Enrolling in Medicare - How Do I Sign up for Medicare Part A & B if I am close to age 65 and get or can get Social Security benefits?


  1. You Already Get Social Security Benefits

    You will not need to do anything. You will be automatically enrolled in Medicare Part A and Part B effective the month you are 65. For example, if your 65th birthday is February 20, 2001, your Medicare effective date would be February 1, 2001. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2001, your Medicare effective date would be January 1, 2001.) Your Medicare card will be mailed to you about 3 months before your 65th birthday. If you do not want Medicare Part B, follow the instructions that come with the card. For complete information on enrollment see the Initial Enrollment Package section.


  2. You Want To Apply for Both Social Security Retirement Benefits and Medicare

    If you are close to age 65 and not yet getting Social Security benefits or Medicare, you can apply for both at the same time. To make sure that your Medicare Part B coverage start date is not delayed, you should apply three months before the month you turn 65. This is the beginning of your 7 month Initial Enrollment Period. If you wait until you are 65, or in the last 3 months of your Initial Enrollment Period, your Medicare Part B coverage start date will be delayed.

    To apply, you can call or visit your local Social Security office or call Social Security at 1-800-772-1213. You can apply online (using the Internet) if you meet certain rules. To apply online, visit www.socialsecurity.gov. You must answer a series of questions that will tell if you can apply online. For example, you must be at least 61 years and 9 months old; plan to start receiving Social Security retirement benefits within the next 4 months; live in the United States or one of its territories/commonwealths; agree to get your Social Security benefits by direct deposit to your bank or other financial institution. You must answer some other questions as well.


  3. You Do Not Yet Get Social Security Benefits and You Only Want To Apply for Medicare

    If you are close to age 65 and not getting Social Security benefits, you must apply for Medicare. You can apply by calling or visiting your local Social Security office, or by calling Social Security at 1-800-772-1213. You should apply three months before the month you turn 65. This is the beginning of your 7 month Initial Enrollment Period. If you wait until you are 65, or in the last 3 months of your Initial Enrollment Period, your Medicare Part B coverage start date will be delayed. You currently cannot apply for Medicare only online (using the Internet).

 
 

How Mdicare Plans Work

Mdicare Prescription Drug Plans

Mdicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Mdicare. They add coverage to:

  • The Original Mdicare Plan,
  • Some Mdicare Cost Plans,
  • Some Mdicare Private Fee-for-Service Plans, and
  • Mdicare Medical Savings Account Plans.
With a Mdicare Prescription Drug Plan:
  • Generally, you pay less for your prescriptions
  • You will get a plan member card after you enroll. You use this card when you go to the pharmacy to get your prescriptions filled
  • You will pay the copayment, coinsurance, and/or deductible, if any

If you have limited income and resources, you may get extra help to pay for your Mdicare drug plan costs.If you want to compare Mdicare Prescription Drug Plans, use the Mdicare Prescription Drug Plan Finder.

 
 
 

Your Mdicare Coverage

Welcome to the Mdicare Coverage section of www.Mdicare.gov. This section provides information about your health care benefits in the Original Mdicare plan (sometimes referred to as "fee-for-service"). By searching this database you will find:

  • Some of the services and supplies the Original Mdicare Plan covers;
  • The conditions that must be met for some services or supplies to be covered;
  • How often services or supplies are covered (limits);
  • How much you pay;
  • Who you can contact if you have additional questions;
  • Some of the services and supplies the Original Mdicare Plan does not currently cover.
More information on Your Mdicare Coverage Database

The information contained in this database is also available in the CMS publication titled Your Mdicare Benefits.

It is important for you to understand that Mdicare does not cover everything, and it does not pay the total cost for most services or supplies that are covered. You should talk to your doctor to be sure you are getting the service or supply that best meets your health care needs.

The amount of your coverage is also dependent on whether you have coverage under Mdicare Part A, Mdicare Part B, or both. Mdicare Part A typically pays for your inpatient hospital expenses and Mdicare Part B typically covers your outpatient health care expenses including doctor fees.

A benefit is a health care service or supply that is paid for in part or in full by Mdicare.

Note: If you belong to a Mdicare Advantage (formerly Mdicare + Choice) plan, it must cover at least the same benefits covered under Mdicare Part A and Part B. However, your costs may be different, and you may have extra benefits, like coverage for prescription drugs or extra days in the hospital. You should contact your Mdicare Advantage plan administrator for specific coverage information for the plan in which you are enrolled. If you are interested in seeing what Mdicare Advantage and Medigap plans are available in your area, please visit the Mdicare Options Compare section of our website.

Frequently Asked Questions about Mdicare Coverage

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Download the Your Mdicare Coverage Database

What is Mdicare
Prescription
Drug Coverage?

Mdicare offers prescription drug coverage for everyone with Mdicare. This is called “Part D.” This coverage may help lower prescription drug costs and help protect against higher costs in the future. It can give you greater access to drugs that you can use to prevent complications of diseases and stay well.

If you join a Mdicare drug plan, you pay a monthly premium. Part D is optional. If you decide not to enroll in a Mdicare drug plan when you are first eligible, you may have to pay a penalty if you choose to join later.

Mdicare drug plans are run by insurance companies and other private companies approved by Mdicare.

There are two ways to get Mdicare prescription drug coverage:

  1. Join a Mdicare Prescription Drug Plans that adds coverage to
    • the Original Mdicare Plan,
    • some Mdicare Private Fee-for Service Plans,
    • some Mdicare Cost Plans, and
    • Mdicare Medical Savings Account Plans.
  2. Join a Mdicare Health Plan (like an HMO or PPO) that includes prescription drug coverage that is a part of the plan. You get all of your Mdicare health care including prescription drug coverage through these plans.


What are Mdicare
Prescription Drug
Plans?

Mdicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Mdicare.

They add coverage to:

With a Mdicare Prescription Drug Plan:

  • Generally, you pay less for your prescriptions.
  • You will get a plan member card after you enroll. You use this card when you get your prescriptions filled.
  • You will pay the copayment, coinsurance, and/or deductible, if any.

If you have limited income and resources, you may get extra help to pay for your Mdicare drug plan costs.




What are Mdicare
Health Plans that
cover Drugs?

Mdicare Health Plans (like HMOs and PPOs) often cover prescription drugs. Mdicare Health Plans include:

  1. Mdicare Advantage Plans
  2. Other Mdicare Health Plans

Mdicare Advantage Plans (like HMOs and PPOs) that include prescription drug coverage as part of the plan are health plan options that are approved by Mdicare but run by private companies. They are part of the Mdicare Program. If you join a Mdicare Advantage Plan you are still in Mdicare.


