medicare prescription drug manual

8/13/2019 Medicare Prescription Drug Manual

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Your Guide to Medicare

Prescription Drug Coverage

C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

This officialgovernment

booklet tells you:

How your coverage works

How you get Extra Help if you havelimited income and resources

How prescription drug coverageworks with other drug coverage

you may have


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Your Guide to Medicare Prescription Drug Coverage isnt a legal document.Official Medicare Program legal guidance is contained in the relevantstatutes, regulations, and rulings.


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Table of Contents

5 Section 1: The Basics5 Medicare prescription drug

coverage is insurance.

7 Pick the prescription drug coveragethat meets your needs.

8 Get help with your choices.

9 Section 2: How It Works10 How is this coverage different rom

Part B coverage or certain drugs?

10 What plans are available in myarea?

11 How much will my drug coveragecost?

15 How can I pay my plan premium?

16 When can I join, switch, or drop adrug plan?

17 How do I switch my plan?

17 How do I join a plan?

17 What is the Part D late enrollmentpenalty?

18 How do I avoid paying a penalty?

19 How much is the late enrollmentpenalty?

20 What inormation do I need to joina Medicare drug plan?

20 Will I get a separate card or myMedicare drug plan?

21 What i I need to fill a prescriptionbeore I get a membership card?

22 Where can I fill my prescriptions?

22 What are the special rules orpeople with End-Stage RenalDisease (ESRD)?

24 What drugs are covered byMedicare drug plans?

27 What i Im taking a drug that isnt

on my plans drug list when mydrug plan coverage begins?

28 What i I join a plan and then mydoctor changes my prescription?

29 Section 3: How to Get

Extra Help29 Ways you may qualiy or Extra

Help.

33 Applying or Extra Help.

35 How long will I get Extra Help i Iqualiy?

37 I I qualiy or Extra Help, what canI do to make sure I pay the rightamount?

38 What i my application or ExtraHelp is denied?

39 What i I dont qualiy or Extra

Help?

41 Section 4: Your

Coverage Choices41 Get help with prescription drug

coverage decisions.

42 What else do I need to think aboutbeore I decide to get Medicareprescription drug coverage?

44 I have only Part A and/or Part Band no drug coverage.

44 I have Medicare and a Medigap(Medicare Supplement Insurance)policy without prescription drugcoverage.

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

coverage.


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46 I have Medicare and get drugcoverage rom a current or ormer

employer or union.48 I have Medicare and a Federal

Employee Health Benefits (FEHB)plan.

49 I have Medicare and RICARE orbenefits rom the Department oVeterans Affairs (VA) that includedrug coverage.

50 I have a Medicare health planwithout prescription drug coverage.

51 I have a Medicare health plan withprescription drug coverage.

52 I have Medicare and Medicaid.

53 I have Medicare and getSupplemental Security Income (SSI)benefits or help rom Medicaidpaying Medicare Part B premiums(belong to a Medicare SavingsProgram).

54 I have Medicare and live in anursing home or other institution.

55 I have Medicare and benefitsthrough Programs o All-inclusiveCare or the Elderly (PACE).

56 I have Medicare and get helprom my State PharmacyAssistance Program (SPAP) payingprescription drug costs.

57 I get help rom an AIDS Drug

Assistance Program (ADAP).58 I have Medicare and get

prescription drug coverage romthe Indian Health Service, ribeor ribal Health Organization, orUrban Indian Health Program.

59 Section 5: Steps to

Choosing a Medicare Drug

Plan59 Step 1: Gather inormation about your

current prescription drug coverage andneeds.

60 Step 2: Compare Medicare drug plansbased on costs, coverage, and customerservice.

62 Step 3: Decide which plan is best oryou, and join.

63 Section 6: Rights and

Appeals63 How do I protect mysel rom raud

and identity thef?

64 What i I need help applying or ExtraHelp, joining a Medicare drug plan,or filing a coverage determination or

appeal?65 What i my enrollment in a Medicare

drug plan is denied?

66 What do I do i my plan wont cover adrug I need?

67 How do I appeal?

70 What i I dont agree with Medicareslate enrollment penalty?

71 What can I do i I have a complaint(also called a grievance) about my plan?

73 Section 7: For More

Information75 State Health Insurance Assistance

Programs (SHIP) phone numbers

77 Definitions

81 Index

Table of Contents (continued)
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section

1 The BasicsMedicare prescription drug coverage is insurance.

Medicare prescription drug coverage (Part D) adds to your Medicarehealth care coverage. It helps you pay or both brand-name and genericdrugs. Medicare drug plans are offered by insurance companies andother private companies approved by Medicare.

You can get coverage two ways:

Medicare Prescription Drug Plans(sometimes called PDPs) addprescription drug coverage to Original Medicare, some MedicarePrivate Fee-or-Service (PFFS) Plans, some Medicare Cost Plans, andMedicare Medical Savings Account (MSA) Plans.

Medicare Advantage Plans (like an HMO or PPO) or other Medicarehealth plansthat offer prescription drug coverage. You generallyget all o your Medicare Part A (Hospital Insurance), MedicarePart B (Medical Insurance), and Medicare Part D (prescription drugcoverage) through these plans. Medicare Advantage Plans with

prescription drug coverage are sometimes called MA-PDs.

In this booklet, the term Medicare drug plans means all plans thatprovide Medicare prescription drug coverage. You must choose and joina Medicare drug plan to get Medicare prescription drug coverage.

Everyone with Medicare has to make a decision about prescriptiondrug coverage. I you dont use a lot o prescription drugs now, youstill may think about joining a Medicare drug plan to help lower yourprescription drug costs now and help protect against higher costs in theuture. I youre new to Medicare and already have other prescriptiondrug coverage, you have new options to think about. I you arent newto Medicare, you may want to look over your options to find drugcoverage that meets your needs. You can join or switch Medicare drugplans between October 15December 7 each year, with your coveragebeginning January 1 o the ollowing year.

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The Basics1Medicare prescription drug coverage is insurance

(continued).

o join a Medicare Prescription Drug Plan, you must have MedicarePart A orhave Medicare Part B (Medical Insurance). o join aMedicare Advantage Planor other Medicare health planwithprescription drug coverage, you must have Medicare Part A andPart B. You must also live in the service area o the Medicare healthplan or drug plan you want to join.

Medicare drug plans may be different rom each other in theprescription drugs they cover, how much you have to pay, and whichpharmacies you can use. All Medicare drug plans must give at leasta standard level o coverage set by Medicare. However, plans offerdifferent combinations o coverage and cost sharing. Having morethan one plan to choose rom helps you get the coverage you want at aprice you can afford.

I you decide to join a Medicare drug plan, compare plans in your areaand choose one that meets your needs. I you dont join a Medicaredrug plan when youre first eligible or Medicare, and you dont havedrug coverage that is expected to pay, on average, at least as muchas standard Medicare prescription drug coverage (called creditableprescription drug coverage), you may have to pay a late enrollmentpenaltyi you join later. Te penalty is in addition to your premiumeach month or as long as you have a Medicare drug plan.

Te health care law has made Medicare drug coverage more affordablewith the gradual closing o the coverage gap (known as the donut

hole). I you reach the coverage gap, youll get a 50% discount oncovered brand-name drugs and some coverage or generic drugs in thegap. See Section 2or more inormation.

