What is Medicare and how do I enroll in Medicare?
Medicare is health insurance for people 65 or older, certain people under 65 with disabilities, and people of any age with End-Stage Renal Disease (ESRD).
Your first chance to get Medicare usually starts 3months before you turn 65 and ends 3 months after you turn 65.
If you're over 65 (or turning 65 in the next 3 months) and not already getting benefits from Social Security, you need to sign up to get Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). You won't get Medicare automatically.
If you are already receiving your Social Security benefits then you will automatically be enrolled in Medicare when you turn 65 or if you receive Social Security disability, then you will automatically be enrolled in Medicare after 24 months.
When you're first eligible for Medicare, you have a 7 month Initial Enrollment Period to sign up for Part A and/or Part B.
If you aren’t automatically enrolled, you can sign up for free Part A (if you’re eligible) any time during or after your Initial Enrollment Period starts. Your coverage start date will depend on when you sign up. If you have to buy Part A and/or Part B, you can only sign up during a valid enrollment period.
If you wait until the month you turn 65 (or the 3 months after you turn 65) to enroll, your Part B coverage will be delayed. This could cause a gap in your coverage.
In most cases, if you don’t sign up for Medicare Part B when you’re first eligible, you’ll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B and could have a gap in your health coverage.
Between January 1–March 31 each year, you can sign up for Part A and/or Part B during the General Enrollment Period if both of these apply:
• You didn't sign up when you were first eligible.
• You aren’t eligible for a Special Enrollment Period (see below).
You must pay premiums for Part A and/or Part B. Your coverage will start July 1. You may have to pay a higher premium for late enrollment in Part A and/or a higher premium for late enrollment in Part B.
Once your Initial Enrollment Period ends, you may have the chance to sign up for Medicare during a Special Enrollment Period (SEP). If you're covered under a group health plan based on current employment, you have a SEP to sign up for Part A and/or Part B anytime as long as:
• You or your spouse (or family member if you're disabled) is working.
• You're covered by a group health plan through the employer or union based on that work.
You also have an 8-month SEP to sign up for Part A and/or Part B that starts at one of these times (whichever happens first):
• The month after the employment ends
• The month after group health plan insurance based on current employment ends
Usually, you don't pay a late enrollment penalty if you sign up during a Special Enrollment Period.
However, COBRA and retiree health plans aren't considered coverage based on current employment. You're not eligible for a Special Enrollment Period when that coverage ends. This Special Enrollment Period also doesn't apply to people who are eligible for Medicare based on having End-Stage Renal Disease (ESRD)
Back to TopWill I get a Medicare insurance card?
When you’re enrolled in Medicare, you’ll get your red, white, and blue Medicare card in the mail. If you're automatically enrolled, you'll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday or your 25th month of getting disability benefits. Your Medicare card shows that you have Medicare health insurance. It shows whether you have Part A (Hospital Insurance), Part B (Medical Insurance) or both, and it shows the date your coverage starts.
Be sure to carry your card with you when you’re away from home. Let your doctor, hospital, or other health care provider see your card when you need hospital, medical or other health services.
This is what your Medicare card will look like.
5 things to know about your Medicare card
- Your card has a Medicare Number that’s unique to you, instead of your Social Security Number. This helps to protect your identity.
- Your card is paper, which is easier for many providers to use and copy.
- If you’re in a Medicare Advantage Plan (like an HMO or PPO), your Medicare Advantage Plan ID card is your main card for Medicare—you should still keep and use it whenever you need care. And, if you have a Medicare drug plan, be sure to keep that card as well. Even if you use one of these other cards, you also may be asked to show your Medicare card, so keep it with you.
- Only give your Medicare Number to doctors, pharmacists, other health care providers, your insurers, or people you trust to work with Medicare on your behalf.
- If you forget your card, you, your doctor or other health care provider may be able to look up your Medicare Number online.
WATCH OUT FOR SCAMS
Medicare will never call you uninvited and ask you to give personal or private information. Scam artists may try to get personal information, like your Medicare Number. If someone asks you for your information, for money, or threatens to cancel your health benefits if you don’t share your personal information, hang up and call 1-800-MEDICARE (1-800-633-4227)
Back to TopHow do I choose Medicare Coverage?
People get Medicare coverage in different ways. You'll get lots of information to help you make a decision about how to get your Medicare coverage:
• An official "Welcome to Medicare" packet with important information about your coverage options.
• Your official "Medicare & You" handbook once you're enrolled and every year each fall.
• Mail from private insurance companies, agents and brokers, marketing the Medicare plans they offer.
There are 2 main ways you can get your Medicare coverage:
Original Medicare – Includes Part A and Part B. You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
• If you want drug coverage, you can join a separate Medicare Prescription Drug Plan (Part D)
• To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also shop for and buy supplemental coverage like a Medicare Supplement Insurance (Medigap) policy from a private insurance company. Medicare supplement and Medigap are the same type of coverage, it is just referred to by two different names.
