Here are answers to the questions most often asked by patients with cancer. The questions and answers are based on the fact that you are eligible and enrolled in Medicare Part B. But you should keep in mind that all Medicare beneficiaries are also eligible to take part in Part D, whether they have only Medicare Part A or Part B, or both. The answers to these questions will be different if you get prescription drug coverage through your former employer's retiree plan or if you are enrolled in a State Medicaid program.

PLEASE NOTE: We have reviewed the law and regulations pertaining to Part D, and we are giving you the American Cancer Society's best answers to these questions. For official answers you must contact the Centers for Medicare & Medicaid Services (CMS) directly at 1-800-MEDICARE or www.medicare.gov. We also encourage you to check with the Part D plans directly if you have questions. The information given in the Frequently Asked Questions section is not intended to favor one plan over another, but only to give basic answers to questions cancer patients may have about their Medicare coverage.

I am a cancer patient and I think Part D might be able to help me with my prescription drug costs. Can they turn me down because I already have cancer?

No. Medicare Part D drug plans must accept all eligible applicants living in their service area regardless of age or health status.

I am getting cancer treatment now. Most of my drugs are covered under Medicare Part B. If I sign up for Medicare Part D, will that change?

No. The drugs that are now covered under Medicare Part B will still be covered under Part B. These are the drugs that you get in your doctor's office as part of your chemotherapy treatment. Part D may help you with other prescriptions that are not covered under Part B, such as certain oral cancer drugs.

I am a cancer patient getting treatment. I've looked on the Medicare Web site and found that some, but not all, of the drugs I'm taking are included on formularies for several drug plans serving my area. How do I know if the rest of my cancer drugs are covered by Medicare if they aren't on the plans' formularies?

Just because a cancer drug is not listed on a plan's formulary does not mean the drug is not covered by Medicare. As the answer to the last question explained, drugs that are covered under Medicare Part B will still be covered under Part B after you sign up for Part D. To find out if a drug is covered under Part B (rather than under Part D), make a list of the drugs that are not on the formulary. Then check with your doctor's office to see if the cancer drugs that are not on the formulary are drugs that you get through an IV in the doctor's office. If the cancer drugs not listed on the formulary are drugs that you would need to get in the office, then these drugs are covered under Part B and not Part D. To be sure that this is the case, check with the plan by calling the beneficiary help line and ask to speak to a customer service representative, or call 1-800-MEDICARE (1-800-633-4227). Your state health insurance assistance program (SHIP) might also be able to help you. SHIP contacts are listed in a chart at the end of this document.

Even if you have made sure that your drugs are on a plan's formulary, you still need to check to see how much your co-pay will be and if your local pharmacy is part of the plan.

What if I bring a prescription for a cancer drug into the pharmacy that is supposed to be covered under Part B? Can the pharmacy or the drug plan deny coverage under Part D?

Generally speaking, the answer is no. Pharmacies and drug plans are not supposed to deny coverage for a cancer drug if you bring a prescription into a pharmacy and the drug might be covered under Part B instead of Part D. But, cancer drugs clearly covered under Part B might not be on a plan's formulary, and your pharmacy or drug plan may deny coverage for these drugs. Also, in some cases a drug plan may require prior authorization for certain drugs to be sure that your diagnosis or use of the drug is in line with Part D coverage. If this happens to you, contact your plan or Medicare (call 1-800-633-4227 or visit www.medicare.gov). to find out how to resolve the problem.

I am confused by all the different prescription drug plans offered in my state. What do I need to do first?

Deciding if Medicare Part D is right for you depends on your personal situation and the prescription drugs you take. Your first step should be to find out what, if any, drug coverage you have already. Do you have prescription drug coverage from an employer or union? Do you have Medicare and a Medigap (Supplemental) policy with drug coverage? Do you have a Medicare Advantage Plan (like an HMO or PPO) or another Medicare Health Plan?