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The Basics1Pick the prescription drug coverage that meets

your needs.

ake time to consider all your prescription drug coverage choicesbeore you make a decision. Look at the prescription drug coverageyou may already have, like coverage rom an employer or union,RICARE, the Department o Veterans Affairs (VA), the IndianHealth Service, or a Medicare Supplement Insurance (Medigap)policy. Compare your current coverage to Medicare prescriptiondrug coverage. Te prescription drug coverage you already have may

change because o Medicare prescription drug coverage, so considerall your coverage options.

I you have (or are eligible or) other types o prescription coverage,read all the materials you get rom your insurer or plan provider.alk to your benefits administrator, insurer, or plan provider beoreyou make any changes to your current coverage.

Note: Prescription drug coverage is insurance. Doctor samples,discount cards, ree clinics, or drug discount Web sites arentprescription drug coverage and arentcreditable prescription drugcoverage.

For details about how Medicare prescription drug coverage mayaffect other coverage, see Section 4.


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The Basics1Get help with your choices.

Visit the Medicare Plan Finder at www.medicare.gov/find-a-planto find plans in your area that cover your prescriptions andpharmacies that can fill your prescriptions.

Call your State Health Insurance Assistance Program (SHIP)orree personalized health insurance counseling. Go to page 75to getthe phone number or the SHIP in your state.

Call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

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section

2 How It WorksHeres what you should compare to find a plan that meets your needs:

Coverage

Medicare drug plans cover generic and brand-name drugs. All plansmust cover the same categories o drugs, but plans can choose whichspecific drugs are covered in each drug category.

Cost

Plans have different monthly premiums. How much you pay or eachprescription depends on which plan you choose. I you have limitedincome and resources, you may qualiy or Extra Helprom Medicarepaying your drug plan costs.

Convenience

Check with the plan to make sure the pharmacies in the plan areconvenient to you. Some plans also allow you to get your prescriptionsby mail. I you spend part o the year in another state, see i the planwill cover you there.

Quality

Use the Medicare Plan Finder at www.medicare.gov/find-a-planto get plan ratings in different categories, like customer service.You can also call 1-800-MEDICARE (1-800-633-4227) or plan ratinginormation. Y users should call 1-877-486-2048.
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How It Works2How is this coverage different from Part B coverage

for certain drugs?Part B gives limited prescription drug coverage. It doesnt cover mostdrugs you get at the pharmacy. You will need to join a prescription drugplan to get Medicare coverage or prescription drugs or most chronicconditions, such as high blood pressure.

Part B covers certain drugs, such as injections you get in a doctorsoffice, certain oral cancer drugs, and drugs used with some types odurable medical equipmentlike a nebulizer or external inusion pump.Under very limited circumstances, Part B covers certain drugs you getin a hospital outpatient setting. You pay 20% o the Medicare-approvedamount or these covered drugs. It also covers the flu and pneumococcalshots. Generally, Medicare drug plans cover other vaccines (like theshingles vaccine) needed to prevent illness.

Note: Generally, sel-administered drugs you get in an outpatient setting(like an emergency room, observation unit, surgery center, or painclinic) arent covered by Medicare Part A or Part B. Your Medicare drug

plan may cover these drugs under certain circumstances. You will likelyneed to pay out-o-pocket or these drugs and send in a claim to yourdrug plan or a reund. Call your plan or more inormation. Also, visitwww.medicare.gov/publicationsto get the act sheet How MedicareCovers Sel-Administered Drugs Given in Hospital Outpatient Settings.

What plans are available in my area?

Get inormation about specific drug plans in your area atwww.medicare.govor by calling 1-800-MEDICARE (1-800-633-4227).

Y users should call 1-877-486-2048. For more inormation on how tocompare plans and join one that meets your needs, see Section 5.

As you compare plans, remember that companies can mail youinormation but theyre not allowed to call you unless youre alreadya plan member. Companies arent allowed to sell plans door-to-doorunless you ask them to come to your home to help you. Also, rememberto keep your personal inormation sae. See pages 6364.
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How It Works2How much will my drug coverage cost?Medicare drug plans differ in exact coverage and costs, but all must offer atleast a standard level o coverage set by Medicare. How much you actuallypay or Medicare prescription drug coverage depends on which drugs youuse, which Medicare drug plan you join, whether you go to a pharmacy inyour plans network, and whether you get Extra Helppaying or your drugcosts. Contact the plan(s) youre interested in to get specific cost inormation.

Your drug coverage costs are affected by:

Monthly premium

Yearly deductible

Copaymentsor coinsurance

Coverage gap(also called the donut hole)

Catastrophic coverage

Monthly premium

Most drug plans charge a monthly ee that differs rom plan to plan. Youpay this ee in addition to the Part B premium. I you belong to a MedicareAdvantage Plan(like an HMO or PPO)or a Medicare Cost Planthatincludes Medicare prescription drug coverage, the monthly premium mayinclude an amount or prescription drug coverage.

Note:A small groupaffecting ewer than 5% o all people with Medicaremay pay a higher monthly premium based on their income.

I you reported a modified adjusted gross income o more than $85,000(individuals and married individuals filing separately) or $170,000 (married

individuals filing jointly) on your IRS tax return 2 years ago (the most recenttax return inormation provided to Social Security by the IRS), you will haveto pay an extra amount or your Medicare prescription drug coverage, calledthe income-related monthly adjustment amount. You pay this extra amountin addition to your monthly Part D plan premium.

Social Security will send you a letter i you have to pay or theincome-related monthly adjustment amount. Check the charts on the nextpage or the amount you will have to pay each month.

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How It Works2If Your Yearly Income in 2010 was You Pay

File Individual Tax Return File Joint Tax Return

$85,000 or less $170,000 or less Your PlanPremium

above $85,000 up to$107,000

above $170,000 up to$214,000

$11.60 + YourPlan Premium

above $107,000 up to$160,000

above $214,001 up to$320,000


above $160,001 up to$214,000

above $320,001 up to$428,000


above $214,000 above $428,000 $66.40 + YourPlan Premium

If Your Yearly Income in 2010 wasYou Pay

File Married & Separate Tax Return

above $85,000 up to $129,000 $48.10 + Your Plan Premium

above $129,000 $66.40 + Your Plan Premium

Your adjustment amount will get taken out o your monthly SocialSecurity, Railroad Retirement, or Office o Personnel Managementcheck, no matter how you usually pay your plan premium. I thatamount is more than whats in your check, you will get a bill romMedicare each month.

I you dont pay your entire Part D premium (including the extra

amount), you may be disenrolled rom your Part D plan. You must payboth the extra amount and your plans premium each month to keepMedicare prescription drug coverage.

I you have to pay a higher amount or your Part D premium and youdisagree, visit www.socialsecurity.govor call 1-800-772-1213. Y usersshould call 1-800-325-0778.
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How It Works2Yearly deductible

Te deductible is what you pay or your prescriptions beore your planbegins to pay. No Medicare drug plan may have a deductible more than$320 in 2012. Some plans charge no deductible.

Copaymentsor coinsurance

You pay these amounts or your prescriptions afer you pay the deductible.You pay your share, and your plan pays its share or covered drugs.

