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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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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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My mother lives at an assisted living facility. She is incontinent – will Medicare help pay for the cost of adult diapers?

Urinary incontinence — the accidental release or loss of bladder control — is a medical condition that affects millions of Americans. It is common for older adults to have some form of incontinence, which can be brought on by stress, recent surgery, an illness, or other condition. Some people have temporary incontinence. For others, it can become a long-term condition. Your mom should be sure and talk with her doctor to find out the best way to treat or manage it, especially if it’s a long term condition.

As for Medicare coverage, Medicare Part A will cover various medical supplies, but only when you are at a hospital or admitted to a skilled nursing facility under a covered Medicare stay. Medicare has very strict rules about what it covers (and does not cover) under Part B with regard to durable medical equipment (which is the category where incontinence supplies would be considered).

Original (fee-for-service) Medicare does not cover “absorbent” products, such as adult diapers, because they are not considered durable. Medicare does offer limited coverage of “urine collection devices,” such as catheters. Some Medicare Advantage plans do cover adult diapers or liners.

To find help with the cost, talk with the Social Services department or the assisted living facility staff or your mom’s doctor. They may be aware of some resources that can possibly help with this expense. In addition, if your mother is eligible, some state Medicaid plans pay for adult diapers.

And, if you are having trouble affording your health supplies, use a web-based screening tool called BenefitsCheckUp to see if you may be eligible for programs that can help pay for health care, housing, food, and more. This tool is completely free and confidential; you can use it at: www.BenefitsCheckUp.org.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: adult diapers, durable medical equipment

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Does Medicare cover an annual physical?

Medicare does not cover complete physical examinations.  However, Medicare does cover annual visits with your doctor.  During these visits, your doctor obtains basic measurements, and you and your doctor discuss your health and plan to help keep you healthy during the next year and into the future.

To get ready for the visit, you complete a Health Risk Assessment, which is a questionnaire about your health status. Your assessment responses – along with the measurements your doctor takes during your visit – help to inform the plan you and your doctor develop to keep you as healthy as possible and make sure you get the medical care, preventive and screening services, medicines, and self-care support you need.

When you first join Medicare, you can get your Welcome to Medicare visit at any time during your first 12 months on Medicare. During this visit, your doctor learns about your medical history and checks your blood pressure, vision, weight, and height. Your doctor will also recommend and either perform or refer you to get any preventive services you need, like screenings and shots.

Starting 12 months after your Welcome to Medicare visit, you can schedule your first Annual Wellness Visit. After that, you can get an Annual Wellness Visit every 12 months. During the Annual Wellness Visit, your doctor will check your blood pressure, weight, height, and assess your body-mass index. You and your doctor review your health, your medicines, and any treatments you receive. You and the doctor create a plan to keep you healthy, including any screenings and shots you may need over the next year, and look ahead to your needs in the next 5 to 10 years. If your doctor finds it necessary, he may refer you to other doctors, or may give you a vision test, an Electrocardiogram (EKG), or any other needed test.

You will not be charged for your Welcome to Medicare visit and Annual Wellness Visits; these services are fully covered by Medicare so there are no deductible charges or co-insurance paid by you. Sometimes one of these visits may be combined with other Medicare services for which cost-sharing does apply.  For example, if your doctor takes your blood pressure during the Welcome to Medicare visit and it’s really high, the doctor should determine a treatment plan to bring your pressure down.  That service is not considered a part of the visit, so you could be charged the regular Medicare Part B 20% co-insurance amount for that part of your interaction with the doctor.  It’s not unusual for doctor visits to include more than one service.  For Medicare, some may be free of cost-sharing while others might cost you.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: Annual Wellness Visit, physical exam, preventive services

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I need to see my doctor for a specific test. How can I find out if Medicare will cover it or not?

Medicare has very strict rules about what it covers, and does not cover. That said, there are many places where you can find general information about your Medicare benefits. Here are some ways to find out:

  • Check out the Medicare & You handbook: This handbook is mailed to people with Medicare every year, usually in September. It gives you a broad overview of what Medicare covers and provides. You can also find this handbook online at Medicare’s website.
  • Use Medicare’s online coverage search tool:
    • Go to Medicare’s homepage
    • Enter the test, service, or item you wish to search
    • Select your state
    • From this list you will see if Medicare covers it, and how much they will cover
  • If you have Original Medicare (Medicare Parts A and/or B), call Medicare at 1-800-633-4227.
  • If you get your Medicare through a private Medicare Advantage health plan such as an HMO or a PPO, call your Medicare plan directly.
  • You may also wish to speak with your doctor; many doctors have experience billing Medicare and will know what will be covered.

If you still have questions, you can get personal help in your area.

Topic: Coverage of services and supplies, Premiums and costs

Keywords: coverage, tests

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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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