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I think I am about to go into the Part D coverage gap. How will I know if I do? And if I do, how will I afford my prescriptions?

Each month that you fill any prescriptions using your Medicare Part D plan, you receive an Explanation of Benefit (EOB) summary in the mail. This summary shows the amount that you have paid for prescriptions drugs to date. It also shows how much your plan has paid to date. The EOB also shows you if you have reached the coverage gap for the year.

In 2014, you enter the coverage gap when your total cost – that is, what you spend plus what your Part D plan spends on prescriptions drugs – reaches a combined amount of $2,850. This amount changes each year.

If you do reach the coverage gap, you get a 50% discount on the cost of covered brand-name drugs and pay only 86% of the cost of covered generic drugs. You also pay a small dispensing fee associated with filling the prescriptions. Once drug costs reach $4,700 you would enter the catastrophic part of Medicare drug coverage, where you will remain for the rest of the year.

If you have the Extra Help/Low-Income Subsidy, you do not have a coverage gap.

Topic: Premiums and costs

Keywords: coverage gap, donut hole, Part D

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I heard it is Open Enrollment for Part D. What’s the best way to review my plan options? And, where can I find the information I need?

Yes, that is right! Now is Open Enrollment Period for Part D. You have from October 15 to December 7 to make changes in your current coverage or to enroll in a Part D drug plan (or a Medicare Advantage plan). Any changes you make during this time take effect January 1, 2014.

It is important that you review your current coverage and consider all your options during this time. This way, you have the best coverage at the most reasonable cost that meets your personal needs come January 1.

And, if you cannot pay for your Part D prescription drugs, or if you need help with your drug copayments, you may be able to get Extra Help. Learn more about Extra Help.

If you are new to Medicare, you can also learn what you need to do and the decisions you will need to make so your Medicare works for you.

Topic: Medicare enrollment and cards, Reviewing and changing plans

Keywords: enrollment, Part D

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My drug plan cost me too much this past year. What can I do?

What you should do is take advantage of the annual Open Enrollment Period. This is the time of year when you can make changes in your Medicare coverage. The period starts on October 15 and ends on December 7, 2013. Your new coverage will start January 1, 2014.

This enrollment period is very important. Why? Because unless you are new to Medicare, have Extra Help to pay your Medicare drug plan costs, or have a special circumstance, you will not be allowed to change your Medicare coverage for another year. So, if you need better coverage, now is the time to review your options.

During this time, you should review your plan options and consider joining a different Medicare drug plan. Remember, you only have until December 7 to switch to a plan that may better meet your needs in 2014, so don’t delay.

Find out how to explore your Part D options, what to consider in a plan, and how to enroll in a new plan.

Topic: Premiums and costs, Reviewing and changing plans

Keywords: drug, Part D, premiums

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I’ve just been prescribed a new drug and was told Medicare won’t cover it. What can I do?

Medicare covers most out-patient drugs through the Part D drug benefit. To get coverage, you must join a Medicare drug plan.

There a few reasons Medicare may not cover your drug:

  • The drug is excluded by law from coverage,
  • The drug is not on your plan’s list of covered drugs, also called the formulary, or
  • The plan may have special rules or set limits on how you get your drugs.

If your current plan does not cover a drug you are taking, there a few things you can do:

  • Ask your pharmacy: Your pharmacy should give you a notice that explains why your prescription could not be filled and how to contact your plan.
  • Ask your plan why the drug is not covered: Call your plan. Look at your plan membership card or other materials for the toll free number.
  • Talk with your doctor: See if your doctor (or other prescriber) can switch you to a similar drug on your plan’s formulary. If not, ask your doctor to give you free samples of the drug.
  • Request an “exception”: If the drug is covered by Medicare but not by your plan, ask your plan to cover it. This is called an “exception.” You will need your doctor who prescribed the drug to tell the plan why you need the specific drug. Contact your doctor and ask if he can help you request an “exception” from your drug plan.
  • Prescription Assistance Programs: See if any local prescription assistance programs in your area may offer this drug at a discount.
  • Review other drug plans: If you cannot get an exception from your plan and there is not an alternative drug, review other drug plans available in your area. Medicare’s coverage of prescription drugs varies from plan to plan. There may be another drug plan that does cover it. Use our QuickCheck tool to get help to compare plans.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: drug, Part D, prescription

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I need the shingles shot. Does Medicare pay for all or part of this cost?