Coverage gap(also called the donut hole)

Most Medicare drug plans have a coverage gapafer you and your planhave spent a certain amount o money or covered drugs, you pay all costsor your drugs out-o-pocket (up to a limit). Not everyone will reach thecoverage gap. Your yearly deductible, coinsurance or copayments, and whatyou pay in the coverage gap all count toward this out-o-pocket limit. Telimit doesnt include the drug plans premium or what you pay or drugsthat arent on your plans drug list.

Some plans offer some coverage during the gap, like or generic drugs.However, plans with gap coverage may charge a higher monthly premium.Check with the plan first to see i your drugs would be covered during thegap.

For 2012, i you reach the coverage gap in your Medicare prescriptiondrug coverage, you will get a 50% discount on covered brand-name drugswhen you buy them, until you reach the out-o-pocket limit. You will alsoget some coverage or covered generic drugs while in coverage gap, andthis coverage will grow each year. In 2012, you will get a 14% discount on

generic drugs you buy while in the coverage gap. In 2013, you will get a 21%discount. By 2020, you will get a 75% discount both or covered generic andbrand-name drugs when in the gap.

Each month that you fill a prescription, your drug plan mails you anExplanation o Benefits (EOB) notice, which tells you how much you havespent on covered drugs and i youve reached the coverage gap. In 2012,your EOB notice will also show the 50% discount on brand-name drugsyou buy in the coverage gap.



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How It Works2Catastrophic coverage

What you pay or drugs and the 50% discount in the coverage gapboth counttoward your out-o-pocket limit. Once you reach your plans out-o-pocketlimit, you come out o the coverage gap and you automatically getcatastrophic coverage. Under catastrophic coverage, you only pay a smallcoinsuranceamount or a copaymentor the rest o the year.

Note: I you get Extra Helppaying your drug costs, you wont have acoverage gap and you will pay either a small copayment or no copaymentonce you reach catastrophic coverage.

Te example below shows the costs or covered drugs in 2012 or a plan

that has a coverage gap.

Ms. Smith joined the ABC Prescription Drug Plan. Her coverage began on

January 1, 2012. She doesnt get Extra Help and uses her Medicare drug

plan membership card when she buys prescriptions.

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7780.

Monthly PremiumMs. Smith pays a monthly premium throughout the year.

1. YearlyDeductible

2. Copaymentor Coinsurance

3. Coverage Gap 4. CatastrophicCoverage

Ms. Smithpays thefirst $320o herdrug costsbeore herplan starts

to pay itsshare.

Ms. Smith paysa copayment,and her planpays its shareor each covereddrug until theircombined

amount (plusthe deductible)reaches $2,930.

Once Ms. Smith and her plan havespent $2,930 or covered drugs, sheis in the coverage gap. In 2012, shegets a 50% discount on coveredbrand-name prescription drugs thatcounts as out-o-pocket spending,and helps her get out o the coverage

gap. For 2012, she also gets 14%coverage on covered generic drugswhile in the coverage gap.

Once Ms. Smithhas spent $4,700out-o-pocket or theyear, her coveragegap ends. Now sheonly pays a smallcopayment or each

drug until the end othe year.

Visit the Medicare Plan Finder at www.medicare.gov/find-a-planto view estimated yearlycosts or each plan and your costs per prescription or each month.
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How It Works2How can I pay my plan premium?

1. Deduct it rom your checking or savings account.

2. Charge it to a credit or debit card.

3. Have your plan bill you each month directly. Some plans bill in advanceor next months coverage. Send your payment to the plannot toMedicare. Contact your plan or their payment address.

4. Withheld unds rom your Social Security payment. Contact your plannot Social Securityto ask or this payment option. It may take up to3 months to start, and its likely the first 3 months o premiums will becollected at one time.

Example o Social Security Withholding:Ms. Browns monthly drug planpremium is $25, and her coverage begins in January. Her first premiumpayment o $75 is collected in March. It includes her premium or January,February, and March. Afer March, only 1 month o premium payments($25) will be withheld rom her Social Security payment each month.

I you have your premium withheld rom your Social Security payment, and

you have another insurer or benefit pay part o your drug plan premium(such as an employer health plan or a State Pharmacy Assistance Program(SPAP)), Social Security will withhold your entire monthly premium. Yourdrug plan will need to give you a reund or the amount your employerhealth plan or SPAP paid. You may experience delays in getting yourreund.

Example: Mr. Andersons monthly drug plan premium is $30. His employerpays $15 toward his premium.

I Mr. Anderson gets his premium withheld rom his Social Securitypayment, the ull $30 will be withheld. Te drug plan will have to give hima reund o $15 or the share o the premium paid by his employer.

I the drug plan bills Mr. Anderson directly, he will pay his share ($15) tohis plan. His employer will pay its share ($15) directly to his plan.

I you qualiy or Extra Help, some or all o your drug plan premiumsmay becovered. For more inormation, see Section 3.
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How It Works2When can I join, switch, or drop a drug plan?

You can join, switch, or drop a Medicare drug plan:

When you first become eligible or Medicare. You can join during the7-month period that begins the 3 months beore you turn 65, includesthe month you turn 65, and ends 3 months afer the month you turn65. I you get Medicare due to a disability, you can join during the 3months beore to 3 months afer your 25th month o disability. You willhave another chance to join during the 7-month period that begins 3months beore the month you turn 65, includes the month you turn 65,

and ends 3 months afer the month you turn 65. Between October 15December 7 each year. Your coverage begins

January 1 the ollowing year, as long as the plan gets your request orenrollment by December 7.

At any time i you qualiy or Extra Help.Tis includes people whohave Medicare and Medicaid, belong to a Medicare Savings Program,get Supplemental Security Income (SSI) benefits, and those who applyand qualiy.

Note: In certain limited circumstances, you may be able to join, drop, orswitch to another Medicare drug plan at other times. For example, youmay be able to switch at other times i you permanently move out o yourdrug plans service area, lose creditable prescription drug coverage, or iyou enter, live in, or leave a nursing home.

I you currently have Medicare prescription drug coverage, you maywant to review your coverage each all season. I youre happy withyour coverage, cost, and customer service, and your Medicare drug plan

is still offered in your area, you dont have to do anything to continueyour coverage or another year. However, i you decide another plan willbetter meet your needs, you can switch to a different plan.
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How It Works2How do I avoid paying a penalty?

Join a Medicare drug plan when youre first eligible,or get othercreditable prescription drug coverageat that time.

Dont go 63 days or more in a row without a Medicare drug plan orother creditable prescription drug coverage.Creditable prescriptiondrug coverage could include drug coverage rom a ormer employeror union, RICARE, the Department o Veteran Affairs (VA), or theIndian Health Service. Your plan must tell you each year i your drugcoverage is creditable coverage. Tey may send you this inormation

in a letter or include it in a newsletter rom the plan. Keep thisinormation, because you may need it i you join a Medicare drugplan later.

ell your Medicare drug plan when you join i you have othercreditable prescription drug coverage.When you join a Medicaredrug plan, the plan may send you a letter asking i you havecreditable prescription drug coverage i the plan believes you went63 days in a row without other creditable prescription drug coverage.Complete the orm and return it to them by the deadline in the letter.

I you dont tell your plan about your creditable prescription drugcoverage, you may have to pay a penalty.


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How It Works2How much is the late enrollment penalty?

Currently, the late enrollment penaltyis calculated by multiplying the1% penalty rate times the national base beneficiary premium ($31.08in 2012) times the number o ull, uncovered months you were eligibleto join a Medicare drug plan but didnt and went without othercreditable prescription drug coverage.

Te final amount is rounded to the nearest $.10 and added to yourmonthly premium. Te national base beneficiary premium maygo up each year, so the penalty amount may also go up every year.In addition to your premium each month, you may have to pay thispenalty or as long as you have a Medicare drug plan.

Example: Mrs. Jones didnt join when she was first eligibleby June 15, 2009. She joined a Medicare drug plan betweenOctober 15December 7, 2011, or an effective date oJanuary 1, 2012. Since Mrs. Jones didnt join when she was firsteligible and went without other creditable prescription drugcoverage or 30 months (July 2009December 2011), she willbe charged a monthly penalty o $9.30 in 2012 ($31.08 nationalbase beneficiary premium x .01 penalty rate x 30 months = $9.32,rounded to nearest $.10 = $9.30). She pays this late enrollmentpenalty monthly in addition to her plans monthly premium.

When you join a Medicare drug plan, the plan will tell you i you owea penalty and what your premium will be.
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How It Works2What information do I need to join a Medicare

drug plan?

Name, birth date, and permanent street address

Inormation ound on your Medicare card (Medicare number)

How you want to pay your plan premiums

Other insurance inormation and any creditable coveragenotices

You may be asked or the ollowing inormation when you join aMedicare drug plan, but its optional and not required to process yourenrollment:

Social Security number

E-mail address

Name and inormation or an emergency contact

Name, address, and phone number o nursing home or institutionwhere you live (i applicable)

Once you join a plan, the company will send you specific materials

you will need, like a membership card, member handbook, drug list,pharmacy provider directory, and complaint and appeal procedures.

Will I get a separate card for my Medicare drug

plan?

When you join a Medicare Prescription Drug Planthat works withOriginal Medicare, the plan will mail you a separate card to use whenyou fill your prescriptions. You will still use your red, white, and blue

Medicare card or hospital and doctor services. I you join a MedicareAdvantage Plan(like an HMO or PPO) or otherMedicare health planwith prescription drug coverage, you will also get a new card to usewhen filling your prescriptions.

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How It Works2What if I need to fill a prescription before I get a

membership card?

Within 2 weeks afer your plan gets your completed application, you willget a letter letting you know they got your inormation. Within 5 weeks,you should get a welcome package with your membership card. I youneed to go to the pharmacy beore your membership card arrives, youcan use any o the ollowing as proo o membership:

Te acknowledgement, confirmation, or welcome letter you got romthe plan.

An enrollment confirmation number you got rom the plan, and theplan name and phone number.

A temporary card you may be able to print rom www.MyMedicare.gov.

Also bring your Medicare and/or Medicaidcard and a photo ID. I youqualiy or Extra Help, see page 37 or more inormation about what youcan use as proo o Extra Help. I you dont have any o the items above,and your pharmacist cant get your drug plan inormation any other way,you may have to pay out-o-pocket or your prescriptions.I you do, savethe receipts and contact your planyou may be able to get back some

o the cost or have the amount credited toward your out-o-pocket

costs.

Once you choose a plan, enroll early in the month. Tis gives theMedicare drug plan time to mail you important inormation, like yourmembership card, beore your coverage becomes effective. Tis way, eveni you go to the pharmacy on your first day o coverage, you can fill yourprescriptions without delay.
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How It Works2What drugs are covered by Medicare drug plans?

Each plan may cover different drugs, so theres no singledrug listthatfits all plans. All Medicare drug plans must make sure the people intheir plan can get medically-necessarydrugs to treat their conditions.Drug lists (ormularies), prior authorization, step therapy, and quantitylimits are some o the rules plans use to make sure certain drugs areused correctly and only when medically necessary. Tese topics aredescribed in the ollowing our sections.

Drug Lists (Formularies)Each Medicare drug plan has its own list o covered prescription,called a ormulary. Plans cover both generic and brand-nameprescription drugs. Medicare drug plans arent required to covercertain drugs, such as benzodiazepines, barbiturates, drugs or weightloss or gain, and drugs or erectile dysunction. Some plans may coverthese drugs as an added benefit. Also, drug plans generally dont payor over-the-counter drugs. Some states may cover these drugs i youhave Medicaid.

o make sure people with different medical conditions can get theprescriptions they need, drug lists or each plan must include arange o drugs in each prescribed category. All Medicare drug plansgenerally must cover at least two drugs per drug category, but theplans can choose which specific drugs they cover. Plans are required tocover almost all drugs within these protected classes: anti-psychotics,anti-depressants, anti-convulsants, immunosuppressants, cancer, andHIV/AIDS drugs.

I you use a drug not on your plans drug list, youll have to pay ullprice instead o a copaymentor coinsurance. All Medicare drug planshave negotiated to get lower prices or the drugs on their drug lists, sousing those drugs will generally save you money. Also, using genericsinstead o brand-name drugs may save you money.

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How It Works2Prior Authorization

You may need drugs that require prior authorization. Tis means beorethe plan will cover a particular drug, your doctor or other prescribermust first show the plan you have amedically-necessaryneed or thatparticular drug. Plans also do this to be sure these drugs are usedcorrectly. Contact your plan about its prior authorization requirements,and talk with your prescriber.

Step Therapy

Step therapy is a type o prior authorization. In most cases, you mustfirst try a certain less-expensive drug on the plans drug listthats beenproven effective or most people with your condition beore you canmove up a step to a more expensive drug. For instance, some plansmay require you first to try a generic drug (i available), then a lessexpensive brand-name drug on their drug list beore you can get asimilar, more expensive brand-name drug covered.

However, i you have already tried the similar, less-expensive drug

and it didnt work, or i your prescriber believes that because o yourmedical condition its medically necessary or you to be on a moreexpensive step-therapy drug, he or she can contact the plan to requestan exception. I your prescribers request is approved, the plan will coverthe more expensive drug.

Example:

Step 1Dr. Smith wants to prescribe an ACE inhibitor to treatMr. Masons heart ailure. Tere is more than one type o ACE

inhibitor. Some o the drugs Dr. Smith considers prescribing arebrand-name drugs covered by Mr. Masons Medicare drug plan.Te plan rules require Mr. Mason to use the generic drug lisinoprilfirst. For most people, lisinopril works as well as brand-name drugs.

Step 2I Mr. Mason takes lisinopril but has side effects or limitedimprovement, Dr. Smith can provide that inormation to theplan to get approval to prescribe a brand-name drug. I approved,Mr. Masons Medicare drug plan will then cover the brand-name

drug.

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How It Works2What if I join a plan and then my doctor changes

my prescription?

Your doctor or other prescriber may need to change your prescriptionor prescribe a new drug. I your doctor prescribes electronically, heor she can check which drugs your drug plan covers through his orher electronic prescribing system. I your doctor doesnt prescribeelectronically, give him or her a copy o your Medicare drug planscurrent drug list.

I your doctor needs to prescribe a drug not on your Medicare drugplans drug list and you dont have any other health insurance thatcovers outpatient prescription drugs, you or your doctor can ask theplan or an exception.

I your plan still wont cover a specific drug you need, you can appeal.I you want to get the drug beore your appeal is decided, you may haveto pay out-o-pocket or the prescription. Keep the receipt and give acopy o it to the person deciding your appeal. I you win the appeal, theplan will pay you back. For more inormation about what to do i a planwont cover a drug you need, see page 66.

