General Overview--How To File a Grievance or Appeal

You have the right to file a complaint/grievance with the plan. You must file your complaint/grievance within 60 calendar days of the date of the event that led to your complaint/grievance. Some examples of why you might file a complaint/grievance include the following…read full article 

What if my plan won’t cover a drug I need?

If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required to pay, you have the right to the following…read full article 

How to Appeal

1. Appeal through your plan-The first level of appeal is called a “redetermination.” The plan’s initial denial notice will explain how to file this appeal. You must request this appeal within 60calendar days from the date of the coverage determination notice. You or your appointed representative must file a written standard request…read full article

Network Pharmacies

Medicare drug plans have contracts with a number of pharmacies that are part of the plan’s “network.” Your plan may not cover your prescription if you don’t go to a network pharmacy. Along with retail pharmacies, your plan’s network may include preferred pharmacies, a mail-order program, and a 60 or 90-day retail pharmacy program…read full article 

List of covered prescription drugs (Formulary)

Each Medicare drug plan will have a list of prescription drugs that it covers. Plans cover both generic and brand-name prescription drugs. The drug lists must include a range of drugs in the most commonly prescribed categories and classes…read full article 

Generic Drugs

According to the Food and Drug Administration (FDA), a generic prescription drug is the same as a brand-name prescription drug in safety, strength, quality, the way it works, how it’s taken, how much should be taken, and the way it should be used…read full article 

Tiers

Many Medicare drug plans place drugs into different “tiers.” Drugs in each tier have a different cost. Some plans may have more tiers and some may have less…read full article 

Coverage Rules

Plans may have coverage rules to make sure that certain drugs are used correctly and only when necessary. These rules may include prior authorization, step therapy, and quantity limits as in other articles in this section. 

Prior Authorization

Some prescription drugs are more expensive than others even though some less expensive prescription drugs work just as well. Other prescription drugs may have more side effects, or have restrictions on how long they can be taken…read full article 

Step Therapy

Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition…read full article  

Example of Step Therapy

Step 1—Dr. Smith wants to prescribe a new sleeping pill to treat Mr. Mason’s occasional insomnia. There is more than one type of sleeping pill available. Some of the drugs Dr. Smith considers prescribing are brand-name only prescription drugs covered by Mr. Mason’s Medicare drug plan…read full article 

Quantity Limits 

For safety and cost reasons, plans may limit the quantity of prescription drugs that they cover over a certain period of time…read full article 

What do I do if my plan won’t cover a prescription drug I need?

If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required to pay, you have the right to the following…read full article

Introduction to Medicare Part D

Part D is the newest addition to Medicare. Part D is prescription drug coverage. You must be enrolled in Medicare before you can apply for Part D coverage. …read full article

What if I already have prescription drug coverage from my Medigap policy? 

If you have a Medigap policy with prescription drug coverage, you chose not to get Medicare prescription drug coverage when you were first eligible. You can still join a Medicare Prescription Drug Plan…read full article

OPTION 1: Join a Medicare Prescription Drug Plan, and keep the Medigap policy you have now, with the drug coverage removed. 

If you join a Medicare Prescription Drug Plan, you can keep the Medigap policy you have now, but without the prescription drug coverage. You will need to tell your Medigap insurance company when your new Medicare Prescription Drug Plan starts, so they can remove the prescription drug coverage from your Medigap policy and adjust your premium.

OPTION 2: Join a Medicare Advantage Plan that includes prescription drug coverage. 

If you join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage, you will get all your health care coverage and prescription drug coverage from that plan. In most cases…read full article

OPTION 3: Keep your Medigap policy with prescription drug coverage.

 If you choose this option, you don’t need to do anything. However, keep in mind that if you join a Medicare Prescription Drug Plan later, you will probably have to pay a late-enrollment penalty. Also, no new Medigap policies with prescription drug coverage can be sold, so the premium for your Medigap policy could increase faster. Be sure to ask your Medigap insurance company how your Medigap premium might change in the future. 

If I join a Medicare Prescription Drug Plan now, will I have to pay a late-enrollment penalty?

This will depend on whether your Medigap policy is considered “creditable prescription drug coverage.” (This means that the Medigap policy is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.)…read full article 

Can I join a Medicare Prescription Drug Plan and keep my Medigap policy with prescription drug coverage?

No, you can’t have both. You must tell your Medigap insurance company if you join a Medicare Prescription Drug Plan so they can remove the prescription drug coverage from your Medigap policy. As soon as you notify your Medigap insurance company, they must adjust your premium to reflect the removal of your Medigap prescription drug coverage. 

