FAQ for Beneficiaries
What is Medicare Prescription Drug Coverage (Part D)?
The Part D drug benefit (also known as “Medicare Rx”) helps Medicare beneficiaries pay for outpatient prescription drugs purchased at retail, mail order, home infusion and long-term care pharmacies.
Unlike Parts A and B, which are administered by Medicare itself, Part D is “privatized.” That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy (i.e., enroll in a plan) offered by one of these companies.
The costs associated with Medicare Part D include a monthly premium, an annual deductible (sometimes waived by the plans), co-payments and co-insurance for specific drugs, a gap in coverage called the “Donut Hole,” and catastrophic coverage once a threshold amount has been met.
Qualified low income individuals can receive help with their Part D costs for premiums, deductibles and co-pays through the Part D Low Income Subsidy (or “Extra Help”), which is administered by the Social Security Administration.
For more information on Medicare Part D, visit http://www.medicare.gov/part-d/index.html
How do I sign up for Medicare Prescription Drug Coverage?
Open Enrollment for 2013
The Annual Open Enrollment for Medicare prescription drug coverage (Part D) was October 15, 2012 – December 7, 2012. This is the one time each year that all people with Medicare can join or change their Medicare drug plan. Plans are making changes to benefits and costs, and there are also new plans in many areas of the country. In 2013, people who enter the coverage gap (“donut hole”) will pay 47.5% of the cost of brand-name drugs on their plan’s formulary while they are in the gap and 79% of the cost of generics on their formularies while they are in the gap. With these changes, your current plan may or may not be the best plan for you in 2013. It is very important to use this time period to compare your plan choices and find the plan that best meets your prescription drug needs at the lowest cost. All plans will make changes in 2013.
How can I get help to pay the costs of Medicare Prescription Drug Coverage?
Extra Help (also known as the Low-Income Subsidy) is available for those who meet certain income and resource limits. If you are eligible, Extra Help can mean significant cost savings on your prescription drugs.
To determine if you or someone you know is eligible: visit www.BenefitsCheckUp.org or call Social Security at 1-800-772-1213/1-800-325-0778(TTY).
If I received Extra Help last year, will I get it this year?
Changes for qualifying for Extra Help in 2012 [PDF] explains changes for those who automatically qualify and those who applied and qualified for Extra Help. Also explains changes in copayments and the process the Social Security Administration uses to review the continued eligibility of those who applied and qualified.
What to do if you no longer automatically qualify for Extra Help with Medicare prescription drug costs: [PDF]
What if I am having a problem with my Medicare prescription drug plan?
You have the right to get a written explanation from your Medicare drug plan if:
• Your doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor.
• You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.
You also have the right to ask your Medicare drug plan for an exception if:
• You believe you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;” or
• You believe you should get a drug you need at a lower cost-sharing amount.
What you need to do:
• Contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.
• Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan.
• When you contact your Medicare drug plan, be ready to tell them:
1. The prescription drug(s) that you believe you need.
2. The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.
3. The date you were told that the prescription drug(s) is not covered.
What if I sign up late for Medicare Prescription Drug Coverage?
The late enrollment penalty is an amount that is added to a person’s Part D premium.
A person enrolled in a Medicare drug plan may owe a late enrollment penalty if one of the following is true:
- He or she didn’t join a Medicare drug plan when first eligible for Medicare Part A and/or Part B, and he or she didn’t have other creditable prescription drug coverage that met Medicare’s minimum standards.
- He or she had a break in Medicare prescription drug coverage or other creditable coverage of at least 63 days in a row.
The late enrollment penalty (also called the “LEP” or “penalty”) is added to the person’s monthly Part D premium for as long as he or she has Medicare prescription drug coverage. This penalty is required by law and is designed to encourage people to join a Medicare drug plan when they’re first eligible or to keep other creditable prescription drug coverage.
The late enrollment penalty amount changes each year. The person will have to pay it each month as long as he or she has Medicare prescription drug coverage, even if the person changes his or her Medicare drug plan.
How can I save money during the ‘Coverage Gap’?
Most Medicare Prescription Drug Plans (Part D) have a temporary limit what they cover for prescription drugs. This limit is called the “coverage gap” (also known as the “donut hole”).