If you already have prescription drug coverage from an employer, union, or a Medigap policy, you will need to figure out whether your drug coverage is as good as or better than the drug coverage you could get under Part D. If your current coverage is as good as or better than Medicare Part D, then you can opt to stay with your current insurer without any future penalty if you change your mind. If your coverage ends at a later date or you choose to join Medicare Part D sometime in the future, you can do so without paying a late enrollment penalty. If your employer or union coverage does end at a later date, you must join a Medicare drug plan within 63 days after your drug coverage ends or is no longer as good as that offered by Medicare.

If you have some drug coverage now, but it's not as good as Medicare, you should look into signing up for Part D. Ask your current insurer or your former employer whether your benefits are equal to the standard benefit under Medicare Part D. If your coverage is not as good as Part D, you can sign up for it. If you do not enroll, you may face a late enrollment penalty.

If you still have questions, call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov. You can also get one-on-one counseling from your State Health Insurance Assistance Program (SHIP) and your local office on aging. SHIP contacts are listed in a chart at the end of this document. The phone number of your local office on aging can be found at www.eldercare.gov or by calling 1-800-677-1116.

Before I decide to enroll in Part D and drop the coverage I have through an employer or union, what do I need to think about?

If you are covered by an employer or union, before you switch to Part D, you should find out how that decision could affect other parts of your medical coverage. In some cases, if you drop your prescription drug coverage under a health plan from your employer or union, you may also lose your hospital and doctor (medical) coverage. This could affect not only your health insurance, but the health insurance of anyone else covered under your policy, such as your spouse or children. You should carefully read all information you get from a former employer or union about your existing drug and health coverage before you decide to join a Part D prescription drug plan. Once you have dropped your employer or union coverage, you may not be able to get it back.

Also, keep in mind that former employer or union coverage might work with Medicare in different ways. For example the employer or union might want their retirees to join a Medicare drug plan, and then the employer or union will provide additional coverage to supplement the Medicare drug plan. (This is much like the way employers and unions sometimes provide health coverage to supplement Medicare doctor and hospital benefits.) It is important that you understand how your employer or union coverage will change under Part D. Your former employer or union should send you a letter telling you whether your drug coverage is better or worse than the Medicare drug benefit. If you have questions, you should call your plan or your employer or union's benefits administrator. Medicare will not be able to tell you what changes your employer or union coverage may implement under Part D.

If you decide to keep your former employer or union's coverage after finding that your coverage is at least as good as Medicare, you will not have to pay a penalty if you later have to join a Medicare drug plan – as long as you join a plan within 63 days after your coverage ends.

What should I do if I am currently covered under TRICARE (military), the Federal Employees Health Benefits Program (FEHB), or if I get my prescription drug coverage from the Veteran's Administration (VA)?

TRICARE, the VA, and FEHB benefits have all been found to be as good as or better than the standard Medicare Part D benefit. So, if you have drug coverage through any of these, you should keep your current coverage. If you decide to join Part D later, or if you lose your TRICARE, VA, or FEHB coverage, in most cases you will not face a late enrollment penalty.

Can I use both VA and Medicare to cover my prescription drugs?

Yes, you can have coverage under both VA and Medicare Part D, but each prescription will only be covered by a single program. You can choose on a prescription-by-prescription basis whether to get the drug under the VA or Medicare plan, but the prescription cannot be covered by both plans at once. Keep in mind that VA coverage might vary from a Part D plan in terms of the medicines that each will cover. Also, keep in mind that the cost of any prescriptions paid by the VA will not count toward reaching your catastrophic coverage level under Medicare Part D.

I have Medigap, and my plan covers prescription drugs. Do I need to enroll in Part D?

If you have a Medigap policy that covers prescription drugs (i.e., Plan H, I, or J), you can keep your Medigap plan with the drug coverage or you can enroll in Medicare Part D – but you cannot have both. If you do enroll in Medicare Part D, you can still keep your Plan H, I or J, but the drug coverage will be removed from the Medigap policy and the premium will be adjusted to reflect the loss of the drug coverage.

If you are thinking about keeping the Medigap drug coverage and not enrolling in a Medicare Part D plan, there are 2 things that you should think about.

