Questions You May Have
(And How to Find Answers!)

Any time you have a change in your pharmacy benefits — whether it's because you change plans or because your prescription drug plan (PDP) makes changes to what it covers — you may have questions about your coverage. Asking the right questions is key to getting the most appropriate medicines and limiting your out-of-pocket costs. Read on to find out what information to look for, and for a list of resources to help you answer your questions.

Will I be able to get the medicine that my doctor and I think is best for me?

Find out if the PDP has a limited list of medicines it will cover (known as a formulary). If someone in your family takes medication for a chronic illness, such as high blood pressure, diabetes, or high cholesterol, make sure that medicine is on the formulary before you select that plan. If it isn’t, and you choose that plan, you will be expected to switch to a different medication or pay for it out-of-pocket. If you are asked to switch, you should discuss it with your health care provider to make sure that you're taking the medication that is best for you.

Find out if the health plan has to pre-approve certain medicines before you can fill the prescription. Many plans require your health care provider to get prior authorization of certain medications before the PDP will pay for them. That means your health care provider must call the PDP for permission to give you a prescription for these medications. Some plans also require you to try a less expensive medicine first before they will pay for the one your health care provider recommends. Check with your plan to understand their authorization process and restrictions in order to avoid a surprise when you get to the pharmacy. And be sure to learn how to request coverage if the PDP will not pay and you feel the medication is important for your health.

Find out how often your PDP changes its formulary. Be aware that even though your medications may be covered at the time you choose your PDP, the PDP may change its list of approved medicines later in the year. If the PDP chooses to take your medication off the formulary or change it to a different tier mid-year, the plan must notify any enrollee who is taking that medication 60 days in advance. You may have to switch to a new medicine if your old medicine is being removed from the formulary because a generic version of the medicine has become available or because of safety concerns. However, if your medicine is being removed from the formulary during the year for any other reason, the plan must continue to cover it for you until the end of the plan year. This is to give you time to talk to your health care provider and determine whether another medicine that the plan does cover will work for you or whether you want to look for another plan that will cover that medication. If your health care provider determines that you cannot switch to a different medicine and you do not want to switch plans, then you need to request a formulary exception (a type of coverage determination) from your plan in order to be allowed to stay on your old medication.

How much will I have to pay for my prescriptions?

Read your benefit explanation and understand your coverage. Medicare benefits levels are complicated. Many PDP's follow a similar model, called the "standard benefit." Unless you are a low income person getting extra benefits, then there are two periods of time when a standard PDP may not pay for your covered prescriptions:

• First, you may have a deductible at the beginning of each year of up to $265. You will have to pay for your covered medications yourself until you have spent this deductible amount of up to $265. Medicare encourages the PDP to give you a discount on the cost of each prescription, but you may be getting the benefit of discounts through lower premiums or cost sharing. Some plans have used discounts to eliminate the deductible.
• Then, for a while, the PDP will pay for most of your medication costs for covered drugs, but you will have to pay a co-pay on most medications.
• After the PDP has paid for about $1500 worth of your covered medicines that year, it will stop paying again. This is like a second deductible period (nicknamed the "donut hole"). If you need to get any more medicines during this period, you will have to pay for them yourself. Again, Medicare encourages the PDP to give you a discount on these medicines just like during the deductible period at the beginning of the year, but in a standard plan you will pay the entire discounted price yourself. Some plans have chosen not to follow the "standard benefit" model and offer some coverage during the donut hole, such as coverage for generics.
• Once you have paid about $3850 yourself for covered prescription medicines, then the PDP will start paying again for any other covered prescriptions you fill that year, but you will pay a much lower co-payment. This is called the catastrophic benefit period. Tell me more about the out-of-pocket threshold for catastrophic benefits.

This process starts over each year, so if you don’t use more than about $2400 of medicines each year, you will only have to pay the first $265 and then your co-pays after that.

Find out about the co-payments. All PDPs will require you to pay some level of co-payment for each prescription. A few PDPs may have just one co-pay amount, for example $10.00, for any prescription. But many PDPs have different levels of co-payments (known as tiered co-pays) for different medicines. If the PDP you are considering has tiers, you should find out which of your medicines are in each tier and what the co-pay amount is for each tier. Note that the PDPs can move your medication from one tier to another at any time. If the amount you will have to pay is more than you can afford because your medication is in the highest tier, you may want to ask your health care provider if there are other medications on a lower tier that are appropriate for you. Also, you may be able to seek a coverage determination for a lower copay amount if the only medication that works for you is in the higher tier. The amount you will have to pay may also be different depending on whether you get your prescription filled at a preferred pharmacy in the plan's network, a non-preferred pharmacy in the plan's network, a pharmacy that is not in the network, or a mail order pharmacy.

