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Frequently Asked Questions about Medicare Part D
Who can get Medicare Part D prescription drug coverage?
I don't take any prescription drugs now. Why should I join a Medicare prescription drug plan?
When can I sign up for my Medicare Part D prescription drug coverage?
Do I have to sign up for Medicare Part D prescription drug coverage?
What if I have prescription drug coverage from an employer or union?
How do I find out if a specific drug is covered under my Medicare Part D plan?
What is the Medicare Prescription Drug Plan late enrollment penalty?
What if my current prescription drugs are not on the formulary or are limited on the formulary?
Who can get Medicare Part D prescription drug coverage?
Any person with Medicare is entitled to the Medicare Part D prescription drug coverage. You must either be entitled to Part A or enrolled in Part B. Members can also be enrolled in a Medicare Part C (Medicare Advantage Plan) but must choose a Part D plan that is offered through the same Medicare Advantage Plan. 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 should I join a Medicare prescription drug plan?
At some point, most people will need prescription drugs to maintain their health. And as medical practice relies more and more on new drug therapies, prescription drug coverage can help limit the high cost of prescription drugs.
When can I sign up for my Medicare Part D prescription drug coverage?
You can sign up for prescription drug coverage each year during the Annual Enrollment Period, which takes place between October 15 and December 7. You will also be able to join a plan, drop a plan, or change plans during this time. Your ability to change your plans are limited at other times of the year.
If I am turning 65 soon and I want to sign up for Medicare Part D prescription drug coverage, do I have to wait until October 15 (through December 7)?
No. If you are turning 65, you may join a Medicare prescription drug plan during your Initial Coverage Election Period for both Medicare Part C 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 not 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, called the Late Enrollment Penalty, if you decide to enroll later. Remember, this penalty is assessed by Medicare, and would apply to any plan, not just AmeriHealth. You will be responsible for paying this penalty each month in addition to a monthly premium 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 late enrollment 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 late enrollment 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. You may get an application in the mail from the Social Security Administration (SSA) for extra help paying for a Medicare prescription drug plan. It is very important that you fill out this application and return it to the SSA. If you don't get an application in the mail, and you think you may qualify for this help, call the SSA at 1-800-772-1213. (TTY users should call 1-800-325-0778.) You can also visit www.socialsecurity.gov on the Web. SSA's application process provides you with the quickest decision. You can also go to your State Medical Assistance office to apply.
How do I find out if a specific drug is covered under my Medicare Part D plan?
There are a number of ways to identify if a drug is covered:
- You can access the plan website and review the drug formulary listing;
- You can refer to www.medicare.gov to access the formulary finder and/or data from specific Medicare Prescription Drug Plans;
- You can call Customer Service at 1-800-645-3965, 1-888-857-4816 for the speech- and hearing-impaired, seven days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to an answering machine.
What is the Medicare Prescription Drug Plan late enrollment penalty?
If you don’t join a Medicare drug plan when you are first eligible, and/or you go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a late enrollment penalty when you enroll in a plan later. The Medicare drug plan will let you know what the amount is and it will be added to your monthly premium. This penalty amount changes every year, and you have to pay it as long as you have Medicare prescription drug coverage. However, if you qualify for extra help, you may not have to pay a penalty. If you must pay a late enrollment penalty, your penalty is calculated when you first join a Medicare drug plan. To estimate your penalty, take 1% of the national base beneficiary premium for the year you join (in 2012, the national base beneficiary premium is $31.08. This amount may change in 2013). Multiply it by the number of full months you were eligible to join a Medicare drug plan but didn’t, and then round that amount to the nearest ten cents. This is your estimated penalty amount, which is added each month to your Medicare drug plan’s premium for as long as you are in that plan. If you disagree with your late enrollment penalty, you may be eligible to have it reconsidered (reviewed). Call Customer Service to find out more about the late enrollment penalty reconsideration process and how to ask for such a review.
You won’t have to pay a late enrollment penalty if:
- you had creditable coverage (coverage that expects to pay, on average, at least as much as Medicare’s standard prescription drug coverage);
- you had prescription drug coverage but you were not adequately informed that the coverage was not creditable (or, as good as Medicare’s drug coverage);
- any period of time that you didn’t have creditable prescription drug coverage was less than 63 continuous days;
- you lived in an area affected by Hurricane Katrina at the time of the hurricane (August 2005) AND you signed up for a Medicare Prescription Drug Plan by December 31, 2006, AND you’ve stayed in a Medicare Prescription Drug Plan;
- you received, or are receiving, extra help through Low Income Subsidy.
What if my current prescription drugs are not on the formulary or are limited on the formulary?
New Members
As a new member in our plan, you might currently be taking drugs that are not on our formulary, or they are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you might be eligible to receive an initial 34-day transition supply of the drug anytime during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day transition supply, we may not continue to pay for these drugs under the transition policy.
If you are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
Continuing Members
As a continuing member in the plan, you will receive your Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) by September 30. You may notice that a formulary medication that you are currently taking is either not on the upcoming year’s formulary or its cost-sharing or coverage is limited in the upcoming year.
In this case, we will provide a transition period consistent with the above transition process for new enrollees.
Change in Level of Care (Setting)
Members who have a change in level of care (setting) will be allowed a one-time, 34-day transition supply per drug. If patients have more than one change in level of care in a month, the pharmacy will have to call the plan for an extension.
How do I switch from an AmeriHealth Medicare plan to another Medicare Advantage Plan or other Medicare Health Plan between October 15 and December 7?
If you want to change from AmeriHealth to a different Medicare Advantage Plan or other Medicare Health Plan, here is what to do:
- Contact the new plan you want to join to be sure it is accepting new members. Also, ask the plan if it offers the Medicare Part D prescription drug benefit.
- Your new plan will tell you the date when your new plan membership begins, and your AmeriHealth membership will end on that same day (this will be your “disenrollment date”).
Remember, you are still a member until your disenrollment date, and must continue to get your medical care as usual through AmeriHealth until the date your membership ends.
You must continue to pay your Medicare Part B premium.
The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.
Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office 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.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.
Please contact AmeriHealth 65 HMO for more information.
In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:
- national chain and independent retail pharmacies
- long-term care and home-infusion pharmacies
- Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies
Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval
