tank, which, according to the Capital Research Center, receives funding from a large number of private interests including pharmaceutical companies,[30] issued a report by Frank Lichtenberg, a business professor at Columbia University, that said the VA National Formulary excludes many new drugs. Only 38% of drugs approved in the 1990s and 19% of the drugs approved since 2000 are on the formulary. He also argues that the life expectancy of veterans "may have declined" as a result.[31]

Paul Krugman disagreed, comparing patients in the Medicare Advantage plans, which are administered by private contractors with a subsidy of 11% over traditional Medicare, to the VA system: mortality rates in Medicare Advantage plans are 40% higher than mortality of elderly veterans treated by the V.A., said Krugman, citing the Medicare Payment Advisory Commission.[32]

The plan requires Medicare beneficiaries whose total drug costs reach $2,700 to pay 100% of prescription costs until $4,350 is spent out of pocket. (The actual threshold amounts will change year-to-year and plan-by-plan, and many plans offer limited coverage during this phase.) This coverage gap is known as the "Donut Hole." While this coverage gap will not affect the majority of program participants, about 25% of beneficiaries enrolled in standard plans find themselves without prescription drug coverage for much of the plan year [33]. However, the Washington Post reports that upwards of 80% of enrollees are satisfied with their coverage, despite the fact that nearly half had chosen plans that do not cover the "donut hole."[34] Medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Most respondents aren't sick, so they don't need medical care, so they're usually satisfied. The only respondents who can evaluate care are respondents who are sick, who are usually a minority.[35]

Critics, such as Ron Pollack, executive director of Families USA, said in late 2006 that even the satisfied enrollees wouldn't be so satisfied the next year when the prices go up.[36] However, a survey released by the AARP in November 2007 found that 85% of enrollees reported being satisfied with their drug plan, and 78% said that they had made a good choice in selecting their plan.[37]

According to a January 2006 article by Trudy Lieberman of Consumers Union, consumers can have up to 50 choices, in hundreds of combinations of deductibles, co-insurance (the percentage consumers pay for each drug); drug utilization techniques (trying cheaper drugs first); and drug tiers, each with their own co-payments (the flat amount consumers pay for each drug). Co-payments differ on whether people buy generic drugs, preferred brands, non-preferred brands or specialty drugs, and whether they buy from an in-network or out-of-network pharmacy. There is no standard nomenclature, so sellers can call the plan anything they want. They can also cover whatever drugs they want.[38]

As a candidate, Barack Obama proposed "closing the 'doughnut hole'" in his campaign agenda, and subsequently proposed a plan to reduce costs for recipients from 100% to 50% of these expenses.[39] The cost of the plan would be borne by the drug manufacturers for name-brand drugs and by the government for generics.[39]

Some enrollees criticize the Medicare Plan Finder as complex to use, especially for many Medicare beneficiaries who have limited computer skills and Internet access. While the use of this tool is essential for people to make an informed choice based on actual costs for each plan it provides no benefit for those dual eligibles who are assigned to plans randomly. However, dual eligibles have the right to switch plans every month in order to enroll in a plan that better meets their prescriptions needs and for beneficiaries that aren't dual-eligible, most health insurance agents and brokers or social workers can help find the best plan for those individuals. CMS funds a national program of counselors to assist all Medicare beneficiaries, including duals, with their plan choices. The program is called State Health Insurance Assistance Program (SHIP).[40]

