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Frequently Asked Questions about AmeriHealth Advantage PDP
1. Who can get Medicare Part D prescription drug coverage?
3. When can I sign up for my Medicare Part D prescription drug coverage?
5. Do I have to sign up for Medicare Part D prescription drug coverage?
6. What if I have prescription drug coverage from an employer or union?
8. What is the drug formulary?
9. How do I receive benefits as a member with a drug formulary?
10. How will my doctor know to prescribe a drug formulary medication?
Who can get Medicare Part D prescription drug coverage?
Any person with Medicare is entitled to Medicare Part D prescription drug coverage. You must first have Medicare Part A (hospital care) and Medicare Part B (medical care). And, you must join a prescription drug plan (a PDP) that is available where you live.
I don’t take any prescription drugs now. Why would I want to join a Medicare prescription drug plan?
Even if you don’t use prescription drugs now, most people with Medicare need or will need prescription drugs to stay healthy. Medicare prescription drug coverage is important since medical practice has come to rely more and more on new drug therapies. Beneficiaries who do not sign-up for a Part D plan or have Creditable Coverage may be penalized by CMS.
When can I sign up for my Medicare Part D prescription drug coverage?
Medicare Part D prescription drug coverage began on January 1, 2006. Many people with Medicare have already signed up for the coverage by joining a prescription drug plan or a Medicare Advantage plan that offers prescription drug. Each year Members have an Annual Election Period (November 15 through December 31), which allows them to make a plan selection for the following year. Your options are limited at other times of the year.
If I will soon turn 65 and I want to sign up for Medicare Part D prescription drug coverage, do I have to wait until November 15 through December 31?
No. If you are turning 65, you may join a Medicare prescription drug plan during the time that is called your Initial Coverage Election Period for both Medicare Part B and Medicare Part D. This period includes the three months before your birth month, your birth month, and three months after your birth month.
Do I have to sign up for Medicare Part D prescription drug coverage?
No. You can choose to join. However, if you do not join a Medicare prescription drug plan when you first become eligible for Medicare, you will pay a penalty when you do decide to enroll in a Medicare prescription drug plan. And, you will pay the penalty each month for as long as you stay in a Medicare prescription drug plan. For most people, joining as soon as possible means you pay your lowest monthly premium. You can also feel secure that you will be protected from any unforeseen, catastrophic drug expenses.
What if I have prescription drug coverage from an employer or union?
If your employer or union plan covers as much as or more than a Medicare prescription drug plan, you can:
- Keep your current drug plan. If you join a Medicare prescription drug plan sometime in the future, you will not pay a monthly penalty.
- Drop your current drug plan and join a Medicare prescription drug plan. However, you may not be able to get back into your employer or union drug plan if you change your mind.
If your employer or union plan covers less than a Medicare prescription drug plan, you can:
- Keep your current drug plan and join a Medicare prescription drug plan to give you more complete prescription drug coverage.
- Just keep your current drug plan. However, if you join a Medicare prescription drug plan later, you will have to pay a monthly penalty.
- Drop your current drug plan and join a Medicare prescription drug plan. However, you may not be able to get back into your employer or union drug plan if you change your mind.
My income is very limited. It will be hard for me to pay the premiums and deductible in a Medicare prescription drug plan. Is there any extra help for me?
People with limited income and resources (including your savings, stocks and bonds, but not counting your home or car) may be able to get extra help paying for prescription drugs. To learn more about the qualifications for extra help refer to the Medicare & You handbook.
To see if you qualify for getting extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY machine users should call 1-877-486-2048, 24 hours a day/7 days a week);
- The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office.
What is the drug formulary?
A formulary is a list of the drugs we cover. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy or through our network mail order pharmacy service, and other coverage rules are followed.
How do I receive benefits as a member with a drug formulary?
At a participating pharmacy, your level of benefits is higher when you use a drug formulary medication, meaning you'll only be responsible for a copay which varies whether you purchase a generic or brand formulary medication. Your benefit for a non-preferred medication will result in a higher copay. A mail order feature is also available for long-term drug purchases.
How will my doctor know to prescribe a drug formulary medication?
Have your doctor review the formulary guide to determine if your prescription medications are on the formulary; you may already be taking drug formulary medications. If you are, you will only pay your copay for these drugs. If you are prescribed covered drugs that are not on the drug formulary, ask your doctor to review your Formulary Pocket Guide to see if another drug on the formulary, such as a generic equivalent or therapeutic alternative, can be used to treat your condition. If, after discussion with your doctor, he/she does not prescribe a drug formulary medication, your covered prescription will be subject to the higher non-preferred copay.
