Medicare Coverage for Prescription Drugs

What is Medicare prescription drug coverage?

Medicare is a federal government program. It provides healthcare coverage for people age 65 or older, or for people of any age who have certain disabilities. Medicare prescription drug coverage helps pay for brand-name and generic prescription drugs. Everyone covered by Medicare is eligible for this coverage.

When can I get Medicare prescription drug coverage?

You may sign up when you first become eligible for Medicare (3 months before the month you turn age 65 until 3 months after you turn 65). If you get Medicare due to a disability, you can join from 3 months before to 3 months after your 25th month of cash disability payments. If you don't sign up when you are first eligible, you will pay a penalty. If you did not join when you were first eligible, your next opportunity to enroll will be from November 15, 2008, to December 31, 2008.

If you join a Medicare prescription drug plan, you must keep the same plan for the calendar year. You can change plans for the next year between November 15 and December 31. In some cases--for example, if you move or enter a nursing facility--you can switch your plan at other times. If you have both Medicare and Medicaid, you can change plans at any time.

How do Medicare drug plans work?

There are 2 ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other health plan that includes drug coverage. A Medicare Advantage or other health plan, such as an HMO or PPO, often provides more benefits at a lower cost than a prescription-only drug plan (PDP).

As with other types of insurance, you will pay a monthly premium and a yearly deductible. These charges depend on which plan you choose. You will also pay a part of the cost of your prescriptions. Drug costs also depend on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium.

You may qualify for help paying for Medicare prescription drug coverage if your combined savings, investments, and real estate (other than your home) are not worth more than:

• $11,710 if you are single
• $23,410 if you are married and living with your spouse.

If you qualify for Medicaid (through your state government) or for Supplemental Security Income, you may not have to pay a premium or deductible.

What drugs are covered?

A list of drugs that a Medicare drug plan covers is called a formulary. Formularies include generic drugs and brand-name drugs. The formulary must include at least 2 drugs in each category and class of the most commonly prescribed drugs (such as blood pressure medicines or diabetes medicines). This makes sure that people with different medical problems can get the treatment they need.

If the plan does not cover the medicine you have been taking, your current drugs may be covered for a certain time while you work with your healthcare provider to find a different drug that is covered by the plan. If your provider decides that you should not switch to a different drug, you or your provider can contact your plan and ask for an exception. This means the plan agrees to pay for the drug you take even if it is not in their formulary. If the plan refuses to give you an exception, you can appeal the plan's decision. Depending on the outcome of the appeal, you may have to pay for the medicine yourself.

Where can I get help?

To help you compare Medicare drug plans, think about what you need in terms of cost, coverage, convenience, and peace of mind now and in the future. Then use one of the resources below to help you find a plan that meets your needs.

• Download the "Medicare & You" handbook from the Medicare Web site http://www.medicare.gov. You can also ask for it to be mailed to you by ordering it online or by calling Medicare toll-free at 1-800-633-4227. The handbook has drug plan information in it, including which plans are available in your area.
• Call Medicare toll-free at 1-800-633-4227,
• Use the Medicare Prescription Drug Plan Finder at the Medicare Web site. To get personalized drug information, you will need to provide:
  • your Medicare card, which shows your Medicare number and effective date (Part A or Part B)
  • date of birth
  • last name
  • zip code.

  To get general drug plan information or to find out what plans are available in your area, you need to answer just a few questions. You can also enter your current prescription drug information to get more detailed cost information.

You can also call your State Health Insurance Assistance Program. Check the "Medicare & You" handbook for the telephone number in your state.

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