- Medicare Part D prescription drug coverage
- Special things people with cancer need to think about
- Who should enroll in Medicare Part D?
- Making a Part D plan decision
- Getting help to pay Medicare Part A and/or Part B premiums (the Medicare Savings Programs)
- Formularies and drug coverage
- Where can I use my Part D drug coverage to fill my prescriptions?
- How much will the Part D drug plan cost?
- Things to know once you’ve chosen a Part D drug plan
- Switching drug plans in the future
- Frequently asked questions
- Where can I get more help?
- Are you ready to get started?
- More information from your American Cancer Society
Frequently asked questions
Here are answers to the Part D questions most often asked by people with cancer. The questions and answers assume that you are eligible and enrolled in Medicare Part B. But keep in mind that all Medicare beneficiaries are also eligible for 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 laws 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 (1-800-633-4227) or www.medicare.gov. We also encourage you to check with the Part D plans directly if you have questions. The information given here 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 have cancer and I think Part D might be able to help me with my 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 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 (chemo) treatment. Part D may help you with other prescriptions that are not covered under Part B, such as certain cancer drugs you take by mouth.
I have cancer and am getting treatment. I’ve looked on the Medicare website and found that some, but not all, of the drugs I’m taking are included on formularies for drug plans in 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 doesn’t mean the drug isn’t covered by Medicare. 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 these are cancer 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 get in the office, then these drugs are covered under Part B. To be sure that this is the case, call the plan’s beneficiary help line (this number is usually listed on your Medicare Part D Plan ID card) and ask to speak to a customer service representative, or call 1-800-MEDICARE. Your state health insurance assistance program (SHIP) might also be able to help you. (See the section called “Where can I get more help?” to learn how to contact your state’s SHIP.)
If you find 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.
If I take a prescription for a cancer drug to the pharmacy and the drug 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. 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’s helpline (see your Medicare Part D Plan ID card) or Medicare (call 1-800-MEDICARE 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 situation and the prescription drugs you take. Your first step should be to learn about 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 keep your current plan. If your coverage ends or you choose to join Medicare Part D sometime in the future, you can do so without paying a late enrollment penalty. But to avoid the penalty, 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 become eligible for Medicare while you have drug coverage that’s not as good as Medicare, you will want to find out about enrolling in Part D. Ask your insurer or your former employer whether your benefits are equal to the standard benefit under Medicare Part D. If your coverage isn’t as good as Part D, you can sign up for Part D. If you don’t enroll right away, you may face penalties.
If you still have questions, call 1-800-MEDICARE or visit www.medicare.gov. You can also get one-on-one counseling from your State Health Insurance Assistance Program (SHIP) or your local office on aging. SHIP contact information is covered in the section “Where can I get more help?” 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 my 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 that of anyone else covered under your policy, such as your spouse or children.
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’ve 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 they will provide coverage to supplement the Medicare drug plan. (This is much like the way employers and unions sometimes provide health coverage to supplement Medicare A and B for doctor and hospital coverage.)
It’s important that you understand how your employer or union coverage will change if you enroll in 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, 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 make if you’re enrolled in 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 join a Medicare drug plan later — as long as:
1. You join a plan within 63 days after your coverage ends.
2. You can produce the letter proving your plan was as good as or better than Part D.
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 that 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 as long as you join the plan within 63 days after coverage ends.
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 if you hit the donut hole. For donut hole information, see “What is the coverage gap, and what do I pay?” in the section called “The Medicare prescription drug coverage: 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 (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 policy. The Medigap premium will be adjusted because you are not paying for drug coverage anymore.
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 pay for your drugs once you hit a certain dollar amount. Also, Medicare Part D will provide catastrophic coverage, which pays about 95% of your drug costs after you’ve spent a certain amount out of pocket. This can be very important for people being treated for cancer.