Plans can change their drug list and prices or drugs. Call your plan orlook on your plans Web site to find the most up-to-date Medicare druglist and prices.

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section

3 How to Get Extra HelpWays you may qualify for Extra Help.

1. You automatically qualiy and dont need to apply.

Medicare mails purple letters to people who automatically qualiy orExtra Help. I you get one, keep it as proo that you qualiy. You dontneed to apply or Extra Help i you get this purple letter.

You automatically qualiy or Extra Help i any o the ollowing are

true: You get ull coverage rom a state Medicaidprogram.

You get help rom your state Medicaid program paying yourMedicare Part B premiums(a Medicare Savings Program).

You get Supplemental Security Income (SSI) benefits.

I you arent already in a Medicare drug plan, you must join oneto get this Extra Help. I you dont join a Medicare drug plan onyour own, Medicare will enroll you in a plan so you get help payingor your prescription drugs, unless you have certain retiree drugcoverage rom a ormer employer or union. I Medicare enrolls youin a plan, then Medicare will send you a yellow letter (i you getull Medicaid coverage or SSI) or a green letter (i you belong to aMedicare Savings Program) letting you know when your coveragebegins. Check to see i the plan covers the drugs you use and i youcan go to the pharmacies you want.

I Medicare enrolls you in a plan that doesnt meet your needs, you

can switch plans at any time, and your new plan will begin the firstday o the next month. I you dont want Medicare to enroll you ina Medicare drug plan (or example, because you want to keep youremployer or union coverage), call the plan listed in the letter.ell them you dont want to be in a Medicare drug plan and want toopt out o enrollment. Or call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048.
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How to Get Extra Help3Medicare Drug Plan Costs if You Automatically Qualifyfor Extra Help

I you have Medicareand...

Yourmonthlypremium*

Your yearlydeductible

Your cost perprescription atthe pharmacy(until $4,700**)

Your cost perprescription atthe pharmacy(afer $4,700**)

Full Medicaid coverageor each ull month youlive in an institution, likea nursing home

$0 $0 $0 $0

Full Medicaid coverageand have a yearly incomeat or below$11,170 (single)$15,130 (married)

$0 $0 Generic and certainpreerred drugs:no more than $1.10Brand-name drugs:no more than $3.30

$0

Full Medicaid coverageand have a yearly incomeabove$11,170 (single)$15,130 (married)


$0

Help rom Medicaidpaying your MedicarePart B premiums


$0

Supplemental SecurityIncome (SSI)

$0 $0 Generic and certainpreerred drugs:no more than $2.60Brand-name drugs:

no more than $6.50

$0

Notes: *Tere are plans you can join and pay no premium. Tere are other plans where you willhave to pay part o the premium even when you automatically qualiy or Extra Help. ell yourplan you qualiy or Extra Help and ask how much you will pay or your monthly premium.

** Your cost per prescription generally decreases once the amount you pay and Medicare pays asthe Extra Help reach $4,700 per year.

Te cost sharing, income levels, and resources listed are or 2012 and can increase each year.Income levels are higher i you live in Alaska or Hawaii, or you or your spouse pays at least halo the living expenses o dependent amily members who live with you, or you work.


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How to Get Extra Help3Medicare Drug Plan Costs if You Apply and Qualifyfor Extra Help

I you have Medicare and... Your

monthly

premium*

Your

yearly

deductible

Your cost per

prescription

at the pharmacy

(until $4,700**)

Your cost per

prescription

at the pharmacy

(afer $4,700**)

A yearly income below$15,079.50 (single)$20,425.50 (married) withresources o no more than$8,440 (single)$13,410 (married)

$0 $0 Generic andcertain preerreddrugs:no morethan $2.60Brand-name

drugs:no morethan $6.50

$0

A yearly income below$15,079.50 (single)$20,425.50 (married)with resources between$8,440 and $13,070 (single)$13,410 and $26,120 (married)

$0 $65 up to 15% othe cost o eachprescription

Generic and certaipreerred drugs:no more than $2.60Brand-name drugno more than $6.50

A yearly income between$15,079.50 and $15,638 (single)$20,425.50 and $21,182 (married)with resources up to$13,070 (single)$26,120 (married)

25% $65 up to 15% othe cost o eachprescription

Generic and certaipreerred drugs:no more than $2.60Brand-name drugno more than $6.50

A yearly income between$15,638 and $16,196.50 (single)$21,182 and $21,938.50 (married)with resources up to

$13,070 (single)$26,120 (married)


Generic and certaipreerred drugs:no more than $2.60Brand-name drug

no more than $6.50

A yearly income between$16,196.50 and $16,755 (single)$21,938.50 and $22,695 (married)with resources up to$13,070 (single)$26,120 (married)


Generic and certapreerred drugs:no more than $2.6Brand-name drugno more than $6.5

Please see the notes below the table on page 30or more inormation.
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How to Get Extra Help3


7780.

Applying for Extra Help.

Whose income and resources count?

Yourown income and resources count.

I youre married and live with your spouse, botho your incomesand resources count, even i only one o you applies or Extra Help.

I youre married and dont live with your spouse when you apply,onlyyourincome and resources count.

Note: Married couples living together who both apply or Extra Helpthrough Social Security can use the same application orm (SSA-1020),available at www.socialsecurity.gov/i1020.

What income counts?

Income means any cash, goods, or services you can use to meet yourneeds or ood or shelter. Examples include (but arent limited to):

Income counted

Wages Earnings rom sel-employment

Social Security benefits

Railroad Retirement benefits

Veterans benefits

Pensions

Annuities

Alimony

Rental income

Workers Compensation

Income notcounted

Income tax reunds Assistance based on need, unded

by a state or local government(such as housing assistance anddisaster assistance)

Foster care payments

Te value o expenses which ablind or disabled person needs towork

In-kind support rom amily orriends, such as ree rent, ood orclothing

Scholarship and education grants
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How to Get Extra Help3I you apply and qualiy or Extra Help

I you qualiy or Extra Help, youll get the Extra Help or thecalendar year as long as youre enrolled in a Medicare drug plan andthere are no changes to your income, resources, or amily size.

Youll also get the Extra Help or the calendar year as long as youdont have a change in your marital status, such as:

Marriage

Divorce

Annulment

Separation (not temporary)

Spouses resume living together afer separating

Death o spouse

I you applied to Social Security or Extra Help and you qualified,notiy them i your marital status changes, because it could raise,lower, or stop the amount o Extra Help you get. Te change in ExtraHelp you get starts the month afer you report the change in your

marital status.

You can report changes in your income, resources, or amily size anytime, and Social Security will review these changes rom August toDecember. Any changes affecting your Extra Help start January 1 othe ollowing year.

I you applied or Extra Help through your state, and you qualiy,your states rules may require you to tell them about changes in yourcircumstances.


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How to Get Extra Help3If I qualify for Extra Help, what can I do to make

sure I pay the right amount?

I you automatically qualiy, you should get a purple, yellow, or greenletter rom Medicare that you can show to your plan as proo you qualiyor Extra Help. I you applied or Extra Help, you can show your planyour Notice o Award letter rom Social Security as proo you qualiy.I you have Supplemental Security Income (SSI), you can use your awardletter rom Social Security as proo you have SSI.