What if I drop my entire Medigap policy (not just the Medigap prescription drug coverage)? 

If you want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage), or you decide to switch to a Medicare Advantage Plan that offers prescription drug coverage, you need to be careful about the timing. If you drop your entire Medigap policy more than 63 days before your new Medicare coverage begins, you will have to pay a late-enrollment penalty. You can join a Medicare Advantage Plan from November 15–December 31 each year

E-Prescribing

E-prescribing or electronic prescribing is an electronic way for doctors to create prescriptions. E-prescribing is an easy way for you to get safe prescriptions and save time and money. When doctors e-prescribe, they don’t have to write prescriptions on paper…read full article  

Quick Facts about Medicare’s Prescription Drug Coverage for People in a Medicare Advantage Plan or Medicare Cost Plan with Prescription Drug Coverage

Medicare offers prescription drug coverage for everyone with Medicare. This coverage is called “Part D.” To get Medicare drug coverage, you must join a Medicare drug plan. There are two ways to get Medicare prescription drug coverage…read full article  

Quick Facts If You No Longer Automatically Qualify For Extra Help With Medicare Prescription Drug Costs

Getting “extra help” means Medicare helps pay your Medicare drug plan’s monthly premium, deductible, and copayments. You automatically qualify for extra help if you have one of the following…read full article  

Quick Facts about Medicare’s Coverage for Prescription Drugs for People who Have Prescription Coverage from an Employer or Union

Medicare offers prescription drug coverage to everyone with Medicare. Whether you are currently employed or retired, it’s important to understand how your employer or union drug coverage works with Medicare prescription drug coverage before you make any decisions about your prescription drug coverage…read full article  

Quick Facts about Medicare Prescription Drug Coverage if you get Supplemental Security Income benefits or your state Medicaid program pays your Medicare premiums

You automatically qualify for extra help for your Medicare prescription drug costs:

·         If you join a Medicare drug plan, you will pay a small amount out of your own pocket for the cost of your drugs.

…read full article 

What do I need to know? 

• To get Medicare prescription drug coverage, you must choose and join a Medicare drug plan.
• You can join a Medicare drug plan between November 15–December 31 each year. Your coverage will begin January 1 of the following year.
• If you join, your costs will vary depending on which plan you choose. In general, you may pay a monthly premium and a yearly deductible (up to the first $295). You will also pay a share of your prescription drug costs, and your plan pays a share. Medicare helps pay for drugs up to a limit ($2,700 in total) and once your total out-of-pocket costs for drugs reach $4,350, you pay 5% of the costs and Medicare pays 95% of the costs for the rest of the year. The amounts shown are for 2009.
• Many people with limited income and resources will get extra help paying for their Medicare prescription drug coverage. People with the lowest incomes and resources will get the most help.

When can I join a Medicare drug plan? 

Generally, you can join, switch, or drop a Medicare drug plan at the following times…read full article

Step 1: Gather information about your current prescription drug coverage and needs. 

Before you choose a Medicare drug plan, it is helpful to gather some information about yourself. You need information about any prescription drug coverage you may currently have as well as a list of the prescription drugs and doses you currently take. You should also gather any notice you received from Medicare, Social Security, or your current Medicare drug plan about changes to your plan.

If you have prescription drug coverage, you need to find out whether it is creditable prescription drug coverage. Your current insurer or plan provider will let you know. If you haven’t heard from them, call your insurer, plan provider, or benefits administrator to find out.

 You apply and qualify

 If you think you may qualify for extra help, call Social Security at 1-800-772-1213, visit www.socialsecurity.gov on the web, or apply at your State Medical Assistance (Medicaid) office. There is no risk or cost to apply. Remember, even if you qualify, you still need to join a Medicare drug plan to get the extra help…read full article 

You automatically qualify and don’t need to apply. 

You automatically qualify and don’t need to apply.   

Medicare mails purple letters to people who automatically qualify for extra help. If you get one, keep this letter as proof that you qualify.

You automatically qualify for extra help if you have any one of the following…read full article 

I have only Part A and/or Part B (the Original Medicare Plan) and no drug coverage 

If you have Part A and/or Part B (check your red, white, and blue Medicare card) and live in a plan service area, you can join a Medicare drug plan to help with the costs of your prescription drugs. You can choose and join a drug plan that meets your needs.