With Mdicare Advantage Plans:

  • You generally get all your Mdicare-covered health care through that plan.
  • You may get extra benefits, such as coverage for vision, hearing, dental, and/or health and wellness programs.
  • You usually will have to pay some other costs (such as copayments or coinsurance) for the services you get. Out-of-pocket costs in these plans are generally lower than in the Original Mdicare Plan, but vary by the services you use.
  • You may have to see doctors that belong to the plan or go to certain hospitals to get covered services.
  • You don’t need to buy a Medigap policy.

Mdicare Advantage Plans include:

Other Mdicare Health Plans

There are some types of Mdicare Health Plans that include prescription drug coverage as part of the plan but that aren’t part of Mdicare Advantage that are still part of the Mdicare Program. With these plans, you generally get all your Mdicare-covered health care through that plan.

Other Mdicare Health Plans include:




How Much Will the
Plans Cost?

Your costs will vary depending on which drugs you use, whether you get extra help paying your Part D costs, and which Mdicare drug plan you choose. Most drug plans charge a monthly premium that varies by plan. You pay this in addition to the Part B premium. Some drug plans charge no premium.

If you have limited income and resources, you may get extra help to pay for your Mdicare drug plan costs.

Depending on what you can afford, you may be able to pick a pan with or without a monthly premium, deductible or coverage gap.




How do I Enroll?

You can enroll in three ways:

  1. Enroll online on this web site.
  2. Call the plan directly.
  3. Call 1-800-Mdicare (1-800-633-4227) and Mdicare will help you enroll. TTY users should call 1-877-486-2048.


Can I Change Plans
After I
Enroll?

Yes. You can change plans under certain circumstances:

  • You can switch plans from November 15 through December 31 of every year.
  • In special circumstances, Mdicare may give you an opportunity to switch to another plan. For example, if you permanently move out of your plan’s service area; if you get help from your state Medicaid program paying Mdicare premiums and/or cost sharing; if you qualify for extra help paying for prescription drugs; if the plan stops offering prescription drug coverage; or if you enter, live in, or leave a nursing home.



For More Information

  • Read Quick Facts about Mdicare's New Coverage for Prescription Drugs
  • Read Other Fact Sheets about Mdicare Prescription Drug coverage as it relates to the following topics:
  • Call 1-800-Mdicare (1-800-633-4227). TTY users should call 1-877-486-2048.
  • Read the Mdicare & You 2007 handbook mailed to you in October.

Click here to get started finding a Mdicare drug plan

 
Am I eligible for
Mdicare prescription
drug coverage?


Mdicare prescription drug coverage is available to everyone with Mdicare.



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What does the
coverage offer?

  • Mdicare prescription drug coverage helps you pay for your prescription drugs.
  • Mdicare prescription drug coverage will cover generic and brand-name drugs.
  • There is extra help for those who need it most.
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How do the plans
work?

  • Mdicare prescription drug plans provide insurance coverage for prescription drugs.
  • Like other insurance, if you join you will pay a monthly premium that varies by plan and pay a share of the cost of your prescriptions.
  • Costs and coverage will vary depending on the drug plan you choose.
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Can I decide not to
join?

  • Joining is your choice. However, if you don’t join when you are first eligible, you may have to pay a penalty if you choose to join later.
  • Like other insurance, you will have to pay this penalty as long as you have Mdicare prescription drug coverage.
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What if I currently
have prescription
drug coverage?

Click on the statement below that applies to you to learn more.

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You get prescription
drug coverage from
TRICARE

  • It will almost always be to your advantage to keep your current coverage without any changes. However, if you have limited income and resources, you may qualify for extra help from Mdicare.
  • Call the Department of Defense at 1-800-538-9552 for information on military retiree benefits.
  • If you have TRICARE for Life (for military retirees), contact your benefits administrator for more information about your TRICARE for Life coverage before making any changes.
  • Go to www.TRICARE.osd.mil on the web for more information on TRICARE for Life.
  • If you lose your TRICARE coverage and join a Mdicare drug plan, in most cases, you won’t have to pay a penalty, as long as you join within 63 days of losing your coverage.
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You get prescription
drug coverage from
the Department of
Veterans Affairs

  • It will almost always be to your advantage to keep your current coverage without any changes. However, if you have limited income and resources, you may qualify for extra help from Mdicare.
  • Before making any changes to your coverage, contact your benefits administrator for more information about your VA coverage.
  • Call the U.S. Department of Veteran Affairs at 1-800-827-1000 for information on Veteran's benefits and services in your area.
  • If you lose your VA coverage and join a Mdicare drug plan, in most cases, you won’t have to pay a penalty, as long as you join within 63 days of losing your coverage.
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You have Medicaid

  • Your drug costs are covered by Mdicare. You will need to join a Mdicare drug plan for Mdicare to pay for your drugs. In most cases, you will pay a small amount out of your own pocket.
  • If you don’t join a plan, Mdicare will enroll you in one to make sure you don’t miss a day of coverage. If you decide you want another plan, you can switch to another plan at any time.
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You are in a nursing
home

  • If you have full coverage from Medicaid and live in a nursing home, you pay nothing out of your own pocket for covered prescription drugs.
  • If you have full coverage from Medicaid and live in an Assisted Living or Adult Living Facility, or a Residential Home, you will pay a small copayment for each drug.
  • Long Term Care pharmacies contract with Mdicare drug plans to provide prescription drug coverage to their residents. If you are entering, living in, or leaving a nursing home, you will have the opportunity to choose or change your Mdicare drug plan. This allows you to choose or change to a plan that contracts with the nursing home's pharmacy and meets your prescription drug needs.

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You get housing
assistance from HUD

If you have Mdicare and get housing assistance from the Department of Housing and Urban Development (HUD), you may want to join a Mdicare drug plan.

If you qualify for the extra help with paying for your drug plan's monthly premium and for the cost of your prescriptions, you won’t lose your housing assistance. However, your housing assistance may be reduced as your prescription drug spending decreases. But please keep in mind that any decrease in your housing assistance will be more than made up for by the value of the extra help paying Mdicare prescription drug plan costs.


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You get food stamps

If you have Mdicare and get food stamps, you may want to join a Mdicare drug plan.

If you do join a plan, you may qualify for extra help paying Mdicare prescription drug costs. If you qualify for extra help, your food stamps benefits may decline, but that decline will be more than offset by Mdicare's extra help.