If you don't get Part D or a Medigap policy when you're first eligible, you may have to pay more to get this coverage later. For Part D, this could mean a lifetime premium penalty.
Medicare Advantage – An "all in one" alternative to Original Medicare. These "bundled" plans include Part A, Part B, and usually Part D. Most plans offer extra benefits that Original Medicare doesn't cover – like vision, hearing, dental, and more.
• Plans may have lower out-of-pocket costs than Original Medicare.
• In most cases, you'll need to use doctors who are in the plan's network.
Back to TopWhat does Medicare Part A and Medicare Part B cover?
In general, Part A covers:
• Inpatient care in a hospital
• Skilled nursing facility care
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care
• Home health care
Part B covers 2 types of services:
• Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
• Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.
Part B covers things like:
• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health
• Inpatient
• Outpatient
• Partial hospitalization
• Getting a second opinion before surgery
• Limited outpatient prescription drugs
Part B deductible & coinsurance:
You pay $185 per year in 2019 for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these:
• Most doctor services (including most doctor services while you're a hospital inpatient)
• Outpatient therapy
• Durable medical equipment (DME)
Back to TopWhat does Medicare Part A and Part B cost?
You usually don't pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A."
Most people get premium-free Part A.
You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you're under 65, you can get premium-free Part A if:
- You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
If you have to buy Part A, you'll pay up to $437 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $437. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $240.
In most cases, if you choose to buy Part A, you must also:
Contact Social Security for more information about the Part A premium.
You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:
- Social Security
- Railroad Retirement Board
- Office of Personnel Management
If you don’t get these benefit payments, you’ll get a bill.
Most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS.
The standard Part B premium amount in 2019 is $135.50. Most people will pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.
Back to TopHow do I decide what I need for Medicare Coverage?
Medicare Parts A & B coverages are not completely comprehensive, leaving you financially responsible for these gaps in coverage. In reality these costs can quickly rise when you become ill or injured depending on the extent of care you need. Additionally, there is no prescription drug coverage that comes with original Medicare, no caps on your annual out-of-pocket expenses that are related to Original Medicare (Parts A & B) services.
You can protect yourself against these unexpected Medicare expenses by purchasing a Medicare Advantage (Part C) or Medicare Supplement (Medigap) plan. These plans can help by providing more consistent costs, annual out-of-pocket maximums and additional benefits not covered by Original Medicare (Parts A & B).
Back to TopWhat is a Medicare Supplement and how does it work?
Medicare Supplement (Medigap) plans are offered through private insurance companies and are designed to fill the gaps in Original Medicare (Parts A & B) coverage. When you purchase a Medicare Supplement plan, Original Medicare remains your primary insurer, allowing you to see any doctor or facility that accepts Medicare with no need for referrals. The Medicare Supplement plan becomes your secondary insurer, that covers non-Medicare covered expenses such as co-payments, deductibles, and provide health care if you travel outside the United States.
Medigap policies don't cover long-term care, dental care, vision care, hearing aids, eyeglasses, and private-duty nursing and prescription drug coverage is not included.
- When you receive covered healthcare services, Medicare will pay its share of the Medicare-approved amount for covered health care costs.
- Then, your Medigap policy pays its share.
For a Medigap plan, you pay a monthly premium to the insurance company in addition to your Medicare Part B premium. The cost of your Medigap policy depends on the type of plan you buy, the insurance company, your location, and your age. A standardized Medigap policy is guaranteed renewable -- even if you have health problems -- if you pay your premiums on time.
However, you may have to wait up to six months for coverage if you have a pre-existing health condition. The insurer through which you buy your Medigap policy can refuse to cover out-of-pocket costs for pre-existing conditions during that period. After six months, the Medigap policy must cover the pre-existing condition. The exception to this rule is if you buy a Medigap policy during your open enrollment period and have had continuous "creditable coverage," or a health insurance policy for the six months before buying a policy. The Medigap insurance company cannot withhold coverage for a pre-existing condition in that case.
Insurance companies set their own prices and rules about eligibility, so it's important to shop around.
Medigap Plans benefits are standardized in most states in the US, so the benefits are the same for a plan no matter what insurance company you choose. Less expensive plans have fewer benefits and higher out-of-pocket costs. More expensive plans include extra benefits, like some Medicare deductibles, additional hospital benefits, at-home recovery, and more. You have to decide what sort of plan makes the most sense for you.
How do Medigap policies work?
You must have Medicare Part A and Part B.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
You pay the private insurance company a monthly premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare.
A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you'll each have to buy separate policies.
You can buy a Medigap policy from any insurance company that's licensed in your state to sell one.
Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can't cancel your Medigap policy as long as you pay the premium.
It's illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you're switching back to Original Medicare.
Fortunately, Medicare supplement plans are available from a variety of insurers to help pay for the following medical expenses:
- Coinsurance and hospital costs for up to one year after Medicare benefits are used up
- Blood transfusions for up to three pints of blood
- Hospice care coinsurance or copayment
- Skilled nursing facility care coinsurance
- Medicare Part A (hospital insurance) deductible
- Medicare Part B (medical insurance) deductible
- Part B excess charge (the difference between the amount a doctor or health care provider can legally charge and the Medicare-approved amount)
- Medical costs incurred while traveling outside of the U.S.
