Helpful Guide to Choosing a Medicare Drug Plan May
Help Meet Deadline
Deadline for changing your Medicare plans is end of
day December 7
Open Enrollment Ends
Nov. 17, 2014 –Medicare Open Enrollment ends on
December 7, 2014, and it is a safe bet that millions of senior citizens
have not taken the time to carefully consider their Medicare health
coverage to be sure it meets their needs at the lowest cost possible.
Below is a very helpful guide provided by the Centers for Medicare &
Medicaid Services that will make this challenge less difficult.
And, an important reminder is not to get confused
about this deadline. CMS runs both the Medicare Open Enrollment and the
Health Insurance Marketplace Open Enrollment for the Affordable Care Act
(Obamacare). The Medicare Open Enrollment goes through December 7. The
Market Place Open Enrollment goes through December 15.
Things to think about when
you compare Medicare drug coverage
There are 2 ways to get Medicare prescription drug
● You can join a Medicare Prescription Drug Plan
and keep your health coverage under Original Medicare.
● Or, you can join a Medicare Advantage Plan
(like an HMO or PPO) that includes Medicare drug coverage and get your
Medicare benefits through a private insurance company.
Whichever you choose, prescription drug coverage
can vary by cost, coverage, convenience, and quality. Some of these
things might be more important to you than others, depending on your
situation and prescription drug needs.
No matter which type of Medicare drug plan you
join, your plan will send you information about plan changes each fall.
You should review your prescription drug needs and compare Medicare drug
plans during Medicare Open Enrollment. You can make changes to your
coverage October 15 and through December 7.
When you get Medicare prescription drug coverage,
you pay part of the costs, and Medicare pays part of the costs. Your
costs will vary depending on which Medicare drug plan you choose and
whether or not you get Extra Help (read more below, “Extra Help is
available”) You should look at your current prescription drug costs to
find a Medicare drug plan that works with your financial situation.
Most drug plans charge a monthly fee that varies by
plan. You pay this fee in addition to the Medicare Part B (Medical
Insurance) premium. If you have a Medicare Advantage Plan or a Medicare
Cost Plan that includes Medicare prescription drug coverage, the monthly
premium you pay to your plan may include an amount for prescription drug
Note: What you pay for Medicare prescription
drug coverage could be higher based on your income. Visit Medicare.gov
to learn more about the monthly premium for drug plans.
Consider automatic premium deduction
When you join a drug plan, think about having your
premiums automatically deducted from your Social Security payment.
Automatic premium deduction has many benefits:
● It takes the worry out of remembering to pay
● Your premiums will get paid on time.
● You’ll be helping the environment by not getting
a paper bill from your plan.
This is the amount you must pay before your drug
plan begins to pay its share of your covered drugs. Some drug plans
don’t have a deductible.
This is the amount you pay for each of your
prescriptions after you’ve paid the deductible (if the plan has one).
Some Medicare drug plans have different levels or “tiers” of coinsurance
or copayments, with different costs for different types of drugs.
Coinsurance means you pay a percentage (25%, for example) of the cost of
the drug. With a copayment, you pay a set amount ($10, for example) for
all drugs on a tier. For example, you might have to pay a lower
copayment for generic drugs than brand-name drugs, or lower coinsurance
for some brand-name drugs than for others.
Most Medicare drug plans have a coverage gap (also
called the “donut hole”). This means that there’s a temporary limit on
what the drug plan will cover for drugs. The coverage gap begins after
you and your drug plan have spent a certain amount for covered drugs. In
2015, once you enter the coverage gap, you pay 45% of the plan’s cost
for covered brand-name drugs and 65% of the plan’s cost for covered
generic drugs until you reach the end of the coverage gap. Not everyone
will enter the coverage gap.
These amounts all count toward you getting out of
the coverage gap:
● Your yearly deductible, coinsurance, and
● The discount you get on brand-name drugs in the
● What you pay in the coverage gap
These amounts don’t count toward you getting out of
the coverage gap:
● Your drug plan premium
● What you pay for non-covered drugs
● What’s paid by other insurance
Some plans offer additional coverage during the
gap, like for generic drugs, but they may charge a higher monthly
premium. Check with the plan first to see if your drugs would be covered
during the gap. In addition to the discount on covered brand-name
prescription drugs, there will be increasing coverage for drugs in the
coverage gap each year until the gap closes in 2020.