See also


  1. ^ Prescription Drug Coverage - General Information: Overview
  2. ^ a b c d e f "Medicare: A Primer," Kaiser Family Foundation, April 2010.
  3. ^ a b c d Jack Hoadley, Juliette Cubanski, Elizabeth Hargrave, Laura Summer, and Tricia Neuman, "Medicare Part D Spotlight: Part D Plan Availability in 2010 and Key Changes Since 2006," Kaiser Family Foundation, November 2009
  4. ^ "Medicare Support Center: Late Enrollment Penalty (LEP)," Oct. 15, 2009
  5. ^ Jack Hoadley, Elizabeth Hargrave, Juliette Cubanski and Tricia Neuman, "The Medicare Part D Coverage Gap: Costs and Consequences in 2007," Kaiser Family Foundation, August 21, 2008
  6. ^ Healthcare Reform: The Doughnut Hole and Me (Part II),
  7. ^ Elizabeth Hargrave, Jack Hoadley, Katie Merrelli, and Juliette Cubansk, "MEDICARE PART D 2008 DATA SPOTLIGHT:SPECIALTY TIERS," The Kaiser Family Foundation, December 2007
  8. ^ Jack Hoadley, Jennifer Thompson, Elizabeth Hargrave, Katie Merrell, Juliette Cubanski and Tricia Neuman "MEDICARE PART D 2008 DATA SPOTLIGHT: The Coverage Gap," Kaiser Family Foundation, November 2007
  9. ^ Jack Hoadley; Elizabeth Hargrave and Katie Merrell; and Juliette Cubanski and Tricia Neumani, "MEDICARE PART D 2008 DATA SPOTLIGHT:PREMIUMS," The Kaiser Family Foundation, November 2007
  10. ^ Relationship between Part B and Part D Coverage
  11. ^ Report on the Medicare Drug Discount Card Program Sponsor McKesson Health Solutions, A-06-06-00022
  12. ^ Medicare Part D / Prescription Drug Benefits: PART D COVERED DRUGS,
  13. ^ Brian Joyce and Denys Lau, PhD, "Medicare Part D Prescription Drug Benefit: An Update," Buehler Center on Aging, Health & Society Newsletter, Volume 22, Number 2, Winter 2009
  14. ^ Jack Hoadley, Elizabeth Hargrave, Katie Merrell, Juliette Cubanski and Tricia Neuman, "MEDICARE PART D 2008 DATA SPOTLIGHT: FORMULARIES M," the Kaiser Family Foundation, January 2008
  15. ^ "MEDICARE DRUG PLANS STRONG AND GROWING," Centers for Medicare and Medicaid Services (CMS) Press Release, Tuesday, January 30, 2007
  16. ^ Pear, Robert (April 29, 2006). "In Scramble for New Medicare Business, a Few Insurers Grab the Most". The New York Times. Retrieved May 12, 2010. 
  17. ^[dead link]
  19. ^ 2009 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS, Table III.C19.—Operations of the Part D Account in the SMI Trust Fund (Cash Basis) during Calendar Years 2004-2018, Page 120 (Page 126 in pdf)
  20. ^ The Institute of Medicine (2006). "Preventing Medication Errors". The National Academies Press. Retrieved 2006-07-21. 
  21. ^ a b Amanda Gardner, "Medicare Prescription Drug Benefit Shows Mixed Results," The Washington Post, April 22, 2008
  22. ^ Jeanne M. Madden et al., "Cost-Related Medication Nonadherence and Spending on Basic Needs Following Implementation of Medicare Part D," Journal of the American Medical Association, 2008;299(16):1922–1928
  23. ^ Yin W, Basu A, Zhang J, Rabbani A, Meltzer DO, Alexander GC, "The Effect of the Medicare Part D Prescription Benefit on Drug Utilization and Expenditures"
  24. ^ Zhang J, Yin W, Sun S, Alexander GC. Impact of the Medicare Prescription Drug Benefit on the use of generic drugs. Journal of General Internal Medicine. 2008;23:1673-1678.
  25. ^ Liu, FX; Alexander GC, Crawford SY, Pickard AS, Hedeker D, Walton SM (August 2011). "The impact of Medicare Part D on out-of-pocket costs for prescription drugs, medication utilization, health resource utilization, and preference-based health utility". Health Services Research 46 (4): 1104–1123. doi:10.1111/j.1475-6773.2011.01273.x. PMID 21609328. Retrieved 11/9/2011. 
  26. ^ Basu, A; Yin W, Alexander GC (February 2010). "Impact of Medicare Part D on Medicare-Medicaid dual-eligible beneficiaries' prescription utilization and expenditures.". Health Services Research. 1 45: 133–151. PMID 20002765. Retrieved 11/10/2011. 
  27. ^ Medicare Part D patients pay more for drugs than veterans
  28. ^ Under The Influence: 60 Minutes' Steve Kroft Reports On Drug Lobbyists' Role in Passing Bill That Keeps Drug Prices High. Lists Senators and Congress members who went on to high-paying jobs as pharmaceutical industry lobbyists after voting for Medicare Part D.
  29. ^ The K Street Prescription, By Paul Krugman, New York Times, January 20, 2006. Some conservatives insist that the Part D debacle vindicates their ideology, and demonstrates that the government can't do anything right. But government works when it's run by people who take public policy seriously. This bill was written by people like Scully and Tauzin who used undue influence to favor their future employers.
  30. ^ Manhattan Institute for Policy Research, SourceWatch[unreliable source?]
  31. ^ Older Drugs, Shorter Lives?: An Examination of the Health Effects of the Veterans Health Administration Formulary
  32. ^ Health Policy Malpractice, Paul Krugman, New York Times, September 4, 2006.
  33. ^ Zhang Y, Donohue JM, Newhouse JP, Lave JR. The effects of the coverage gap on drug spending: a closer look at Medicare Part D. Health Affairs. 2009 Mar-Apr;28(2):w317-25.
  34. ^ Success of Drug Plan Challenges Democrats; Medicare Benefit's Cost Beat Estimates, By Lori Montgomery and Christopher Lee, Washington Post, November 26, 2006
  35. ^ Capital: In health care, consumer theory falls flat, David Wessel, Wall Street Journal, September 7, 2006. Researchers at Rand Corp. and Department of Veterans Affairs asked 236 elderly patients at 2 managed care plans about to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care area easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chan, UCLA, lead author.
  36. ^ Group Says Gap in Medicare Drug Coverage Will Be Costly, By Christopher Lee, Washington Post, November 2, 2006.
  37. ^ Teresa A. Keenan, "Prescription Drugs and Medicare Part D: A Report on Access, Satisfaction, and Cost," AARP, November 2007 (News Release: AARP Survey Finds Medicare Drug Plans are Prescription for Healthy Drug Behaviors)
  38. ^ "Part D From Outer Space", by Trudy Lieberman, The Nation, January 30, 2006.
  39. ^ a b "Obama Unveils 'Doughnut Hole' Solution: People who fall in the Part D coverage gap would only pay half the cost of brand-name medications". AARP Bulletin Today. 2009-06-22. 
  40. ^ "State Health Insurance Counseling and Assistance Programs (SHIPs)". Centers for Medicare & Medicaid Services. 


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