Second, in deciding whether to keep your Medigap policy, you will need to maintain creditable prescription drug coverage just in case you need to join a Medicare Part D plan later. (Your Medigap 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 more. Even if your coverage does meet this standard, you’ll have to prove it by getting and keeping a letter from your current plan.
How do I know if the drugs I take now will be covered under Part D?
You can figure out what plans cover your drugs and also compare the co-pays. 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. And some plans with a low monthly premium may charge higher co-pay amounts.
People with cancer are often prescribed expensive medicines to treat the disease and keep it from coming back. If you’re being treated for cancer, 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 Medicare Plan Finder online. You have to enter each drug by name and dose, so you’ll want to start by getting all your prescription drugs in front of you. The Medicare Plan Finder is on the Medicare website at www.medicare.gov/find-a-plan You’ll enter your zip code and all the drugs you take to do a general search, then you’ll get a list of plans that cover the drugs you need. Once you have this, you can go to each plan’s Web site for information on premiums, co-pays, appeal rights, and more. The Medicare Plan Finder also allows you to do a personalized search by entering more details about yourself. This gives you a list of plans that would best meet your specific needs.
If you don’t have access to a computer, or don’t feel comfortable using the Internet, call 1-800-MEDICARE. It’s important that you make the most informed decision you can.
I have a limited income and few resources. How do I apply for help with my Part D monthly premiums and co-pays?
If your income is less than an amount set by Medicare every year, you may be able to get help paying your premium, deductible, and co-pays for Medicare Part D. The amount of help, called 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.
After you apply, 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’ll get a letter letting you know if you qualify.
Certain people automatically qualify for Extra Help with prescription drug costs under Part D:
- Medicare beneficiaries who also qualify for Medicaid (called dual eligible)
- People who get help from Medicaid to pay their Part B Medicare premiums
- Medicare beneficiaries who get Supplemental Security Income (SSI) benefits
See the section called “Getting help to pay Medicare Part A and/or Part B premiums (the Medicare Savings Programs)” for more on this. You can also call 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP) for more information. (See the section called “Where can I get more help?” for SHIP contact information.)
Other options for financial help
If you are not eligible for Medicaid or Extra Help, there are other ways to get help 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 aren’t paid by the Part D plan. Payments made by these SPAP programs can be counted as out-of-pocket expenses to meet 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 count as personal out-of-pocket spending. They aren’t counted towards the deductible or the limit for catastrophic coverage by a Part D plan.
Finally, if you’re a Medicare beneficiary who is covered by Medicaid and you 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 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 be enrolled 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 they’ll need to help you select a plan or compare plans. This information includes:
- 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 be on your Medicare card.
- Your name, birth date, zip code, and the county you live in
- Information about any drug coverage you already have, including the number and company name, which should be on the ID card
- A list of all the prescription drugs you take and the dose, as well as 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?
If you don’t qualify for Extra Help and get your cancer drugs for free or at a discount from the drug company, you may worry about whether this will change if you enroll in Part D plan.
Many cancer patients who are eligible for Medicare Part D have questions about whether they’ll 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 makers 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’s a generic drug or another treatment 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 then picking up 95% of the beneficiary’s drug costs.
The OIG has said that drug manufacturers may give free or low-priced outpatient prescription drugs to Medicare beneficiaries who do not enroll in Part D. But many drug companies are hesitant to help Medicare beneficiaries.
This is mostly because drug makers 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 other prescription drugs the person might need. Drug makers also know that nearly all beneficiaries will be better off if they sign up for Part D as soon as they’re 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 drug is being given to the enrollee outside of the Part D benefit to ensure that no payment is made by the Part D plan for that 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 check with PAP programs, even if you are enrolled in Part D. But it’s up to the drug manufacturer whether or not to offer a PAP and, if they do, whether they will help you.
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 makers are allowed to give money to independent charities that help needy patients with 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 with incomes too high to qualify for help from Medicare to pay for their Part D plan, since the charities’ income restrictions are often more flexible.
Last Medical Review: 09/13/2013
Last Revised: 09/13/2013