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Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. On January 1, 2006, Medicare prescription drug coverage was made available to everyone with Medicare. This drug coverage may help lower prescription drug costs and help protect against higher costs in the future.
You can get Medicare prescription drug coverage in the following ways:
You can choose and join the Medicare drug plan that works for you. You will pay a monthly premium. All drug plans must provide coverage that is at least as good as the standard Medicare has established. Some plans might offer more coverage and additional drugs for higher monthly premiums. If you decide not to join a Medicare drug plan when you are first eligible, you may have to pay a penalty if you decide to join later.
If you have low income and resources, you may qualify for extra help. Most people who qualify for this extra help will pay reduced, or no, premiums, a reduced, or no, deductible, and lower copayments of no more than $6 for each prescription. The amount of extra help depends on your income and resources. If you qualify, you will need to join a plan to get drug coverage. If you apply and qualify, and don’t join a plan, Medicare will enroll you in one by December 31, 2010 to make sure you get this important coverage.
If you already have prescription drug coverage, you should talk to your plan, benefits administrator, or insurer before making any changes. You will be notified about any changes in your current coverage so you can decide if you should join a Medicare drug plan.
You should still consider joining a Medicare drug plan. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay the lowest possible monthly premium. If you don’t join a plan by December 31, 2009, and you don’t currently have prescription drug coverage through another source such as an employer or union, you will have to wait until the next open enrollment period. When you do join, your premium cost will be 1% higher per month for every month that you wait to join. You will pay this penalty as long as you have Medicare prescription drug coverage. For example: if you join by December 31, 2009, your coverage will begin January 1, 2010.
For more information on Medicare prescription drug coverage, read the “Medicare & You” handbook mailed to you in October. It will list the specific plans available in your area. After October, if you need help:
Generally if you join a Medicare Prescription Drug Plan, you can only change plans under certain circumstances. You can choose to switch your current plan from November 15 through December 31 of every year.
Enrollment is generally for the calendar year. In certain cases, such as if you move or enter a nursing home, you can switch your plan at other times.
If you have both Medicare and Medicaid, you have more flexibility in switching plans.
For personalized assistance, you can call your State Health Insurance Assistance Program (see your copy of the “Medicare & You” handbook for their telephone number). The handbook will be available to you beginning in October. You can also visit www.medicare.gov on the web or call 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Look for information about events in your local newspaper or listen for information on the radio. You can also get personalized counseling by calling your local office on aging. For the telephone number, visit www.eldercare.gov on the web.
If you already have prescription drug coverage through a Medicare private health plan or other insurance, check with your current plan to see if this coverage is changing. Your plan or insurer will notify you in the fall of 2009 to let you know if your coverage pays, on average, at least as much as standard Medicare prescription drug coverage or if it is changing.
Talk to a family member, friend, or other caregiver to help you decide what drug coverage meets your needs. You may also:
No. Joining a Medicare drug plan is your choice.
You can join a Medicare Prescription Drug Plan in the following ways:
By paper application. Contact the company offering the drug plan you choose and ask for an application. Once you fill out the form, mail or fax it back to the company.
On the plan’s website. Visit the drug plan’s Web site to see if you can enroll online.
On Medicare’s website. You will also be able to enroll in a plan at www.medicare.gov on the web using Medicare’s online enrollment center.
By calling 1-800-MEDICARE. You can enroll by calling 1-800-MEDICARE (1-800-633-4227) and talking to a Medicare customer service representative. TTY users should call 1-877-486-2048.
In general, these are the ways you can pay your Medicare drug plan premiums:
The open enrollment period is November 15 to December 31 of each year. In most cases, if you don't join between these dates, and you didn’t have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage, you will have to wait until open enrollment to join. When you do join, your premium cost will go up at least 1% per month for every month that you wait to join. You must pay this penalty as long as you have Medicare prescription drug coverage. If you join during open enrollment, your coverage will begin January 1st of the following year.
You will be able to join November 15 to December 31 of each year. Your coverage would begin January 1 of the following year. If you choose not to join when you are first eligible and later change your mind, you could pay a penalty.
When you get Medicare prescription drug coverage, you pay part of the costs and Medicare pays part of the costs. You pay a premium each month to join the drug plan. If you have Medicare Part B, you also pay your monthly Part B premium. If you belong to a Medicare Advantage Plan or Medicare Cost Plan, the monthly premium you pay to the plan may increase if you add prescription drug coverage.
Your costs will vary depending on which plan you choose. Your plan must, at a minimum, provide a standard level of coverage as shown below. Some plans offer more coverage or lower premiums.
Standard Coverage (the minimum coverage drug plans must provide)
If you enroll for 2010, for covered drugs you will pay
Medicare drug plans will cover generic and brand name drugs. Plans may have rules about what drugs are covered in different drug categories to be sure people with different medical conditions can get the treatment they need.
Most plans will have a formulary, which is a list of drugs covered by the plan. This list must always meet Medicare’s requirements, but it can change when plans get new information. Your plan must let you know at least 60 days before a drug you use is removed from the list or if the costs are changing. If your doctor thinks you need a drug that isn’t on the list, or if one of your drugs is being removed from the list, you or your doctor can apply for an exception or appeal the decision.