If you have other discount cards, ask how much the drug would cost if you used one of them instead of using your Medicare card. Medicare drug plans may not charge you a price that is higher than the pharmacy's price for the medicine if you bought it without insurance. During the deductible and coverage gap periods, you may be able to save money by using other types of discount cards. As long as the medicine you get is covered by your plan, and you buy it from a pharmacy that is in the plan's network, you can send a copy of the receipt to your plan and ask to have it counted toward your out-of-pocket limit that determines when you enter and exit the coverage gap. Learn more about the coverage gap.

How do I request coverage of prescriptions the PDP denied?

Find out about the Medicare appeal process offered by the PDP. If you really need a medication because of a valid medical reason, you can often get it covered. But you must go through the Medicare appeal process. The first step is to ask the PDP for a coverage determination . If the PDP agrees that you really need the medication based on the information your health care provider gives the plan, then the request for coveragewill be granted. If not, you will receive a denial notice that includes information telling you how to use the Medicare appeal process. There are several additional levels of appeals, so you can appeal to external agencies if you are not satisfied with the PDP's response. If you can't wait for the process to finish, you may need to pay for the drug yourself and then file an appeal to be paid back by the plan later.

You should be aware that you probably will not be notified of your right to request a coverage determiniation when you are first told that the prescription can't be filled. So you must become familiar with how to make the request on your own initiative.

Does the PDP allow me to use my current pharmacy?

Look at which pharmacies are in the PDP's network. PDPs generally include the vast majority of pharmacies in their networks. But you can get the list of pharmacies in the network by looking at the PDP's Web site, calling the member services phone number on the back of your ID card, or reading the written materials that the PDP sends you. You can also ask at your pharmacy to find out if they participate with the PDP you are enrolled in or plan to enroll in.

Find out if the PDP has preferred and non-preferred pharmacies. Even if your pharmacy is in the PDP network, it may be a non-preferred pharmacy. If it is, you may have to pay more to get your medicines there. A PDP may have preferred and non-preferred pharmacies in the network, and may also exclude some pharmacies from the network altogether. Medicare allows PDPs to charge higher copays if you go to a non-preferred pharmacy. If you go to a pharmacy that is not in the network at all, you may be denied benefits unless it is an emergency.

What if I have a Complaint about my Prescription Drug Plan?

You have a right to file complaints about your plan that are not related to appealing for coverage or payment for a drug. You should file your complaint (called a grievance) within 60 days of whatever led to your dissatisfaction. Some examples of complaints you might have include:

• Waiting on hold for too long when you call your plan.
• Getting “junk mail” from your drug plan about other products that the company offers.
• Not getting a decision on a request for coverage within the required time frame.
• Not getting notices about things the plan is required to tell you about, for example, if a medicine is removed from the formulary.

To file a complaint, you may either call or write to your plan. The plan is required to have a process to hear and resolve your grievance. They must tell you their decision within 30 days regarding of when you make your complaint. Plans must keep records of all grievances, which are reviewed by the federal government when they evaluate the plans.

You may also file a complaint with the office of the Medicare ombudsman. This office is responsible for assisting you with grievances, as well as appeals. The Medicare ombudsman’s office can be reached at 1-800-MEDICARE (1-800-633-4227) or online at http://www.cms.hhs.gov/center/ombudsman.asp.

Where to Get Answers

The following resources can help you get answers to these and other questions you may have:

• Materials that the PDPs provide for you
• The Web site for the PDP (look for general benefit information and plan requirements, as well as information on their current formulary)
• The Medicare Web site (www.medicare.gov) has information to help you compare PDPs
• Materials sent to you in the mail by Medicare
• The Medicare consumer phone line: 1-800-633-4227 (You can reach a live operator by pressing zero on your phone once the automated menu starts.)
• Your state's Area Agency on Aging or State Health Insurance Assistance Program
• Social Security, on the Web at www.socialsecurity.gov or by phone at 1-800-722-1213