Once you get out of the coverage gap, you
automatically get “catastrophic coverage.” Catastrophic coverage means
that you only pay a small coinsurance amount or copayment for covered
drugs for the rest of the year.
Late enrollment penalty
If you don’t join a Medicare drug plan when you’re
first eligible, and you don’t have other creditable prescription drug
coverage or get Extra Help, you’ll likely pay a late enrollment penalty.
Creditable prescription drug coverage is coverage (for example, from an
employer or union) that’s expected to pay, on average, at least as much
as Medicare’s standard prescription drug coverage.
If you’re subject to the penalty, you may have to
pay it each month for as long as you have Medicare drug coverage. For
more information about the late enrollment penalty, visit Medicare.gov
or call 1-800-MEDICARE (1-800-633-4227). TTY users should call
Extra Help is
If you have limited income and resources,
you may be able to get Extra Help paying your prescription drug
coverage costs. People who qualify may be able to get their
prescriptions filled and pay little or nothing out of pocket.
You can apply for Extra Help at any time. There’s no cost to
apply for Extra Help, so you should apply even if you’re not
sure if you qualify. To apply for Extra Help online, visit
socialsecurity.gov/i1020. Or, call Social Security at
1-800‑772‑1213 to apply by phone or to get a paper application.
TTY users should call 1-800‑325‑0778.
Review your prescription drug needs, and look for a
plan that meets these needs. Plans may vary in what drugs they cover,
and some may have special rules that you must follow before a drug is
A formulary is a list of the drugs that a Medicare
drug plan covers. It includes how much you pay for each drug. If the
plan uses tiers, the formulary lists which drugs are in each tier.
Formularies include both generic and brand-name drugs. In general, each
Medicare drug plan’s formulary must include most types of drugs that
people with Medicare use. However, each drug plan has its own formulary,
so you should check to make sure your drugs are covered.
Medicare drug plans may require “prior
authorization.” This means that before the Medicare drug plan will cover
certain prescriptions, your doctor must contact the plan for approval.
Your doctor may need to provide additional information about why the
drug is medically necessary for you before you can fill the
prescription. Plans may also require “step therapy” on certain drugs.
This means you must try one or more similar, lower cost drugs before the
plan will cover the prescribed drug. Plans may also set “quantity
limits”—limits on how much medication you can get.
Check with each Medicare drug plan you’re
considering to make sure your current pharmacy is in the plan’s network,
or there are pharmacies convenient to you. Some Medicare drug plans
charge lower copayments or coinsurance amounts at some pharmacies in
their network than at others. Also, some Medicare drug plans may offer a
mail-order program that will allow you to have drugs sent directly to
your home. You should consider the most cost effective and convenient
way to have your prescriptions filled.
Important: Even if you’re not changing
plans, make sure your pharmacy is still in your plan’s network next
year. Plans may change their network pharmacies each year.
In addition to a plan’s costs, coverage, and
convenience, you should also review the quality ratings for plans before
you decide which one best meets your needs. Medicare uses information
from member satisfaction surveys, plans, and health care providers to
give overall performance star ratings to plans. A plan can get a rating
between 1 and 5 stars. A 5-star rating is considered excellent. These
ratings are listed on the Medicare Plan Finder at
You can switch to a Medicare Advantage Plan or a
Medicare Prescription Drug Plan that has 5 stars for its overall plan
rating once from December 8–November 30. The overall plan ratings are
available at Medicare.gov/find-a-plan. Medicare updates these ratings
each fall for the following year. These ratings can change each year.
● You can only switch to a 5-star Medicare
Prescription Drug Plan if one is available in your area.
● You can only use this Special Enrollment Period
once during the above timeframe.
Medicare.gov/find-a-plan to find and compare plans.
…look at drug plans that have included
your drug on their formularies. Then compare costs.
…want extra protection for high
prescription drug costs.