If you qualify, compare how much your costs are with your current drug coverage to what your costs would be with Mdicare prescription drug coverage and the extra help.

If you are near the food stamps eligibility cutoff, you may lose your minimum food stamp benefits because you will be paying less for your prescription drugs. But please keep in mind that any decrease in food stamp benefits will be more than made up for by the value of the extra help with paying for your prescription drug costs.


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You have health
insurance through a
current or former
employer or union

Mdicare will help employers or unions continue to provide retiree drug coverage that meets Mdicare’s standards. You should get communications from your employer or union (or the plan that administers your coverage) about how your drug coverage compares to Mdicare prescription drug coverage, and how they are intended to work together.

Read all materials from your employer or union carefully to be sure you make a good prescription drug coverage decision. They will help you understand your options and make your decision much easier.

If you have questions, visit their website, or contact the office listed in their materials. If you aren’t sure whom to contact, contact your benefits administrator or the office that answers questions about your coverage.


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Your state pharmacy
program pays for your
prescriptions

Each state decides how its State Pharmacy Assistance Program works with Mdicare prescription drug coverage. Some states give extra coverage when you join a Mdicare prescription drug plan. Some states have a separate state program that helps with prescriptions. Contact your State Pharmacy Assistance Program to get more information.


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You are in a Mdicare
Health Plan (like an
HMO, or PPO)

You are usually required to get your drug coverage from your current health plan if you decide to stay in the plan. Contact your current health plan if you have any questions about your coverage.


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You have Medigap
(Mdicare Supplement Insurance)

If you have a Medigap policy with prescription drug coverage, you may want to look at your coverage and see what prescription drugs aren’t covered or what part of the costs you pay yourself. Most prescription drug coverage offered by Medigap policies, on average, is not at least as good as Mdicare prescription coverage. You will generally save money and get better coverage with the new Mdicare prescription drug coverage.


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You have
Supplemental Security
Income benefits or get
help from your state
Medicaid program
paying your Mdicare
premiums

You need to join a Mdicare drug plan for Mdicare to pay for your drugs. You automatically qualify for extra help for your prescription drug costs. If you don’t join a plan, Mdicare will enroll you in one to make sure you don’t miss a day of coverage.


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You get prescription
drug coverage from
FEHBP

It will almost always be to your advantage to keep your current coverage without any changes. However, if you have limited income and resources, you may qualify for extra help from Mdicare. If you decide to make changes to your current coverage, you should first contact your benefits administrator. You can contact them by calling 1-888-767-6738. If you lose your FEHBP coverage and join a Mdicare drug plan, in most cases, you won’t have to pay a penalty, as long as you join within 63 days of losing your FEHBP coverage.


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Prescription Drug Coverage

Everyone with Mdicare, regardless of income, health status, or prescription drugs used, can get prescription drug coverage.

Basic Information
Basic information about Mdicare prescription drug coverage, what it is, who can get it, when you can get it, how you can get it and why you should get it.

Things to Consider
Information about how to look at the cost, coverage, and other important factors of Mdicare drug coverage when selecting a plan that meets your needs.

Common Situations
To help you get started thinking about Mdicare drug coverage, find the situation that describes you and find out what you need to do.

Landscape of Local Plans

Mdicare Prescription Drug Plan Finder
An interactive tool that allows you to narrow your search for a Mdicare prescription drug plan based on your personal preferences such as cost, drugs covered and participating pharmacies.

Formulary (Drug) Finder
You enter the drugs you use. This interactive tool finds plans in your area whose formularies cover those drugs.

Enrollment Center
Use this tool to join the Mdicare drug plan you've selected.

Publications
View, print or order Mdicare publications.

Other Resources

Partners
Information and tools for people and organizations assisting those with Mdicare who are considering Mdicare prescription drug coverage.

Additional Mdicare Drug Plan Details for Partners
Download lists of all National plans, all Stand-alone Prescription Drug Plans and their 2007 Regional Low-Income Premium Subsidy Amounts, and all Mdicare Advantage and Other Mdicare Health Plans.

Press Releases
This links to the full Mdicare & Medicaid release database. To find news releases about the prescription drug plan enter "prescription plan" in search box.

 

Prescription Drug Coverage: Basic Information


What is Mdicare prescription drug coverage?
Mdicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Mdicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.
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Who can get Mdicare prescription drug coverage?
Everyone with Mdicare is eligible for this coverage, regardless of income and resources, health status, or current prescription expenses.
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When can I get Mdicare prescription drug coverage?
You may sign up when you first become eligible for Mdicare (three months before the month you turn age 65 until three months after you turn age 65). If you get Mdicare due to a disability, you can join from three months before to three months after your 25th month of cash disability payments. If you don't sign up when you are first eligible, you may pay a penalty. If you didn't join when you were first eligible, your next opportunity to join will be from November 15, 2008 to December 31, 2008.
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How does Mdicare prescription drug coverage work?
Your decision about Mdicare prescription drug coverage depends on the kind of health care coverage you have now. There are two ways to get Mdicare prescription drug coverage. You can join a Mdicare prescription drug plan or you can join a Mdicare Advantage Plan or other Mdicare Health Plan that offers drug coverage.

Whatever plan you choose, Mdicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.

Like other insurance, if you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or by visiting http://www.mdicare.gov/Library/ExternalSiteRedirector2.asp?Language=English&URLPath=http://www.ssa.gov/prescriptionhelp/&URLDescription=Help With Mdicare Prescription Drug Plan Costs section on the Social Security Administration website on the web.
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Why should I get Mdicare prescription drug coverage?
Mdicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. Even 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 protection from unexpected prescription drug bills in the future.
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What if I have a limited income and resources?
There is extra help for people with limited income and resources. If you qualify for extra help, Mdicare will pay for almost all of your prescription drug costs. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting http://www.mdicare.gov/Library/ExternalSiteRedirector2.asp?Language=English&URLPath=http://www.ssa.gov/prescriptionhelp/&URLDescription=Help With Mdicare Prescription Drug Plan Costs section on the Social Security Administration website on the web.
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Prescription Drug Coverage: Things to Consider

To get Mdicare coverage for your prescription drugs, you must choose and join a Mdicare drug plan. Regardless of how a Mdicare drug plan decides to offer this coverage, there are some key factors that may vary. Some of these factors might be more important to you than others, depending on your situation and drug needs. These factors are:

Cost

Premium
This is the monthly cost you pay to join a Mdicare drug plan. Premiums vary by plan.
Deductible
This is the amount you pay for your prescriptions before your plan starts to share in the costs. Deductibles vary by plans. No plan may have a deductible more than $265 in 2007. Some plans may not have any deductible.
Copayment/Coinsurance
This is the amount you pay for your prescriptions after you have paid the deductible. In some plans, you pay the same copayment (a set amount) or coinsurance (a percentage of the cost) for any prescription. In other plans, there might be different levels or "tiers," with different costs. (For example, you might have to pay less for generic drugs than brand names. Or, some brand names might have a lower copayment than other brand names.) Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.
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Coverage

Formulary
A list of drugs that a Mdicare drug plan covers is called a formulary. Formularies include generic drugs and brand-name drugs. Most prescription drugs used by people with Mdicare will be on a plan's formulary. The formulary must include at least two drugs in categories and classes of most commonly prescribed drugs to people with Mdicare. This makes sure that people with different medical conditions can get the treatment they need.
Prior Authorization
Some drugs are more expensive than others even though some less expensive drugs work just as well. Other drugs may have more side effects, or have restrictions on how long they can be taken. To be sure certain drugs are used correctly and only when truly necessary, plans may require a "prior authorization." This means before the plan will cover these prescriptions, your doctor must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered. Plans might have other rules like this to ensure that your drug use is effective.
Coverage Gap
If you have high drug costs, you may consider which plans offer additional coverage until you spend $3,850 (in 2007) out-of-pocket. In some plans, if your costs reach an initial coverage limit, then you pay 100% of your prescription costs. This is called the coverage gap. This "gap" in coverage is generally above $2,400 (in 2007) in total drug costs until you spend $3,850 out-of-pocket. Some plans might offer some coverage during the gap. Even in plans where you pay 100% of covered drug costs after a certain limit, you would still pay less for your prescriptions than you would without this drug coverage.
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Convenience

Drug plans must contract with pharmacies in your area. Check with the plan to make sure your pharmacy or a pharmacy in the plan is convenient to you. Also, some plans may offer a mail-order program that will allow you to have drugs sent directly to your home. You should consider all of your options in determining what is the most cost-effective and convenient way to have your prescriptions filled.
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Peace of Mind Now and in the Future

Even if you don't take a lot of prescription drugs now, you still should consider joining a drug plan. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay a lower monthly premium in the future since you may have to pay a penalty if you choose to join later. You will have to pay this penalty as long as you have a Mdicare drug plan. If you reach the point where you have spent $3,850 (in 2007) out-of-pocket for drug costs during the year, the plan will pay most of your remaining drug costs. This protection could start even sooner in some plans.
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Things to Think about when You Compare Plans

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Prescription Drug Coverage: Common Situations

To help you get started thinking about Mdicare drug coverage, find the situation that describes you and learn what you need to do.

"I have Original Mdicare only, or Original Mdicare and a Medigap ('Supplement') Policy without drug coverage"
What you need to do

"I have Original Mdicare and a Medigap ('Supplement') Policy with drug coverage."
What you need to do

"I am a retiree and I have drug coverage through my (or my spouse's) former employer or union."
What you need to do

"I have a Mdicare Advantage Plan (like an HMO or PPO) or other Mdicare Health Plan."
What you need to do

"I have Mdicare and Medicaid, and I get my drug coverage from Medicaid."
What you need to do

"I have limited resources and live on limited income."
What you need to do

"I have Original Mdicare only, or Original Mdicare and a Medigap ('Supplement') Policy without drug coverage."

If you use an average amount of prescription drugs, Mdicare's prescription drug coverage could pay over half of your drug costs. If you have very high unexpected drug costs, Mdicare will pay up to 95% of these costs after you spend $3,850 out-of-pocket in a year.

What you need to do:
To get this prescription drug coverage, you can join a Mdicare Prescription Drug Plan that covers prescription drugs only and keep your Original Mdicare coverage the way it is. Or you can join a Mdicare Advantage Plan or other Mdicare Health Plan that covers doctor and hospital care as well as prescriptions.

Mdicare Advantage Plans usually give you extra benefits and/or lower costs, but only if you use the doctors and hospitals that participate in the plan's "network." If you do not opt for prescription drug coverage when you are first eligible, you may have to pay a late enrollment penalty to get drug coverage later.
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"I have Original Mdicare and a Medigap ('Supplement') Policy with drug coverage."

Mdicare prescription drug coverage will generally provide significant savings compared to what you are paying in copayments for drugs under your Medigap plan, and will generally provide much better protection against unexpected drug expenses as well.

What you need to do:
Decide between keeping your Medigap policy with prescription drug coverage and joining a Mdicare plan that offers prescription drug coverage. You have probably received information in the mail for plans in your area offering coverage. Compare your current coverage to Mdicare prescription drug coverage.

Unlike Medigap, most of the cost of Mdicare prescription drug coverage is paid by Mdicare, and will never run out if you have unexpected drug costs. Also, if you do not join a Mdicare Prescription Drug Plan or a Mdicare Advantage Plan that offers prescription drug coverage when you are first eligible, you may have to pay a late enrollment penalty to get drug coverage later. If you opt for Mdicare prescription drug coverage, tell your insurer, and the drug portion of your Medigap policy will be removed.
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"I am a retiree and I have drug coverage through my (or my spouse's) former employer or union."

Mdicare will help employers or unions continue to provide retiree drug coverage that meets Mdicare's standard. Your former employer or union has choices about how they will work with Mdicare.

What you need to do:
Your former employer or union probably mails a letter each year to its members with Mdicare. This information explains how they will work with Mdicare on prescription drug coverage and what decisions you will have to make. If you do not hear from them, visit their website or call your benefits administrator.
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"I have a Mdicare Advantage Plan (like an HMO or PPO) or other Mdicare Health Plan."

Mdicare is working with Mdicare Advantage and other Mdicare Health Plans to help them provide even more coverage and/or lower costs. Your plan will let you know about the prescription drug options they will offer. You can also choose to switch to another Mdicare Advantage Plan or Mdicare Health Plan. Or you could choose the Original Mdicare Plan and join a Mdicare Prescription Drug Plan.

What you need to do:
Read the information you got in the mail explaining any additional prescription drug coverage your plan will offer.
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"I have Mdicare and Medicaid, and I get my drug coverage from Medicaid."

