Medicare Part D 101

Given all the changes with Medicare reform, understanding your Medicare benefits may be more difficult. This guide was prepared to help make Medicare changes easier to understand.

The Medicare Modernization Act passed in 2003 provided for the introduction of Medicare prescription drug coverage, also known as Medicare Part D. Coverage began on January 1, 2006. Anyone who is entitled to Medicare Part A or enrolled in Medicare Part B is eligible to enroll in the new prescription drug coverage, which offers substantial federal help to people with Medicare by paying some of the costs of prescription drugs.

Key elements of the standard Part D coverage

In 2012, beneficiaries with standard Medicare prescription drug coverage will pay a $320 annual deductible and then 25 percent of drug costs from $321 to $2,930. When total yearly drug costs (i.e., paid by the beneficiary and the plan) reach $2,930, the beneficiary pays 100 percent of the cost of each prescription until the beneficiary's yearly out-of-pocket costs reach $4,700. At that point, the beneficiary pays about five percent of the cost of each drug. Extra help will be available for those with limited incomes and resources.

Here’s another way of looking at it:

This is insurance coverage

Medicare prescription drug plans provide insurance coverage for prescription drugs. Like other insurance, if you join you will pay a monthly premium and a share of the cost of your prescriptions. Costs will vary depending on the drug plan you choose.

If you have a Medicare Advantage HMO or PPO plan

If you are enrolled in a Medicare Advantage plan, and would like to add prescription drug coverage, you must get your Part D prescription drug coverage through the same plan. The plan may offer enhanced drug benefits for an additional premium.

Like Part B, the new Medicare Part D drug coverage is entirely voluntary

The Part D program has an “opt-in” rule, which means that, with few exceptions, beneficiaries need to actively sign up for the drug coverage by completing an enrollment form and joining a Medicare-approved plan (either an MAPD or PDP).

This is different from how you sign up for Part B, which is through the Social Security Administration. With Part D, you sign up with a private plan that has been approved by Medicare to cover prescription drugs. While some Medicare beneficiaries may be automatically enrolled in a Part D drug plan based on income level, for most people it works like this: if you do not sign up with a drug plan, you do not get the Part D drug benefit.

Paying your Part D premiums

Like Medicare Part B, there is a monthly premium for your Medicare Part D drug coverage. Just like your Part B premium, your Part D premium can be automatically deducted from your Social Security check and you will not need to write a check each month. You can also pay the monthly Part D premium directly to the PDP or MAPD plan. If you need help paying your Part D premium, extra help is available. Learn more about low-income subsidy.

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