You can also give your plan any o the ollowing documents as proo.Each item must show you were eligible or Medicaidduring a month aferJune 2010.

Proo you have Medicaid and live

in an institution or get home and

community-based services

Other proo you have Medicaid

A bill rom an institution(like anursing home) or a copy o a state

document showing Medicaid paidor your stay or at least a month

A print-out rom your statesMedicaid system showing youlived in the institution or at least amonth

A document rom your statethat shows you have Medicaidand are getting home and

community-based services

A copy o your Medicaid card(i you have one)

A copy o a state documentthat shows you have Medicaid

A print-out rom a stateelectronic enrollment file, orscreen print rom your statesMedicaid systems that showsyou have Medicaid

Any other document romyour state that shows you haveMedicaid

Your plan must accept any o these documents as proo you qualiy orExtra Help. As soon as you have given them any one o these documents,your plan must make sure you pay no more than the right amount to fillyour prescriptions.

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How to Get Extra Help3I you qualiy or Extra Helpbecause you have Medicaid, but you dont

have or cant find any o these documents, ask your plan or help. Your planmust also contact Medicare so Medicare can get proo that you qualiy, iits available. You should expect your request to take anywhere rom severaldays to up to 2 weeks, depending on the circumstances. Be sure to tell yourplan how many days o medication you have lef. Your plan and Medicarewill work to process your request beore you run out o medication, ipossible.

I you paid or prescriptions since you qualified or Extra Help, you

may be able to get back part o what you paid. Keep your receipts,and call Medicares Limited Income Newly Eligible ransition (NE)Program at 1-800-783-1307 or more inormation. Y users should call1-877-801-0369.

I your plan doesnt correct a problem to help you pay the right amountor your prescriptions, or doesnt respond to your request or help, ortakes longer than expected to get back to you, call 1-800-MEDICARE(1-800-633-4227) to file a complaint. Y users should call 1-877-486-2048.

What if my application for Extra Help is denied?

You have the right to appeal the decision. I you applied with SocialSecurity, they will give you a hearing by phone unless you choose a casereview. Either way, Social Security will review those parts o the decisionwhich you believe are wrong and will look at any new acts you provide.Social Security may also review those parts which you believe are correct.Someone who wasnt involved in the first decision will decide your case.

o request an appeal, call Social Security at 1-800-772-1213. Y usersshould call 1-800-325-0778. You can also get a copy o orm SSA-1021(Appeal o Determination or Help with Medicare Prescription DrugCosts) by visiting www.socialsecurity.gov/i1020.

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Your Coverage Choices4I have Medicare and a Medigap (Medicare

Supplement Insurance) policy with prescription

drug coverage.Beore 2006, some Medigappoliciesincluded prescription drug coverage.I you still have a Medigap policy with prescription drug coverage, yourMedigap insurer must send you a detailed notice each year describingyour choices or prescription drug coverage and stating whether theirdrug coverage is creditable prescription drug coverage. Some o yourchoices or prescription drug coverage include:

Joining a Medicare Prescription Drug Planand keeping your currentMedigap policy without the prescription drug coverage.

Joining a Medicare Advantage Planthat includes prescription drugcoverage. You would get all your health care coverage includingprescription drug coverage rom this plan, and you wouldnt need aMedigap policy. I you join a Medicare Medical Savings Account (MSA)Plan(a type o Medicare Advantage Plan) you can continue to use yourMedigap drug coverage, since MSAs cant offer Medicare prescription

drug coverage. Keeping your current Medigap policy with the prescription drug

coverage included.

Inormation you get rom your Medigap insurer describes these choices indetail. You can also check with your State Insurance Department to findout what other options you may have or prescription drug coverage.

I you decide to join a Medicare Prescription Drug Plan, you can keepyour current Medigap policy without the prescription drug coverage.

You will need to tell your Medigap insurer when your Medicareprescription drug coverage starts. Tey must remove the prescriptiondrug coverage rom your Medigap policy and adjust your premiumbasedon this change. Also, you may have to pay a late enrollment penaltyto join a Medicare Prescription Drug Plan i the prescription drug

coverage you have had under your Medigap policy isnt creditable

prescription drug coverage. You may have to pay this higher premiumor as long as youre in a Medicare Prescription Drug Plan.

ip:Contactyour Medigapinsurer beoreyou make any

changes to yourprescriptiondrug coverage.
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Your Coverage Choices4I have Medicare and a Federal Employee Health

Benefits (FEHB) plan.

During the open enrollment season you will get inormationabout your prescription drug coverage and whether its creditableprescription drug coverage. Read this inormation careully.

Contact your FEHB insurer beore making any changes. It willalmost always be to your advantage to keep your current coveragewithout any changes. It isnt cost effective or most people coveredunder a FEHB plan to join a Medicare drug plan unless they qualiy

or Extra Help. Caution:You cant drop FEHB drug coveragewithout also dropping FEHB plan coverage or hospital and medicalservices, which may mean higher costs or these services.

I you do qualiy or Extra Help paying Medicare prescription drugcosts, see how your costs with a Medicare drug plan and any ExtraHelp would compare to your FEHB plan prescription drug coverage.

I you ever lose your FEHB coverage and need to join a Medicaredrug plan, in most cases you wont have to pay a late enrollment

penalty, i you join within 63 days o losing FEHB coverage. I you join a Medicare drug plan, you can keep your FEHB plan.

For more inormation, call the Office o Personnel Management at1-888-767-6738, or visit www.opm.gov/insure/health/. Y usersshould call 1-800-878-5707. You can also call your plan.
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Your Coverage Choices4I have Medicare and Medicaid.

Medicare helps pay or your prescription drugs instead o Medicaid.Because you have Medicaid, Medicare automatically gives you Extra Helpwith your Medicare drug plan costs. See pages 2930or inormationabout your costs. I you live in an institution(like a nursing home), inmost cases you pay nothing or your covered prescriptions.

I you havent joined a Medicare drug plan, Medicare will enroll you in adrug plan to make sure you have drug coverage (unless you already havecertain retiree drug coverage). Medicare sends you a yellow notice tellingyou what drug plan youre in and when your coverage starts. Check to seei the plan covers the drugs you take and includes the pharmacies you use.You can switch to a different Medicare drug plan at any time.

I you filled any covered prescriptions beore your Medicare drug plancoverage started, you may be able to get back some o the money youspent. Call Medicares Limited Income Newly Eligible ransition (NE)Program at 1-800-783-1307 or more inormation. Y users should call1-877-801-0369.

I you dont want Medicare prescription drug coverage and you dont wantMedicare to enroll you in a Medicare drug plan (or example, because youhave othercreditable prescription drug coverage), call 1-800-MEDICARE(1-800-633-4227) and tell them you want to opt out o (decline) Medicareprescription drug coverage. Y users should call 1-877-486-2048.

Caution: I you call 1-800-MEDICARE and opt out o a Medicare drugplan, you could be lef without any prescription drug coverage. You can

change your mind and join a Medicare drug plan at any time withoutpenaltyas long as you continue to qualiy or Extra Help.

In limited cases, some state Medicaid programs may pay or prescriptionsMedicare doesnt cover. I you continue to qualiy or Medicaid, Medicaidwill still cover the other health care costs that Medicare doesnt cover.I you arent sure whether you still qualiy or Medicaid, call your StateMedical Assistance (Medicaid) office. o get the phone number, visitwww.medicare.gov/contacts, or call 1-800-MEDICARE.