As of January 1, 2006, Mdicare covers your prescription drugs. The prescription drug coverage from Mdicare has no premiums, no deductibles, and no gaps, and you will pay very little or nothing for almost all prescriptions. Once you are enrolled in a Mdicare Prescription Drug Plan, you usually will remain in that plan if you don't take any action to change plans. If Mdicare must assign you to a different prescription drug plan at any time, they will mail you a letter explaining the change and your options.

What you need to do:
You should review your drug plan coverage regularly to make sure your current plan is meeting your needs. Each year, you should review your coverage and compare it to any new plans that might be available for the coming year. Decide which Mdicare plan offers the prescription drug coverage you would like. When you are new to Mdicare, if you do not sign up for a plan, Mdicare will sign you up for one to make sure you do not miss a day of coverage. Mdicare will send you a letter to let you know which plan you are in. You can switch to a different plan if you choose.
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"I have limited resources and live on limited income."

What you need to do:
If your resources are less than $11,710 (single) or $23,410 (married) and your income is limited, you may qualify for extra help paying for Mdicare Prescription Drug Coverage. These resource limits are for 2007 and may increase each year. The resource limits include $1,500 per person for burial expenses. Resources include your savings and stock, but not your home or car. If you haven't received an application or information about the extra help, and you think you may qualify, you should apply. You can apply online by visiting the Help With Mdicare Prescription Drug Plan Costs section on the Social Security Administration website.
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Glossary

Term Definition
Annual Deductible

The amount you must pay for your prescriptions or other medical care, before your Mdicare drug plan or Mdicare Health Plan begins to pay. These amounts can change every year.

If "Under Review" appears, it means that the prescription drug coverage is still being discussed by Mdicare and the plan.

Any Willing Doctor

A doctor, hospital, or other health care provider that agrees to accept the plan's terms and conditions related to payment and that meets other requirements for coverage

Approval Status

If Mdicare has approved the coverage and costs offered by the company for the year 2008. "As submitted by organization" means the company has a current contract with Mdicare, but Mdicare is still discussing the coverage and costs offered by the company for 2008.

Assignment

In the Original Mdicare Plan, this means a doctor or supplier agrees to accept the Mdicare-approved amount as full payment. If you are in the Original Mdicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.

Benefit Period

A "benefit period" begins the day you go to a hospital or skilled nursing facility (SNF). The benefit period ends when you haven't received any hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods.

Catastrophic Coverage

Once your total drug costs reach the $6,153.75 maximum, you pay a small coinsurance (like 5%) or a small copayment for covered drug costs until the end of the calendar year

Cobrand

Refers to the partner relationships established between Mdicare Prescription Drug Plans and other organizations. Some drug plans enter into agreements with other organizations to help market their drug plans. These relationships are between the drug plan and the partner organizations and are outside of the contract with Mdicare.

Coinsurance

The amount you may be required to pay for services after you pay any plan deductibles. In the Original Mdicare Plan, this is a percentage (like 20%) of the Mdicare approved amount.
You have to pay this amount after you pay the deductible for Part A and/or Part B. In a Mdicare Prescription Drug Plan or Mdicare Health Plan, the coinsurance will vary depending on how much you have spent.

Company Name

Name of company that contracts with Mdicare to offer a Mdicare Prescription Drug Plan or a Mdicare Health Plan. (The number next to the name is for Mdicare's use only.)

Copayment

In some Mdicare health and prescription drug plans, the amount you pay for each medical service, like a doctor's visit, or prescription. A copayment is usually a set amount you pay. For example, this could be $10 or $20 for a doctor's visit or prescription. Copayments are also used for some hospital outpatient services in the Original Mdicare Plan.

Cost Sharing

The amount you pay for health care and/or prescriptions. This amount can include copayments, coinsurance, and/or deductibles.

Coverage Gap

Mdicare drug plans may have a "coverage gap," which is sometimes called the "donut hole." A coverage gap means that after you and your plan have spent a certain amount of money for covered drugs (no more than $2,700), you have to pay out-of-pocket all costs for your drugs while you are in the "gap." The most you have to pay out-of-pocket in the coverage gap is $4,350 . This amount doesn't include your plan's monthly premium that you must continue to pay even while you are in the coverage gap. Once you've reached your plan's out-of-pocket limit, you will have "catastrophic coverage." This means that you only pay a coinsurance amount (like 5% of the drug cost) or a copayment (like $2.40 or $6.00 for each prescription) for the rest of the calendar year.

Note: If you get extra help paying your drug costs, you won't have a coverage gap. However, you will probably have to pay a small copayment or coinsurance amount.

Deductible

The amount you must pay for health care or prescriptions, before Original Mdicare, your Mdicare drug plan, your Mdicare Health Plan, or your other insurance begins to pay. For example, in Original Mdicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year.

Demonstration/Pilot Program

Special projects that test improvements in Mdicare coverage, payment, and quality of care. Some follow Mdicare Advantage rules, but others don't. Demonstrations are usually for a specific group of people and/or are offered only in specific areas. There are also pilot programs for people with multiple chronic illnesses designed to reduce health risks, improve quality of life, and provide savings.

Disenroll

Ending your health care and/or prescription drug coverage with a health plan or drug plan.

Drug Plan Summary Score

This score summarizes the drug plan's quality and performance.

How is the summary score determined?

This score is a summary of the drug plan's performance on 19 different topics in four categories:


  • Drug plan customer service. Includes how well the drug plan handles calls and how well the drug plan makes decisions about member appeals.
  • Member complaints and staying with drug plan. Includes how often members have made complaints against the drug plan and how often members choose to stay with the drug plan from one year to the next.
  • Member experience with drug plan. Combines member satisfaction data collected by Mdicare?s annual survey.
  • Drug pricing and patient safety. Includes how well the drug plan is doing with pricing of prescriptions and providing accurate pricing information on the Mdicare website, and how often the drug plan's members got certain prescriptions that have a high risk of side effects in patients 65 and older.

Why is the summary score important?

The summary score makes it easy for you to compare drug plans based on quality and performance.


You can look up the drug plan's score in each of the four categories that make up the summary score. You can also look up the drug plan's scores in the 19 individual topics that make up the score in those four categories.


Employer or Union Retiree Plans

Health plans that give health and/or drug coverage to employees, former employees, and their families. These plans are offered to people through their (or a spouse's) current or former employer or employee organization.

Enhanced Alternative Plan

Enhanced Alternative Plans can offer a more comprehensive level of coverage, with lower cost-sharing and/or additional coverage of certain drugs excluded from the standard level of coverage and basic alternative coverage. Premiums may be higher for these plans, but they offer more coverage.