…look for plans that offer coverage in the
coverage gap, and then check with those plans to be sure
your drugs would be covered during the gap. (The plans may
charge a higher monthly premium.)
…want your drug expenses to be balanced
throughout the year.
…look at plans with low or no deductibles
or with additional coverage in the coverage gap.
…take a lot of generic prescriptions.
…look at plans with tiers that charge you
nothing or low copayments for generic prescriptions.
…don’t have many drug costs now, but want
coverage for peace of mind and to avoid future penalties.
…look for plans with low monthly premiums
for drug coverage. If you need prescriptions in the future,
all plans still must cover most drugs used by people with
…like the extra benefits and lower costs
that are available by getting your health care and
prescription drug coverage from one plan and are willing to
accept the plan’s restrictions on what doctors, hospitals,
and other health care providers you can use.
…look for Medicare Advantage Plans with
prescription drug coverage.
>Change from a Medicare
Advantage Plan back to Original
>Switch from one Medicare
Advantage Plan to another
Medicare Advantage Plan.
>Switch from a Medicare
Advantage Plan that doesn't
offer drug coverage to a
Medicare Advantage Plan that
offers drug coverage.
>Switch from a Medicare
Advantage Plan that offers drug
coverage to a Medicare Advantage
Plan that doesn't offer drug
>Join a Medicare Prescription
> Switch from one
Medicare drug plan to another
Medicare drug plan.
>Drop your Medicare
prescription drug coverage
for Considering Health Plan
Does the plan provide the services
that you need?
How much are your premiums,
deductibles, and any other costs?
How much do you pay for services
such as hospital stays or doctor
visits? Is there an annual limit on
what you could pay out-of-pocket for
hospital choice – Do the doctors
that you want to see accept the plan
you’re considering? Do you have to
select hospitals and health-care
providers from a specified network?
If you’d like to see a specialist,
do you first have to obtain a
drugs – How much will you have
to pay for prescription drugs, and
are the medications that you need
included in the plan's formulary?
care – Medicare uses a Star
Rating System to measure how well
Medicare Advantage plans perform.
Plan ratings range from one to five
stars, with five stars representing
the highest rating. Find out what
the Star Rating is for those plans
that you’re considering.
– Before selecting a plan, find
out the location and office hours of
the health-care providers that you
would be utilizing. Additionally,
determine which pharmacies you would
have access to, and if prescriptions
can be mailed.
Will the plan cover you if you
travel to another state or outside
the United States?
Each year, you have the opportunity to join or
switch Medicare drug plans during Medicare Open Enrollment. You can make
changes October 15 through December 7.
If you switch plans during this time, your coverage
with the new plan will start on January 1.
As you make a decision about your health and
prescription drug coverage, remember to review your current health and
prescription drug plans. Health and drug plan benefits and costs can
change each year. Look at other plans in your area to see if one may
better meet your needs. If you want to keep your current plan, and it’s
still being offered next year, you don’t need to do anything for your
enrollment to continue.
I get help?
To help you compare Medicare drug plans, think
about what you need in terms of cost, coverage, convenience, and
quality. Then, visit Medicare.gov/find-a-plan to see which plans are
available in your area. To get personalized information, you need:
● Your Medicare card that has your Medicare number
and Medicare effective date (Medicare Part A (Hospital Insurance) or
Medicare Part B (Medical Insurance).
● Date of birth
● Last name
● ZIP code
To get general Medicare drug plan information or to
find out what plans are available in your area, just answer a few simple
questions. You can also enter your current prescription drug information
to get more detailed cost information. Note: This tool provides useful
information to help you review Medicare drug plans based on your current
drug needs. The drug costs displayed are estimates and may vary based on
the specific quantity, strength and/or dosage of medication, whether you
buy your prescriptions at the pharmacy or through mail order, and the
pharmacy you use.
● Call 1-800-MEDICARE (1-800-633-4227). TTY
users should call 1-877-486-2048.
● Call your State Health Insurance Assistance
Program (SHIP) for personalized counseling at no cost to you. Visit
Medicare.gov/contacts, or call 1-800-MEDICARE to find the phone number
for your state.
If you have employer or union coverage, call your benefits administrator
before you make any changes to your coverage.
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