Shingles is a painful skin rash caused by the same virus that causes chickenpox. And people age 50 and over are most at risk. It can cause lifelong pain even after the rash is gone. But you can prevent shingles by getting the shingles vaccination.

All Medicare Part D drug plans are required to cover the shingles vaccine. Part D plans have very specific rules about where you need to get the shot in order for the plan to cover both the injection (the vaccine itself) and the administration of it, that is to say, giving you the shot. You should call your Part D plan, and find out their specific coverage rules.

Also, the amount you have to pay for the vaccine varies from plan to plan. You should contact your current plan to find out the costs specific to you. Your plan should be able to tell you what your cost-sharing amount for the vaccine is. The cost-sharing amount, or the amount you have to pay, can be either:

  • A copayment (fixed amount such as $15), or
  • A coinsurance (a percent of the drug cost such as 25%).

Ask your plan:

  • How much do they charge you (your copayment or coinsurance) for the vaccine?
  • Do you need to get the shot at your doctor’s office in order to get coverage?
  • Can you get the shot at a pharmacy or drugstore and get reimbursed by your plan?

The shingles vaccine can help you avoid a very painful and often lifelong condition that could limit your activities. Let Medicare help you stay healthy by getting the vaccine if you have not had it yet.

And if you have limited income and resources, you may be eligible for Part D Extra Help. This program helps you pay for certain Part D costs, such as the coinsurance and copayments, making the cost of your vaccine much more affordable.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: Part D, shingles, vaccine

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How can I pay my monthly premium for Medicare?

Depending on which parts of Medicare you are referring to, there are a couple of different ways:

  • Medicare Parts A and B premiums: If you do not yet receive Social Security benefits, Medicare will bill you directly for your Part A and/or B premiums. (Note: Most people do not have to pay a Part A premium since they paid into Part A while they were still working.)Your bill will come every quarter, or every 3 months. You can choose to pay by check or money order, credit card, or have it automatically deducted from your bank account. Medicare Easy Pay is an electronic payment option for people with Medicare who are directly billed for their Medicare premiums by the Centers for Medicare & Medicaid Services (CMS). This payment option allows you to have your Medicare premiums automatically deducted from either your savings or checking account free-of-charge each month.You can sign up for the Medicare Easy Pay at any time. Please call 1-800-MEDICARE (1-800-633-4227) to request a Medicare Easy Pay Packet. TheMedicare Easy Pay Packet includes a Medicare Easy Pay brochure, an Authorization Agreement for Preauthorized Payments, instructions for completing the authorization form, and a pre-addressed return envelope. Once you submit the form, it usually takes 30 to 60 days to process your authorization.If you sign up for Medicare Easy Pay, you will get a monthly Notice of Medicare Premium Payment Due (CMS-500) that will show the amount of the deduction from your bank account. The automatic deduction will also appear on your monthly bank statement as an Automated Clearing House (ACH) transaction. If you are already receiving Social Security benefits, your Medicare Part B premium will be automatically deducted from your check.
  • Medicare Advantage Plans: If you choose to get your Part A and B benefits through a private Medicare Advantage (MA) or Medicare Advantage-Prescription Drug (MA-PD) health plan, you will likely have to pay a monthly premium in addition to Part A and/or B premium. Your health plan will send you a bill.There are a few options on how to pay your Medicare Advantage plan premium such as sending a payment, paying by credit card, or having the payment taken directly out of your checking or savings account. You should contact your plan directly to find out the payment options.
  • Medicare Part D: As for Medicare Part D (drug coverage), this is a separate premium that is paid to the drug plan. Again, your plan will send you a bill. And, you should contact your plan directly to find out the payment options.Keep in mind you may have the option to have your Part D premium taken from your monthly Social Security benefit. However, this payment option is not recommended. It can cause delays in coverage, and be hard to fix when the wrong premium amount is taken out.Note: If you cannot afford your Part D premium, or if you need help with your drug copayments, you may be able to get Extra Help. Learn more about Extra Help.

Topic: Premiums and costs

Keywords: Part D, premiums

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My wife and I changed to different Part D plans for 2013. Do we need to notify our 2012 plan about the change?