Estimated Annual Cost

When using this tool, this is an estimate of the average amount you might expect to spend each year for your health and/or drug coverage. The estimates include:

  • Plan benefits (coverage);
  • Costs for premiums, copayments, deductibles, coinsurance, and;
  • Costs not covered by your insurance.

Your out-of-pocket costs are based on actual health and/or drug coverage use by people with Mdicare, and they may differ depending on your age and health status. Also, if you have limited income and resources, your expenses may be lower.

Favorites

Your "favorites" are plans that you're interested in. When you're trying to decide which plan to join, you can create a list of plans you're interested in so that you can return to the Mdicare Prescription Drug Plan Finder later and still be able to see those plans. To add or remove plans from your list of "favorites", click the "Add" or "Remove" buttons on the right side of screen under the "favorites" column.

Formulary

A list of drugs covered by a plan

Generic Drug

A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.

Guaranteed Issue Rights

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can't deny you a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can't charge you more for a policy because of past or present health problems.

Health Maintenance Organization (HMO)

A type of Mdicare Health Plan that is available in most areas of the country. Plans must cover all Mdicare Part A and Part B health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan's list except in an emergency. Your costs may be lower than in the Original Mdicare Plan.

High-Deductible Medigap Policy

A type of Medigap policy that has a high deductible but a lower premium. You must pay the deductible before the Medigap policy pays anything. The deductible amount can change each year.

If I Qualify for Extra Help, will My Full Premium be Covered?

When using the Mdicare Prescription Drug Plan Finder, if $0 appears under the premium column, it means that the extra help you are receiving will cover the premium for that plan. If an amount of $1 or greater appears under the premium column, it means you will have to pay part of the premium because the extra help won't cover all of it. You would be responsible for paying this monthly amount if you choose to enroll in that plan.

Independent Reviewer

An independent reviewer, also known as an independent review entity (IRE), is an outside organization that has a contract with Mdicare. If you appeal a decision about your coverage or if your drug plan doesn't make a timely appeals decision, the IRE may review your case. The IRE has no connection to the drug plan. Refer to your drug plan's explanation of coverage for more details about the appeals process. Click here for more information on Mdicare appeals: www.Mdicare.gov/basics/appeals.asp

Initial Coverage Limit

Once you have met your yearly deductible, and until you reach the $2400 maximum, you pay a copayment (a set amount you pay) or coinsurance (a percentage of the total cost) for each covered drug.

In-Network

Doctors, hospitals, pharmacies, and other healthcare providers that have agreed to provide members of a certain insurance plan with services and supplies at a discounted price. In some insurance plans, your care is only covered if you get it from in-network doctors, hospitals, pharmacies, and other healthcare providers.

Medicaid

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Mdicare and Medicaid.

Medically Necessary

Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of you or your doctor.

Mdicare Advantage Plan

Health plan options that are approved by Mdicare but run by private companies. They are part of the Mdicare Program.

With Mdicare Advantage Plans:

  • You generally get all your Mdicare-covered health care through that plan.
  • Coverage can include prescription drug coverage.
  • You may get extra benefits, such as coverage for vision, hearing, dental, and/or health and wellness programs.
  • You may have lower out-of-pocket costs than the Original Mdicare Plan.
  • You may have to use the plan's doctors and hospitals to get services.

You don't need to buy a Medigap policy.

Mdicare Cost Plan

A Mdicare Cost Plan is a type of HMO. These plans may work in much the same way, and have some of the same rules, as Mdicare Advantage Plans. In a Mdicare Cost Plan, if you go to a non-network provider, the services are covered under the Original Mdicare Plan. You would pay the Mdicare Part A and Part B coinsurance and deductibles.

Mdicare Health Plan

Mdicare Health Plans offer Part A and Part B coverage all in one drug plan and many also include Mdicare Prescription Drug coverage.

Mdicare Medical Savings Account (MSA) Plan

A type of Mdicare Advantage Plan. Medical Savings Account (MSA) Plans have two parts. The first part is a high-deductible Mdicare Advantage MSA Health Plan. This health plan won't begin to pay covered costs until you have met the annual deductible, which varies by plan. The second part is a Medical Savings Account into which Mdicare deposits money that you may use to pay health care costs.

Mdicare Prescription Drug Plan

A Mdicare Prescription Drug Plan is a stand-alone drug plan that adds drug coverage to Original Mdicare, some Mdicare Private Fee-for-Service plans, some Mdicare Cost plans, and Mdicare Medical Savings Account plans.

Mdicare Advantage Plans may also offer prescription drug coverage that must follow the same rules as Mdicare Prescription Drug Plans.

Mdicare Savings Program

Medicaid programs that help pay some or all Mdicare premiums and deductibles.

Mdicare SELECT

A type of Medigap policy that may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Mdicare Special Needs Plan

A special type of Mdicare Advantage Plan that provides all Mdicare Part A and Part B health care and services to people who can benefit the most from things like special care for chronic illnesses, care management of multiple diseases, and focused care management. These plans may limit membership to people

  • in certain institutions (like a nursing home),
  • eligible for both Mdicare and Medicaid, or
  • with certain chronic or disabling conditions.

Mdicare-approved Amount

In the Original Mdicare Plan, this is the amount a doctor or supplier can be paid, including what Mdicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount charged by a doctor or supplier.

Medigap Policy

Mdicare supplement insurance sold by private insurance companies to fill "gaps" in Original Mdicare Plan coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are up to 12 standardized Medigap policies labeled Medigap Plan A through Plan L. Medigap policies only work with the Original Mdicare Plan.

Monthly Premium

The periodic payment to Mdicare, an insurance company, or a health care plan for health care or prescription drug coverage. In a few cases, a note will say "Under Review" instead of a premium amount. This means Mdicare and the company are still discussing the amount.

Non-preferred pharmacy

A network pharmacy that offers covered drugs to plan members at higher out-of-pocket costs than what the member would pay at a preferred network pharmacy.

Open Enrollment Period (Medigap)

A one-time only six month period when you can buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Mdicare Part B and you are age 65 or older (or under age 65 in some states). During this period, you can't be denied coverage or charged more due to past or present health problems.

Optional Supplemental Benefits

Services not covered by Mdicare that enrollees can choose to buy or reject. Enrollees that choose such benefits pay for them directly, usually in the form of premiums and/or cost sharing. Those services can be grouped or offered individually and can be different for each Mdicare Health Plan offered.