I have Medicare and a Medigap (Medicare Supplement Insurance) policy without prescription drug coverage 

If you currently have Medicare and a Medigap policy that doesn’t provide prescription drug coverage, you can join a Medicare drug plan to help with the costs of your prescription drugs. Your choices are listed below…read full article

I have Medicare and a Medigap (Medicare Supplement Insurance) policy with prescription drug coverage 

Before 2006, some Medigap policies included prescription drug coverage. If you still have a Medigap policy with prescription drug coverage, your Medigap insurer must send you a detailed notice each year describing your choices for prescription drug coverage and whether the drug coverage under your Medigap policy is creditable prescription drug coverage…read full article

I have Medicare and get drug coverage from a current or former employer or union 

Medicare helps employers and unions continue to offer high quality prescription drug coverage. Before you make a decision about whether to join a Medicare drug plan, it’s important for you to understand how your employer or union drug coverage works with Medicare…read full article

Your (or your spouse’s) employer or union tells you that your current coverage IS creditable prescription drug coverage 

• You can keep this coverage as long as it is still offered by your employer or union.
• You won’t have to pay a late enrollment penalty if your employer or union stops offering prescription drug coverage as long as you join a Medicare drug plan within 63 days after the coverage ends.

Note: You should keep any materials your employer or union sends you that tell you your prescription drug coverage is creditable. You may need to provide it to your Medicare drug plan as proof of creditable prescription drug coverage if you decide to join a Medicare drug plan later.…read full article 

I have Medicare and a Federal Employee Health Benefits (FEHB) plan

 The FEHB Program offers health coverage for current and retired federal employees.

• If you are covered under a FEHB plan, you will get information during the open season about your prescription drug coverage and whether it is creditable prescription drug coverage. Read this information carefully.

…read full article

I have Medicare and TRICARE or benefits from the Department of Veterans Affairs (VA) that include drug coverage

 If you get health care benefits from TRICARE or the VA, you need to know the following:

• As long as you still qualify, you can keep your TRICARE or VA prescription drug coverage. You should get information each year from TRICARE or your VA provider about your coverage and whether it is creditable prescription drug coverage. Read this information carefully.

…read full article 

I have a Medicare Health Plan without prescription drug coverage 

If you have a Medicare Advantage Plan (like an HMO or PPO) or another Medicare Health Plan that doesn’t include prescription drug coverage, you may want to consider other ways to get Medicare prescription drug coverage…read full article

I have a Medicare Health Plan with prescription drug coverage 

If you have prescription drug coverage from a Medicare Advantage Plan (like an HMO or PPO) or other Medicare Health Plan, in most cases you will need to get your Medicare prescription drug coverage from your plan…read full article

I have Medicare and Medicaid 

Medicare helps pay for your prescription drugs instead of Medicaid. Because you have Medicaid, Medicare automatically gives you extra help with your Medicare drug plan costs.  If you live in an institution (like a nursing home), in most cases you pay nothing for your covered prescriptions…read full article

I have Medicare and get Supplemental Security Income (SSI) benefits or help from Medicaid paying Medicare Part B premiums (belong to a Medicare Savings Program)

 If you have Medicare and get SSI or get help from Medicaid paying your Medicare Part B premiums (or were eligible for either in all or part of this year), you automatically qualify for extra help paying Medicare prescription drug coverage costs…read full article  

I have Medicare and live in a nursing home or other institution

• If you move into or move out of a nursing home or other institution, you can switch Medicare drug plans at that time. You can switch Medicare drug plans at any time while you are living in the institution.
• If you aren’t able to join on your own, your authorized representative can enroll you in a plan that meets your needs.

…read full article  

I have Medicare and benefits through Programs of All-inclusive Care for the Elderly (PACE)

PACE combines medical, social, and long-term care services for frail people who live and get health care in the community. These programs are a joint Medicare and Medicaid option in some states…read full article  

I have Medicare and get help from my State Pharmacy Assistance Program (SPAP) paying prescription drug costs

Several states have programs to help certain people pay for prescription drugs. Each state makes its own rules on how to provide drug coverage to its members. Depending on your state, the State Pharmacy Assistance Program (SPAP) will…read full article  

I have Medicare and get prescription drug coverage from the Indian Health Service, Tribe or Tribal Health Organization, or Urban Indian Health Program

• You and your community may benefit if you join a Medicare drug plan. Ask your health provider or benefits coordinator if joining a plan is right for you. If you decide to join, they can help you find a plan.
• If you get prescription drugs through an Indian health pharmacy, you pay nothing and your coverage won’t be interrupted.

…read full article