Medicare Prescription Drug Plans must include at least two drugs in every drug category. The plans must also do the following:
Make a list of all the your current medications, including name, dose size (for example- 2 pills, 300mg in each pill), dosage frequency (for example- 2 times a day) and monthly costs of your current prescriptions. You can use this information to compare the list of drugs (also called a formulary) that are covered under each plan. You can get the list of drugs a plan covers by calling the plan, visiting the plan’s website, or visiting www.medicare.gov on the web.
A formulary is a list of specific drugs a Medicare drug plan will cover. Plans must cover all types of drugs required by Medicare, but within each type it can limit which specific drugs it will cover. It may also charge different cost-sharing amounts for different drugs within a type of drug.
Yes. Your plan must let you know at least 60 days before a drug you use is removed from the list or if the costs are changing. Most plans will have a formulary, which is a list of drugs covered by the plan. This list must always meet Medicare’s requirements, but it can change when plans get new information.
Yes. Medicare Part B will still cover drugs that it covers now (like some cancer drugs) that are usually given out by a doctor in his or her office. Drugs that are not covered under Part A or Part B will, in most cases, be covered under Medicare prescription drug coverage.
Yes. Medicare drug plans will include drugs in all disease categories. They must also have an appeals and exceptions process. That process must include ways to help people who have trouble handling the process themselves.
Yes. Medicare drug plans must cover drugs and/or categories of drugs that are commonly used by seniors and people with disabilities.
A Medicare drug plan is required to offer standard prescription drug coverage, and may choose to offer additional coverage. A standard plan can’t cover benzodiazepines. However, a Medicare drug plan may cover benzodiazepines if it offers more than standard coverage. The premium for these plans will most often be higher than for standard plans.
Yes. Certain drugs are excluded, which means they can’t be provided as part of standard Medicare prescription drug coverage. Some examples of excluded drugs include benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for relief of colds. However, except for non-prescription over-the-counter drugs, a plan can choose to cover excluded drugs if the plan offers more than standard coverage. Non-prescription drugs can’t be included. However, under certain circumstances, they may be provided at no cost.
If you need a drug that is not on the covered drug list, or that is on the list but you think it should be covered for a lower co-payment, you can do the following:
If a drug is found to be unsafe, it will no longer be covered. You will get a written notice from your plan of why the drug is no longer covered, a list of other drugs that are the same type that may be used in its place, and the expected cost. Talk to your doctor about what drug you should take.
If a drug is no longer covered by your Medicare drug plan for non-safety reasons, or if it is covered at a higher cost, your plan must let you know 60 days before the change. If you don’t get a 60-day notice, the plan must let you get a 60-day supply when you get your next refill for the previous cost.
Medicare will help employers or unions continue to provide retiree drug coverage that meets Medicare’s standards.
Your (or your spouse’s) former or current employer or union will send you information about how your current coverage compares to the Medicare standard prescription drug coverage by November 14. This information is important because it can effect the decision you will need to make this fall about if and when you sign up for Medicare prescription drug coverage.
If your (or your spouse’s) employer or union has determined that your current coverage, on average, is at least as good as the Medicare standard prescription drug coverage (called creditable prescription drug coverage):
Caution: If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health coverage.
If your employer or union plan is not as good as Medicare prescription drug coverage, find out about your options from your benefits administrator. You may be able to:
Medicare is working with your Medicare Advantage Plan or other Medicare Health Plan to help them provide even more coverage or lower costs. If you currently have prescription drug coverage from your plan, you will get a notice from your Medicare Advantage Plan or other Medicare Health Plan about your prescription drug choices. Read any materials you get from your plan carefully.
If you don’t have prescription drug coverage, and want to add it, you can:
If you stay in your current plan that isn’t offering drug coverage in 2010, you will have to pay a penalty if you want to switch to a plan that offers prescription drug coverage later.
As long as you still qualify, your TRICARE, VA, or FEHB prescription drug coverage is not changing. You should contact your benefits administrator or FEHB insurer for information about your TRICARE, VA, or FEHB coverage before making any changes. It will almost always be to your advantage to keep your current coverage without any changes. If you lose your TRICARE, VA, or FEHB coverage and you join a Medicare drug plan, in most cases, you won’t have to pay a penalty, as long as you join within 63 days.
Medicare, will pay for your prescription drugs. Medicaid will still cover other care that Medicare doesn’t cover.
You will have continuous Medicare prescription drug coverage and, in most cases, will pay a small amount out of your own pocket. Medicare pays for almost all of the cost of your drugs if you join a Medicare Prescription Drug Plan or a Medicare Advantage Plan or other Medicare Health Plan with Medicare prescription drug coverage.
Compare coverage and choose a plan. Medicare will enroll you in a plan if you do not choose one yourself by October, but you can still compare plans and choose another plan by December 31, 2009. If you decide you want another plan, you can switch to another plan at any time without a penalty.
If you have Medicare and full coverage from Medicaid, and live in an institution (like a nursing home), you will pay nothing for your covered prescription drugs.