First, Medicare Part D will have greater dollar value than the prescription drug benefit in the Medigap plans. In Medigap, you pay the full premium, and the drug coverage is capped, meaning it will not provide coverage if you have very high drug bills. And, Medicare Part D will provide catastrophic coverage, which pays about 95% of drug expenses after you've spent a certain amount out of pocket. This can be very important for beneficiaries being treated for cancer.

Second, in deciding whether to keep your Medigap policy, you should be aware of the need to maintain creditable prescription drug coverage if you later wish to join a Medicare Part D plan (i.e., coverage should be as good as or better than Medicare Part D). If your coverage does not meet this standard and you later decide to enroll in Medicare Part D, you could be charged a higher premium.

How do I know if the drugs I take now will be covered under Part D?

Every prescription drug plan under Medicare Part D has a formulary (a list of drugs that the plan covers). Formularies include both generic drugs and brand name drugs. Most prescription drugs used by Medicare beneficiaries will be on each plan's formulary, but the cost of each drug will vary under the different plans. Cancer patients are often prescribed expensive medicines to treat the disease and keep it from coming back. You should figure out what plans cover your drugs and also compare the co-pays. Some plans with a low monthly premium may charge higher co-pay amounts. If you are a cancer patient, you should know that the Medicare drug plans must cover almost all cancer drugs.

The easiest way to research drug formularies for the Part D drug plans in your area is to use the "Formulary Drug Finder" which can be found on the Medicare Web site at http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp. Once you have a list of plans that cover the drugs you need, you can also go to each plan's individual Web site for information on premiums, co-pays, appeal rights, and more. If you don't have access to a computer, or don't feel comfortable using the Internet, call 1-800-MEDICARE (1-800-633-4227). It is important that you make the most informed decision possible for your situation.

I have a limited income and few resources. How do I apply for financial assistance with my Part D monthly premiums and co-pays?

If your income is less than an amount set by Medicare every year, you may qualify for help paying the premium and co-pays under Medicare Part D. The amount of extra help you get will depend on your income and resources.

If you think you might qualify, contact your Social Security Administration office or your state Medicaid office to apply. You can also apply online at www.socialsecurity.gov.

Certain people automatically qualify for extra help with prescription drug costs under Part D:

• Medicare beneficiaries who also qualify for Medicaid (called "dual eligibles")
• people who get help from Medicaid paying their Medicare premiums
• Medicare beneficiaries who get Supplemental Security Income (SSI) benefits

Call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP) for more information. (SHIP contacts are listed in a chart at the end of this document.)

If you are not eligible for Medicaid or special low-income assistance, there are other ways to get help in paying for the costs of drugs not covered in your Part D drug plan. Many states have state pharmacy assistance programs (SPAPs) that offer prescription drugs at a deep discount to people who have incomes below a certain level. These programs must work with Part D plans by extending coverage for some drug costs that are not paid by the Part D plan. Payments made by these SPAP programs can be counted as out-of-pocket expenses for purposes of meeting a Part D plan's deductible and for meeting the limit for catastrophic coverage. Call your state Medicaid office to find out if your state has a program to help Medicare beneficiaries pay their drug costs.

Payments by other drug assistance programs – for example, the patient assistance programs sponsored by drug companies or state AIDS drug assistance programs – do not qualify as personal out-of-pocket spending. They are not counted by a Part D plan in deciding if someone has met the deductible or the limit for catastrophic coverage.

Finally, if you are a Medicare beneficiary who is covered by Medicaid and live in a nursing home, you can enroll in a Part D plan and pay no premium. You will also have no co-pays for prescription drugs under Part D for any drugs that are on the plan's formulary or approved through the appeals process. The same is true if you have joined a Program of All-inclusive Care for the Elderly (PACE).

I applied for extra help with my Medicare prescription drug costs using Social Security's application. Now what?

Social Security will process your application. If your application is not complete, they will call you or write to you and ask you for the missing information. Your application will be processed as quickly as possible and you will get a letter letting you know if you qualify.