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Your Coverage Choices4I have Medicare and get Supplemental Security

Income (SSI) benefits or help from Medicaid

paying Medicare Part B premiums (belong to a

Medicare Savings Program).I you have Medicare and get SSI or belong to a Medicare SavingsProgram (or were eligible or either at any time this year), Medicarewill send you a purple notice letting you know you automaticallyqualiy or Extra Helppaying your Medicare prescription drugcoverage costs. You get it automatically when you join a Medicaredrug plan. See pages 2930or more inormation about your costs.

I you dont join a Medicare drug plan on your own, Medicare will

enroll you in a Medicare Prescription Drug Plan, to make sure you

have coverage, unless you already have certain retiree drug coverage.Medicare sends you a yellow notice (i you have SSI) or a green notice(i you belong to a Medicare Savings Program) letting you know whenyour coverage begins. You can switch to a different Medicare drugplan at any time without penaltyas long as you continue to qualiy or

Extra Help.

I you dont want Medicare prescription drug coverage, and you dontwant Medicare to enroll you in a Medicare drug plan (or example,because you have other creditable prescription drug coverage), call1-800-MEDICARE (1-800-633-4227) and tell them you want to optout o (decline) Medicare prescription drug coverage. Y usersshould call 1-877-486-2048.

Caution: I you call 1-800-MEDICARE and tell them you dont wantto join a Medicare drug plan, you could be lef without prescriptiondrug coverage. You can change your mind and join a Medicare drugplan at any time without penalty as long as you continue to qualiy orExtra Help.
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Steps to Choosing a Medicare Drug Plan5Reer to the worksheets on pages 6061. Compare the Medicare

drug plans based on whats most important to your situation andyour drug needs. You may want to ask yoursel:

Which plan(s) cover the prescriptions I take?

Which plan gives me the best overall price on all o myprescriptions?

What is the monthly premium, yearly deductible, and thecoinsuranceor copayment(s)?

Which plan(s) allows me to use the pharmacy I want?

Which plan(s) allows me to get prescriptions through the mail?

Which plan(s) provides me with coverage in multiple states (i Ineed it)?

How are the plans quality ratings?

Will I have to pay a penaltybecause I waited to join?

Can my coverage start when I want it to?

Is it likely that I will need protection against unexpected drug

costs in the uture? Am I satisfied with my Medicare drug plans service (i I already

have a plan)?

I you need help with your Medicare prescription drug coveragedecisions, call your State Health Insurance Assistance Program(SHIP). See page 75or their phone number. You can also visitwww.medicare.gov/contacts, or call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.

Step 3: Decide which plan is best for you, and

join.

Afer you pick a plan that meets your needs, call the companyoffering it and ask how to join. You may be able to join by phone,by paper application, or online. You will have to give the numberon your Medicare card when you join.

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section

6 Rights and AppealsHow do I protect myself from fraud and identity theft?

Help protect yoursel by knowing whether Medicare Advantage PlansandMedicare Prescription Drug Plansare marketing to you properly. Tese plansand people who work with Medicare arentallowed to:

Charge you a ee to enroll in a plan.

Send you unwanted emails.

Come to your home uninvited to get you to join a Medicare plan. Call you, unless youre already a plan member. I youre a member, the agent

who helped you join can call you.

Offer you cash to join their plan or give you ree meals while trying to sellyou a plan.

Enroll you into a drug plan over the phone unless you call them and ask toenroll.

Ask you or payment over the phone or Internet. Te plan must send you a

bill. Sell you a non-health related product, like an annuity or lie insurance

policy, while trying to sell you a Medicare health or drug plan.

Make an appointment to tell you about their plan unless you agree (inwriting or through a recorded phone discussion) to the products beingdiscussed. During the appointment, they can only try to sell you theproducts you agreed to hear about.

alk to you about their plan in areas where you get health care, like anexam room, hospital patient room, or at a pharmacy counter.

ry to sell you their plans or enroll you during an educational event, like ahealth air or conerence.

Independent agents and brokers working or plans must be licensed by thestate. Te plan must tell the state which agents are selling their plans.

I youre in a Medicare Prescription Drug Planand you think the plan maybe breaking these rules, call the Medicare drug plan integrity contractor at1-877-7SAFERX (1-877-772-3379).
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Rights and Appeals6You can appoint your representative in one o the ollowing ways:

1. Fill out an Appointment o Representative orm (CMS Form Number1696) available at www.cms.gov/cmsorms/downloads/cms1696.pd, or call1-800-MEDICARE (1-800-633-4227) and ask or a ree copy. Y usersshould call 1-877-486-2048.

2. Submit a letter that includes the ollowing:

Your name, address, and phone number

Your Medicare number (ound on your red, white, and blue Medicare

card)A statement appointing someone as your representative

Te name, address, and phone number o your representative

Te proessional status o your representative or their relationship toyou

A statement authorizing the release o your personal and identifiablehealth inormation to your representative

A statement explaining why youre being represented

Your signature and the date you signed the letterYour representatives signature and the date they signed the letter

You must send the orm or letter with your appeal request. See page 67onhow to request an appeal. Te person helping you must send a copy o theorm or letter each time you file a coverage determinationor appeal, so itsa good idea to make at least one additional copy o the orm or letter beoreyou send it. I you have questions about appointing a representative, call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

What if my enrollment in a Medicare drug plan is

denied?

Medicare drug plans generally have to accept all eligible applicants who livein their service area, regardless o the applicants age or health status. I yourenrollment orm is denied, the company will send you a letter explainingwhy. You may contact the plan or more inormation about your options.

ip:Keepyour personalinormationsae. Dontgive yourinormationto anyone whocomes to your

home (or callsyou) uninvitedsellingMedicare-relatedproducts.
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Rights and Appeals6How do I appeal?

I you ask or a coverage determinationand then you disagree withthe plans decision, you can appeal the decision. Tere are five levelso appeal available to you, but you must ollow the order listed below:

1. Request an appeal through your plan.

Te first level o appeal is called a redetermination. Any unavorablecoverage determination decision you get rom your plan will tell youhow to file a redetermination. You must request this appeal within

60 calendar days rom the date o the coverage determination notice.You, your representative, or your doctor or other prescriber can askyour plan or either a standard or an expedited redetermination. Youmust make your standard redetermination request in writing unlessyour plan allows you to file a request by phone. Your request will beexpedited (sped up) i your plan determines, or your prescriber tellsyour plan, that your lie or health may be at risk by waiting or astandard decision. You can make an expedited request in writing orby phone. Your request will notbe expedited i youre asking to get

paid back or a drug you already bought.

While your plan must accept any written request, you may want toinclude:

Your name, address, and Medicare number shown on yourMedicare card

Te name o the prescription drug you want your plan to cover

Reason(s) why youre appealing, and any supporting documentationthat you believe may help your case

Your signature or the signature o your representative

Te plan has 7 calendar days (or a standard request or or a requestto pay you back) or 72 hours (or an expedited request) rom the dateit gets your appeal request to let you know its decision.


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Rights and Appeals6Your plan must give you its decision generally no later than 30

days afer it gets your complaint. Te plan may extend the 30-daynotification by up to 14 days i you (or your representative) request anextension, or i the plan can show good reason or needing additionalinormation and that the delay is in your best interest.