Original Mdicare Plan

A fee-for-service health plan that lets you go to any doctor, hospital, or other health care supplier who accepts Mdicare and is accepting new Mdicare patients. You must pay the deductible. Mdicare pays its share of the Mdicare-approved amount, and you pay your share (coinsurance). In some cases you may be charged more than the Mdicare approved amount. The Original Mdicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Out-of-Network

Generally, an out-of-network benefit provides you with the option to access plan services outside of the plan's contracted network of providers. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.

Out-of-Pocket Costs

Health care costs that you must pay on your own because they are not covered by Mdicare or other insurance.

PACE (Programs of All-inclusive Care for the Elderly)

PACE combines medical, social, and long-term care services for frail people who live and get health care in the community. They are a joint Mdicare and Medicaid option in some states. To be eligible, you must:

  • Be 55 years old, or older,
  • Live in the service area of the PACE program,
  • Be certified as eligible for nursing home care by the appropriate state agency , and
  • Be able to live safely in the community.

The goal of PACE is to help people stay independent and live in their community as long as possible, while getting high quality care they need.

Part A (Hospital Insurance)

The part of Mdicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

Part B (Medical Insurance)

Mdicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that aren't covered by Part A.

Plan members who qualify for extra help

These drug plan members qualify to get extra help from Mdicare paying their prescription drug coverage costs. This extra help is also known as the "Low-Income Subsidy." People who qualify for this program get help paying their Mdicare drug plan's monthly premiums, annual deductible, and prescription co-payments.

Plan Name

The name of the plan offered by the company that contracts with Mdicare.

Point of Service (POS)

An HMO option that lets you use doctors and hospitals outside the plan for an additional cost.

Pre-existing conditions

A health problem you had before the date that a new insurance policy starts.

Preferred Pharmacy

A network pharmacy that offers covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy.

Preferred Provider Organization (PPO)

A type of Mdicare Advantage Plan available in a local or regional area in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Premium

The periodic payment to Mdicare, an insurance company, a health care plan, or a drug plan for health care or prescription drug coverage.

Pricing Method

Insurance companies set their own premiums for Medigap (Mdicare Supplement Insurance) policies. How they set the price affects how much you pay now and in the future. Medigap policies can be prices or "rated" in three ways:

  1. Community-rated (or "no-age-rated")
  2. Issue-age-rated
  3. Attained-age-rated
Prior Authorization

Prior authorization means that you will need prior approval from an insurance plan before you fill your prescription. If a drug has prior authorization, you will need to work with the plan and your doctor to obtain an exception. For prior authorization information, you can access the plan's website to identify the specific requirements for that plan. Many prior authorization requirements can be resolved at the point of sale and do not require any additional information from your physician. Knowing what the prior authorizations are before going to your doctor's office may save you time at the pharmacy counter.

Private Fee-for-Service Plan

A type of Mdicare Health Plan in which you may go to any Mdicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Mdicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Mdicare-covered benefits. You may have extra benefits the Original Mdicare Plan doesn't cover.

Qualified Mdicare Beneficiary (QMB)

A Medicaid program for people with Mdicare who need help in paying for Mdicare services. The person with Mdicare must have Mdicare Part A and limited income and resources. For those who qualify, the Medicaid program pays Mdicare Part A and Part B premiums, and Mdicare deductibles and coinsurance amounts for Mdicare services.

Quantity Limitation

For safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time. If the drug has a quantity limit restriction, you should contact the plan for more details. If you take one pill per day and the drug has a 30 day/month quantity limit, the impact will be minimal (i.e., you may not be able to refill the prescription until a few days before running out of pills). If you currently take 2 pills per day and the quantity limit is 30 pills per month, you would need to work with the plan to get authorization for the higher quantity.

Referral

A written order from your primary care doctor for you to see a specialist or get certain services. In many HMOs, you need to get a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for your care

Service Area

The area where a health plan accepts members. For plans that require you to use their doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.

Skilled Nursing Facility

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

Specified Low - Income Mdicare Beneficiary (SLMB)

A Medicaid program that pays for Mdicare Part B premiums for individuals who have Mdicare Part A, a low monthly income, and limited resources.

Stars

Stars for each plan show how well the plan performs in that particular category. Star ratings range from 1 star to 5 stars, where a rating of 1 star means "poor" quality and 5 stars means "excellent" quality.

Step Therapy

In some cases, plans require you to first try one drug to treat your medical condition before they will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, then the plan will cover Drug B. If a drug has step therapy restrictions, you will need to work with the plan and your doctor to obtain an exception.

Summary Score for Health Plan Quality

How Well is the Health Plan Doing?

This category has a single rating that summarizes how well the health plan is doing across all areas of health plan quality and performance reported on this website.

The summary score is calculated by combining the health plan's ratings in the following categories:


  • Staying Healthy: Screenings, Tests and Vaccines. This category covers how well each health plan works to detect and prevent illness.
  • Getting Timely Care from Doctors and Specialists. This category shows how easily people in each health plan are able to get the care they need from primary care doctors and specialists.
  • Managing Chronic (Long-Lasting) Conditions. This category has information on how well each health plan helps people with chronic or long-lasting health conditions.
  • Ratings of Health Plan Responsiveness and Care. This category shows how well each health plan responds when its members need information and care.
  • How Well and Quickly Health Plans Handled Appeals. This category provides information on how well and how quickly each health plan handles appeals, and whether the health plan?s decisions are upheld by outside experts.

Why is this summary score important?

This "summary score of health plan quality" provides a quick and easy way for you to compare the overall quality and performance of health plans. You can use the separate ratings to get more details on topics of special interest to you.


Tiers

Drugs on a formulary are often organized into different drug "tiers," or groups of different drug types. Your cost depends on which drug tier your drug is in.

For example, a plan may form tiers this way:

  • Tier 1 - Generic drugs.
  • Tier 2 - Preferred brand-name drugs.
  • Tier 3- Non-preferred brand name drugs.

Contact the plan to learn more about its specific tier structure.

Timely Appeals Decision

An appeals decision is considered to be timely when it meets Mdicare's appeals timeframes. The specific timeframe depends on the type of appeal, and ranges from 24 hours to 7 days. Refer to your drug plan's explanation of coverage for more details about the appeals process.

*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.

This glossary explains terms in the Mdicare program, but it is not a legal document. The official Mdicare program provisions are found in the relevant laws, regulations,and rulings.
 