To have Medicare help pay for your drugs, you must join a plan that provides Medicare prescription drug coverage. You can choose and join the plan that meets your needs. If you don’t use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you won’t have to pay a penalty if you choose to join later.
Contact your Medigap insurer for information about your policy. If you have your Medigap policy from a current or former employer or union, call your benefits administrator.
If Medicaid covers both your health care and your prescription drugs, you have “full” Medicaid benefits.
No. Since you have both Medicare and full Medicaid coverage, you automatically qualify for extra help and you don’t need to apply.
If you don’t want the plan that Medicare chooses, you can switch any time to another plan that you prefer. Just call the new plan to find out how to join. When you join the new plan your coverage under the old plan will end automatically.
You can call 1-800-MEDICARE (1-800-633-4227) if you don’t want Medicare prescription drug coverage and you don’t want Medicare to enroll you in a plan. However, if you choose to do this, you could be left with no prescription drug coverage as of January 1st because after that date Medicaid will not pay for any drugs that would be covered under a Medicare drug plan.
If you have Medicare and full Medicaid coverage, you can change plans at any time. The change will be effective at the beginning of the next month.
If Medicare covers a prescription drug, Medicaid will not pay for it. However, Medicare drug plans don’t have to cover every drug that’s included in Medicare prescription drug coverage. They only have to cover every type of drug. You should review what drugs are covered by the Medicare drug plans available in your area and try to join one that covers the same prescriptions you take now. If the plan doesn’t cover your exact prescriptions, it’s required to have a transition period where your current drugs may be covered for a certain length of time while you work with your doctor to find an alternative prescription drug to take that is covered by the plan. If your doctor believes you need to take your current prescription drug and should not switch to a covered prescription drug, you or your doctor can contact your plan and ask it to give you an “exception” which means the plan agrees to pay for your current drug. If the plan refuses to give you an exception, you can appeal the plan’s decision.
However, if you are currently stabilized on certain specific prescription drugs (like drugs for depression, cancer or HIV/AIDS), you don’t have to switch to a different prescription drug. Please talk to your doctor or pharmacist to see if your prescription drugs qualify.
When you join, the Medicare drug plan will send you information about its appeal procedures. Read the information carefully and call your plan if you have any questions.
Some state Medicaid programs may choose to cover some or all of the few prescriptions not covered by Medicare prescription drug coverage. Contact your State Medical Assistance Office for more information.
No. State Medicaid programs may provide you with information about certain plans, but they can’t make you join a specific plan.
If the State covers that kind of drug for people who get Medicaid but don’t have Medicare, then Medicaid must still cover that drug for you. You need to check with your state Medicaid program to see if it will cover a drug not covered by Medicare.
Yes. Medicaid no longer covers prescription drugs covered by Medicare prescription drug coverage. If you don’t join a Medicare drug plan Medicare will automatically enroll you in a Medicare drug plan. However, you can choose and join a different plan at any time.
Yes. SPAPs must provide assistance to people eligible for Medicare prescription drug coverage regardless of which Medicare drug plan they join.
People with lower income and resources may qualify for extra help paying for Medicare prescription drug costs. The amount of extra help you get is based on your income and resources. You may qualify if your income is less than $16,245 for single individuals or $21,855 for a married couple living together, and your resources are less than $12,510 if you are single or $25,010 if you are married and living with your spouse.*
*Income levels are for 2009, resource and cost-sharing amounts are for 2009, and will increase each year. The size of your family can also effect whether you qualify based on income. If you live in Alaska or Hawaii, income levels are higher.
You may automatically qualify for extra help.
You may get a letter from Medicare saying that you automatically qualify for extra help and don’t have to fill out the application from the Social Security Administration (SSA).
You automatically qualify for extra help and don’t need to apply if you:
You may apply and qualify for extra help.
If you didn’t automatically qualify, the Social Security Administration (SSA) sent people with certain incomes an application for this extra help. If you got this application, fill it out and send it back to SSA as soon as possible. If you didn’t get an application but think you may qualify, call 1-800-772-1213, visit www.socialsecurity.gov on the web, or apply at your State Medical Assistance office. You can also visit the website to get more information. After you fill out the application from SSA, they will mail you a letter telling you if you qualify for extra help in two to three weeks.
Yes. There is no risk or cost to apply. If you qualify, you will get extra help paying for the annual deductible, premiums, and co-payments for Medicare prescription drug coverage.
You will need your Social Security number and financial information for you and your spouse (if married and living together), including information on deposits in bank accounts, income from pensions, investments or annuities, and face value of life insurance policies to complete the application. However, you should apply even if you think you don’t have all of this information.
Your eligibility will be reviewed every year to see if you still qualify for extra help. If you do qualify, you don’t need to reapply because the review will be sent to you automatically. However, if, in any year we tell you that you don’t qualify, but you think you do, you will have to reapply.
The amount of extra help you get is based on your income and resources. If you automatically qualify for extra help, you will have continuous drug coverage and only pay a small co-payment for each prescription (up to $6.30). Look at your “Medicare & You” handbook for your costs if you apply and qualify for extra help.