I your complaint has to do with a plans reusal to expedite acoverage determinationor redetermination, and you havent yetbought or didnt get the drug, you must be given the decision no laterthan 24 hours afer the plan gets the complaint.

I you think you were charged too much or a prescription, call thecompany offering your plan to get the most up-to-date price. I theplan doesnt take care o your complaint, call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.


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For More Information7Note: I you want Medicare to give your personal health inormation

to someone other than you, you need to let Medicare know in writing.You can fill out a Medicare Authorization to Disclose PersonalHealth Inormation (CMS Form Number 10106) orm atwww.medicare.gov/MedicareOnlineForms , or call 1-800-MEDICARE(1-800-633-4227) to get a copy o the orm. Y users should call1-877-486-2048.

For more inormation about your current drug coverage, contactyour benefits administrator, insurer, or plan.

For more inormation about applying or Extra Helpwith yourMedicare drug plan costs, call Social Security at 1-800-772-1213, orvisit www.socialsecurity.gov. Y users should call 1-800-325-0778.

For ree personalized counseling on Your Coverage Choices, contactyour State Health Insurance Assistance Program (SHIP). You canfind the phone number or your states SHIP on the next page.

Words in

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For More Information7DefinitionsCoinsuranceAn amount you may be required to pay as your share othe cost or services afer you pay any deductibles. Coinsurance is usually apercentage (or example, 20%).

CopaymentAn amount you may be required to pay as your share o thecost or a medical service or supply, like a doctors visit or prescription. Acopayment is usually a set amount, rather than a percentage. For example,you might pay $10 or $20 or a doctors visit or prescription.

Coverage DeterminationTe first decision made by your Medicare drugplan (not the pharmacy) about your drug benefits, including the ollowing:

Whether a particular drug is covered

Whether you have met all the requirements or getting a requested drug

How much youre required to pay or a drug

Whether to make an exception to a plan rule when you request it

I the drug plan doesnt give you a prompt decision (72 hours or standardrequests, 24 hours or expedited requests), and you can show that the delaywould affect your health, the plans ailure to act is considered to be acoverage determination. I you disagree with the coverage determination, thenext step is an appeal.

Coverage Gap (Medicare Prescription Drug Coverage)A period otime in which you pay higher cost sharing or prescription drugs until youspend enough to qualiy or catastrophic coverage. Te coverage gap (alsocalled the donut hole) starts when you and your plan have paid a set dollar

amount or prescription drugs during that year.

Creditable Prescription Drug CoveragePrescription drug coverage (orexample, rom an employer or union) that is expected to pay, on average, atleast as much as Medicares standard prescription drug coverage. People whohave this kind o coverage when they become eligible or Medicare can keepthat coverage without paying a penalty, i they decide to enroll in Medicareprescription drug coverage later and they do not have a gap in coverage omore than 63 days.


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For More Information7DeductibleTe amount you must pay or health care or

prescriptions, beore Original Medicare, your prescription drug plan,or your other insurance begins to pay.

Drug ListA list o prescription drugs covered by a prescription drugplan or another insurance plan offering prescription drug benefits.Tis list is also called a ormulary.

ExceptionA type o Medicare prescription drug coveragedetermination. A ormulary exception is a drug plans decision tocover a drug thats not on its ormulary or to waive a coverage rule.A tiering exception is a drug plans decision to charge a lower amountor a drug that is on its non-preerred drug tier. You must requestan exception, and your prescriber must send a supporting statementexplaining the medical reason or the exception.

Extra HelpA Medicare program to help people with limited incomeand resources pay Medicare prescription drug program costs, such aspremiums, deductibles, and coinsurance.

InstitutionFor the purposes o this publication, an institution is aacility that provides short-term or long-term care, such as a nursinghome, skilled nursing acility (SNF), or rehabilitation hospital. Privateresidences, such as an assisted living acility or group home, arentconsidered institutions or this purpose.

MedicaidA joint Federal and state program that helps with medicalcosts or some people with limited income and resources. Medicaidprograms vary rom state to state, but most health care costs arecovered i you qualiy or both Medicare and Medicaid.

Medically NecessaryServices or supplies that are needed or thediagnosis or treatment o your medical condition and meet acceptedstandards o medical practice.


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For More Information7Medicare Advantage Plan (Part C)A type o Medicare

health plan offered by a private company that contracts withMedicare to provide you with all your Medicare Part A and Part Bbenefits. Medicare Advantage Plans include Health MaintenanceOrganizations, Preerred Provider Organizations, PrivateFee-or-Service Plans, Special Needs Plans, and Medicare MedicalSavings Account Plans. I youre enrolled in a Medicare AdvantagePlan, Medicare services are covered through the plan and arent paidor under Original Medicare. Most Medicare Advantage Plans offerprescription drug coverage.

Medicare Cost PlanA type o Medicare health plan available insome areas. In a Medicare Cost Plan, i you get services outside othe plans network without a reerral, your Medicare-covered serviceswill be paid or under Original Medicare (your Cost Plan pays oremergency services or urgently-needed services).

Medicare Health PlanA plan offered by a private company thatcontracts with Medicare to provide Part A and Part B benefits topeople with Medicare who enroll in the plan.

Medicare Medical Savings Account (MSA) PlanMSA Planscombine a high deductible Medicare Advantage Plan and a bankaccount. Te plan deposits money rom Medicare into the account.You can use the money in this account to pay or your health carecosts, but only Medicare-covered expenses count toward yourdeductible. Te amount deposited is usually less than your deductibleamount so you generally will have to pay out-o-pocket beore yourcoverage begins.

Medicare Prescription Drug Plan (Part D)A stand-alone drugplan that adds prescription drug coverage to Original Medicare, someMedicare Cost Plans, some Medicare Private-Fee-or-Service Plans,and Medicare Medical Savings Account Plans. Tese plans are offeredby insurance companies and other private companies approved byMedicare. Medicare Advantage Plans may also offer prescriptiondrug coverage that ollows the same rules as Medicare PrescriptionDrug Plans.


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A

AIDS Drug Assistance Program (ADAP) 57Appeals 20, 2728, 38, 6470, 71

C

Catastrophic Coverage 11, 14Complaint 20, 38, 64, 71Costs 5, 25, 5962Coverage Determination 6467, 71, 77Coverage Gap 11, 1314

Creditable Prescription Drug Coverage 6, 1618, 42, 4549, 51,5253, 5759, 70, 77

D

Drug List (Formulary) 20, 78

E

Employer or Union Coverage 18, 22, 29, 31, 41, 4647End-Stage Renal Disease 22Exception 2529, 66, 68, 78Extra Help 2940

F

Federal Employee Health Benefits Plan 48Fraud 6364

G

Grievance 71

I

Income and Resources 9, 31, 33, 39, 41

Indian Health Service 7, 18, 58L

Limited Income Newly Eligible ransition (NE) Program 38, 52

M

Medicaid 16, 21, 24, 35, 3740, 52, 5455, 58, 73, 78Medicare Advantage Plan 56, 11, 20, 22, 4445, 4951, 63, 79Medicare Cost Plan 5, 11, 5051, 79Medicare Medical Savings Account (MSA) 5, 45, 50, 79

Index


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medicare prescription drug manual

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