I got a letter telling me that I will be automatically enrolled in a Medicare drug plan. What if I want to choose a different plan?

If you are a Medicare beneficiary and you also qualify for Medicaid benefits (commonly called dual eligible), you must enroll in a Medicare Part D drug plan. You may have gotten a letter telling you that you were automatically enrolled in a Medicare drug plan if you didn't choose one on your own. If you decide you would rather be in a different plan, you can switch plans as often as once a month.

I don't have a computer and can't use the Internet. How can I get information on Medicare Part D?

You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Before calling this number, you should gather information that the operator will need to help you select a plan or compare plans. This information will include:

• your Medicare claim number, which is on your Medicare card and on the Medicare Summary of Benefits form you get each time you use your Medicare card
• the dates your Medicare Part A (hospital benefits) and Medicare Part B (medical benefits) first went into effect . Both of these dates should appear on your Medicare card.
• your name, birth date, zip code, and the county you live in
• information about any drug coverage you already have
• a list of prescription drugs you currently take and the dose, and number of pills you take every day for each drug

What effect will signing up for Medicare Part D have on my getting help from a patient assistance program? Right now I get my cancer drugs for free or at a discount from the manufacturer due to the high costs of the drugs. Will I still get this help when I am enrolled in Part D? I don't qualify for low-income assistance in Part D, and the co-pays for the drug are more than I can afford on top of my Part D premiums and deductible.

Many cancer patients who are eligible for Medicare Part D have questions about whether they will be able to keep getting help from drug companies who give them free or low-cost drugs. The concern for drug companies is how to continue their programs without violating federal fraud and abuse laws. Federal law (commonly referred to as the anti-kickback statute) prevents drug manufacturers from giving drugs to Part D enrollees except under certain conditions. The Department of Health and Human Services' Office of the Inspector General (OIG), which enforces the anti-kickback rules, has identified 2 main problems with patient assistance programs (PAPs). First, drug manufacturer PAPs can lead patients to use a certain drug, even if there is another treatment, such as a generic drug, that might work as well. Second, the OIG believes that PAPs can increase Medicare's cost by moving enrollees through the "donut hole" more quickly. This means that Medicare beneficiaries would get catastrophic coverage earlier, with Medicare picking up 95% of the beneficiary's drug costs.

The OIG has said that manufacturers may give free or low-priced outpatient prescription drugs to Medicare beneficiaries who do not enroll in Part D. But many manufacturers are hesitant to help any Medicare beneficiaries. This is mostly due to the fact that drug manufacturers view their PAPs as help for people who do not have any drug coverage. Also, drug companies usually only give 1 or 2 drugs through their PAPs – they cannot give total coverage for beneficiaries' other prescription drug needs. Drug manufacturers also know that nearly all beneficiaries will be better off if they sign up for Part D as soon as they are eligible.

Drug companies can give free or reduced cost drugs directly to Part D enrollees if certain conditions are met:

• Any help from a PAP cannot count toward a beneficiary's out-of-pocket costs.
• The PAP must notify the Part D plan that the drugs are being given to the enrollee outside of the Part D benefit to ensure that no payment is made by the Part D plan for the drug.
• Drug makers must guarantee that the drug will be available for the entire coverage year, and keep accurate records.

Some drug companies do not want to run their PAPs under these conditions. Most drug companies will review applications for assistance on a case-by-case basis, so it may still be worthwhile to apply, even if you are enrolled in Part D. But it is the drug manufacturer's decision whether or not to take part in a PAP and to whom they will give assistance.

Cancer patients enrolled in Part D who cannot find a PAP to help them get their drugs may be able to get help through charities that specialize in helping people with co-pays. Drug manufacturers are allowed to give money to independent charities that help needy patients with their medical expenses. They can't give money, though, if the charity steers patients toward a certain company's drugs. These charities can be especially helpful for patients whose income is too high to qualify for help from Medicare to pay for their Part D plan, since their income restrictions are usually more flexible.

Last Medical Review: 10/23/2008
Last Revised: 10/23/2008