General Information
Are You Having Trouble Paying for Prescription Drugs? - 11318

This brochure explains in simple terms and pictures about applying for extra help with prescription drug costs. (2 pages)

View Adobe PDF - 11318  (size: 776.49 KB) Revised 7/1/2007

This publication is also viewable in Spanish  (size: 4.11 MB) Revised 7/1/2007

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Do You Need Extra Help with Mdicare Drug Costs? - 11318-AA

This brochure explains in simple terms and pictures about applying for extra help with prescription drug costs. (2 pages)

View Adobe PDF - 11318-AA  (size: 4.08 MB) Revised 9/1/2007

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Getting Medical Care and Prescription Drugs in a Disaster or Emergency Area - 11377

This fact sheet provides information about the special rights you have to get care and prescription drugs if you are in a disaster or emergency area. (4 pages)

View Adobe PDF - 11377  (size: 72.40 KB) Revised 9/1/2008

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Have you done your Yearly Mdicare Plan Review? - 11220

This brochure explains important steps people with Mdicare should take to review their coverage each year. (5 pages)

View Adobe PDF - 11220  (size: 250.56 KB) Revised 11/1/2008

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How Mdicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings - 11333

Provides information about how to get reimbursed through Mdicare Part D for self-administered drugs you get in hospital outpatient settings (3 pages)

View Adobe PDF - 11333  (size: 364.86 KB) Revised 12/1/2008

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Mdicare at a Glance - 11082

This fact sheet includes basic information about the Mdicare Program and Mdicare plan choices. (4 pages)

View Adobe PDF - 11082  (size: 74.39 KB) Revised 9/1/2008

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Mdicare Basics: A Guide for Families and Friends of People with Mdicare - 11034

Provides caregivers a guide through eight critical decision points in the health care process. (49 pages)

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Use Mdicare’s Information on Quality to Help You Compare Plans - 11226

This fact sheet explains the quality measures on Mdicare Prescription Drug Plan Finder and Mdicare Options Compare at www.Mdicare.gov and how you can use the information to help you choose and join a plan that meets your needs. (4 pages)

View Adobe PDF - 11226  (size: 366.78 KB) Revised 11/1/2008

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What Is Mdicare/Medicaid - 11306

This publication provides a brief overview of Mdicare and Medicaid. To view this publication in other languages, click here. (2 pages)

View Adobe PDF - 11306  (size: 68.54 KB) Revised 4/1/2008

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Withholding Mdicare Prescription Drug Premiums from your 2009 Social Security Payment - 11400

This tip sheet explains how premium withhold deductions work if you switch drug plans in 2009. (2 pages)

View Adobe PDF - 11400  (size: 256.51 KB) Revised 12/1/2008

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Whether you choose to go to your local pharmacy to get your prescriptions filled or take advantage of the unique opportunity to receive your prescriptions through the mail, your Standard Option benefits will have you covered.

Mail Service Pharmacy

Available to Standard Option members only, the Mail Service Pharmacy Program is a convenient and affordable way to receive the medications you use regularly by mail. For the cost of one copayment, you can have up to a 90-day supply (minimum 22-day supply) of your maintenance medications delivered directly to your door.

Retail Pharmacy (Preferred)

Just show your ID card at one of the 60,000 Preferred network pharmacies. You pay only your share of coinsurance of the Plan Allowance for each prescription or refill and there are no deductibles to meet. It's that easy. You pay your coinsurance and don't have to file a claim!

To locate a Network pharmacy, visit the Provider Directory on this Web site or call 1.800.624.5060. When calling, follow the telephone prompt instructions to hear the most up-to-date listing of Network pharmacies in your area 24 hours a day. Customer Care representatives are also available Monday through Friday, 8 a.m. to 9 p.m. and Saturday from 8 a.m. to 6 p.m. Eastern Time to assist you.

Retail Pharmacy (Non-preferred)

If you have Standard Option, you may also purchase your prescription drugs and supplies from Non-preferred pharmacies. You will have to pay the full amount up front for these items when you purchase them and then file a Retail Prescription Drug claim form for reimbursement. You can easily download the claim form from this Web site or call the Retail Prescription Drug Program and ask to have a claim form mailed to you. You can also photocopy the claim form for future use, if needed.

Reimbursement

  • Pay the full price for the prescription.
  • Get an itemized bill from the out-of-network pharmacy. It should clearly show the following information:
    • Name and address of the pharmacy
    • Patient's name
    • Prescription number
    • Date filled
    • Name of drug or supply, strength, quantity and dosage
    • Amount charged for each medicine or supply
  • Ask your pharmacist to help you fill out the Pharmacy Information and Prescription Information sections of the Retail Prescription Drug claim form.
  • Fill in the Subscriber Information and Patient Information sections of the claim form. Don't forget to include the member's signature.
  • Send the completed claim form and any related pharmacy receipt(s) to:
    Blue Cross and Blue Shield Service Benefit Plan
    Retail Pharmacy Program
    P.O. Box 52057
    Phoenix, AZ 85072-2057

When your claim is processed, we will reimburse you up to 55% of the Average Wholesale Price (AWP) for covered medicines and supplies purchased at a Non-preferred pharmacy.

Remember, although you can purchase your covered drugs and supplies at a Non-preferred pharmacy, you will receive an increased level of benefits and experience greater convenience when you use the Mail Service Pharmacy Program or a Preferred retail pharmacy.

Below is a summary of what you will pay for up to a 90 day supply using Standard Option Pharmacy benefits:

  Preferred Pharmacy Benefit Non-preferred Pharmacy Benefit

Mail Service Benefit

Generic — $0 copayment for the first 4 fills, thereafter, $10 copayment per fill

Brand — $65 for first 30 fills, thereafter, $50 per fill

There is no benefit

Retail Benefit

Coinsurance
Generic Level I 20% of the Plan allowance
Brand Level II & III 30% of the Plan allowance

Up to 45% of the Average Wholesale Price (AWP) plus any difference between the AWP and the billed charge, no deductible

Influenza Vaccine Benefit

One vaccine per flu seasons at no additional cost to you

There is no benefit

Managing medication costs

To learn more about how to fill your prescriptions and make the most of your prescription benefits, visit the Pharmacy section of this Web site. Information about your prescription benefits is also available in your 2009 Service Benefit Plan Brochure.

After enrolling in the Service Benefit Plan, you will be able to register with Caremark.com. Here you will have access to additional features for your pharmacy benefits, such as:

  • Calculate the lowest-cost option for your prescription refills.
  • View your prescription history.
  • Look up drug interactions and side effects.
  • Get reliable information on health, nutrition, fitness, and much more.