You do not need to contact your old plan. Your coverage automatically switched as of January 1. You should have received materials, including your new plan’s identification card and a booklet explaining your plan’s coverage information in the mail by the end of 2012. You should be all set to fill prescriptions in January.

If you have not yet received your new plan’s insurance card, you should call your new plan immediately. Or, you contact Medicare at 1-800-MEDICARE (1-800-633-4227).

Also, it’s always important to keep in mind that if you have limited income and resources you may be eligible to get help paying for your costs in Medicare, including your Medicare drug expenses.

  • Part D Extra Help: If you cannot pay for your Part D prescription drugs, or if you need help with your drug copayments, you may be able to get Extra Help paying. Learn more about Extra Help.
  • Medicare Savings Programs: If you have a limited income and assets, you may qualify for help paying for your Medicare Part B premium and other Medicare costs.
  • Find out if you are eligible using BenefitsCheckUp. This online tool is free and confidential. You can even apply for Extra Help using this tool.

Topic: Reviewing and changing plans

Keywords: Part D

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I am over age 65 and still working. I have health insurance through my job. Do I still need to enroll in Part D?

It is always your decision whether to join a Part D plan. If you are 65 or older and still working and do not have Part D, here is the first question you should ask yourself to help you decide if you should enroll in Part D: Does your job-related health insurance cover your prescription drugs?

If YES: Ask your employer whether your current health insurance plan is considered “creditable” by Medicare. In other words, does the employer health insurance give you the same coverage for drugs that you would have if you were in a basic Medicare Part D plan? Your employer is required to tell you this.

If your job’s health insurance plan is “creditable,” then you do not need to enroll in a Part D plan right now.

If your job’s health insurance plan is not considered “creditable” coverage, you may want to consider enrolling in a Part D plan as soon as possible, so that you do not have to pay a higher penalty.

If NO: If you don’t have health insurance from your employer, or your job-related health insurance does not cover prescriptions, or your employer’s insurance plan is not “creditable,” then you may have to pay a penalty to enroll in a Part D plan. The longer you wait to enroll in a Part D plan without having “creditable” coverage, the higher this penalty could be.

Topic: Medicare enrollment and cards

Keywords: enrollment, Part D

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I am not taking any medications right now. Does it ever make sense for someone like me to delay enrolling in Part D and accept the penalty?

Generally, we encourage anyone who is eligible for Part D (and who does not otherwise have creditable coverage, or coverage “as good as” Medicare) to enroll and get Part D coverage.

That said, Part D is a voluntary program, and you are right that one option is to delay enrollment and pay the penalty later on when you decide to enroll. However, it’s hard to say that you should delay enrolling now because you currently take no prescription drugs. That’s because no one can predict the future. And Part D is insurance to help you should you need help with your prescription drug costs.

Here are some important things to keep in mind when you are making this decision:

  • Your health may change: As you age and your health status changes, your need for prescription drugs may grow. The cost of those drugs may also increase over time. Consider signing up for one of the least expensive Part D plans in your area now (some areas even offer plans with $0 monthly premium), especially if you have a chronic health condition that could worsen with age.
  • Penalty costs may go up: The cost of the Medicare Part D penalty depends on how long you went without creditable prescription drug coverage. So, what may be a small penalty amount, say if you only delayed Part D for a year, could become costly if you waited 5 years. How so? For example, if you went without creditable coverage for one year, in 2012 you would roughly pay $3.70 in monthly penalty amount, plus any monthly Part D premium. If you had been without coverage for say 5 years, you would pay $18.60 every month in 2012, in addition to your monthly premium. You can see this penalty amount can become costly. And, this is a lifetime penalty — meaning as long as you have Part D you may have to pay the penalty, and it can increase every year.
  • You can enroll only at certain times: Keep in mind that you may have to wait until the next available Open Enrollment Period to get Part D coverage. There are only limited times of the year, and in only certain exceptional situations, in which you can enroll in a plan.For example, if your health suddenly changed, and you needed prescription coverage, you may have to wait to enroll during the annual enrollment period, which runs each year from Oct. 15 to Dec. 7, with coverage taking effect the following January 1. If you don’t enroll when you’re first eligible, you may end up in a situation where you need coverage, but you don’t have a special enrollment period and must wait until the next annual enrollment period to get it.

Topic: Medicare enrollment and cards

Keywords: drug, enrollment, Part D

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