- Out-of-pocket limit
There are going to be some changes in the plans starting on January 1, 2020 and the following information depicts the benefits for the plans starting on that date.
The chart below shows basic information about the different benefits Medigap policies cover.
Yes = the plan covers 100% of this benefit
No = the policy doesn't cover that benefit
% = the plan covers that percentage of this benefit
N/A = not applicable
|
Medigap Benefits
|
Medigap Plans
|
|
A
|
B
|
C
|
D
|
F*
|
G
|
K
|
L
|
M
|
N
|
|
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
|
Part B coinsurance or copayment
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
50%
|
75%
|
Yes
|
Yes***
|
|
Blood (first 3 pints)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
50%
|
75%
|
Yes
|
Yes
|
|
Part A hospice care coinsurance or copayment
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
50%
|
75%
|
Yes
|
Yes
|
|
Skilled nursing facility care coinsurance
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
50%
|
75%
|
Yes
|
Yes
|
|
Part A deductible
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
50%
|
75%
|
50%
|
Yes
|
|
Part B deductible
|
No
|
No
|
Yes
|
No
|
Yes
|
No
|
No
|
No
|
No
|
No
|
|
Part Bexcess charge
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
|
Foreign travel exchange (up to plan limits)
|
No
|
No
|
80%
|
80%
|
80%
|
80%
|
No
|
No
|
80%
|
80%
|
|
Out-of-pocket limit**
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
$5,560
|
$$2,780
|
N/A
|
N/A
|
* Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount of $2,300 before your Medigap plan pays anything.
** After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year.
*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don't result in inpatient admission.
Starting January 1, 2020, Medigap plans sold to new people with Medicare won’t be allowed to cover the Part B deductible. Because of this, Plans C and F will no longer be available to people new to Medicare starting on January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) or are covered by one of these plans before January 1, 2020, you’ll be able to keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans.
If you live in one of these 3 states, Medigap policies are standardized in a different way.
Massachusettes
If you live in Massachusetts, you have guaranteed issue rights to buy a Medigap policy, but the policies are different.
Basic benefits
- Inpatient hospital care: covers the Part A coinsurance plus coverage for 365 additional days after Medicare coverage ends.
- Medical costs: covers the Part B coinsurance (generally 20% of the Medicare-approved amount).
- Blood: covers the first 3 pints of blood each year.
- Part A hospice coinsurance or copayment.
Medigap plans
Core Plan
Covers
- Basic benefits .
- 60 days per calendar year of inpatient days in mental health hospitals.
- State-mandated benefits (yearly Pap tests and mammograms. Check your plan for other state-mandated benefits).
Doesn't cover
- Part A: inpatient hospital deductible.
- Part A: skilled nursing facility coinsurance.
- Part B: deductible.
- Foreign travel emergency.
Supplement 1 Plan
Covers
- Basic benefits.
- Part A: inpatient hospital deductible.
- Part A: skilled nursing facility coinsurance.
- Part B: deductible.
- Foreign travel emergency.
- 120 days per calendar year of inpatient days in mental health hospitals.
- State-mandated benefits including yearly Pap tests and mammograms. Check your plan for other state-mandated benefits.
Wisconsin
If you live in Wisconsin, you have guaranteed issue rights to buy a Medigap policy, but the policies are different.
Basic benefits
- Inpatient hospital care: covers the Part A coinsurance
- Medical costs: covers the Part B coinsurance (generally 20% of the Medicare-approved amount)
- Blood: covers the first 3 pints of blood each year
- Part A hospice coinsurance or copayment
Medigap plan
Basic Plan
Covers
- Basic benefits
- Part A: skilled nursing facility coinsurance
- 175 days per lifetime in addition to Medicare's benefit of inpatient mental health coverage
- 40 home health care visits in addition to those paid for by Medicare
- State mandated benefits
-
Important plan information
Plans known as "50% and 25% Cost-sharing Plans" are available. These plans are similar to standardized Plans K (50%) and L (25%). A high-deductible plan ($2,000) is also available.
Insurance companies are also allowed to offer these riders to a Medigap policy:
- Part A deductible
- Additional home health care (365 visits including those paid by Medicare)
- Part B deductible
- Part B excess charges
- Foreign travel emergency
- 50% Part A deductible
- Part B copayment or coinsurance
Minnesota
If you live in Minnesota, you have guaranteed issue rights to buy a Medigap policy, but the policies are different.
Basic benefits
- Inpatient hospital care: covers the Part A coinsurance
- Medical costs: covers the Part B coinsurance (generally 20% of the Medicare-approved amount)
- Blood: covers the first 3 pints of blood each year
- Part A hospice and respite care cost sharing
- Parts A and B home health services and supplies cost sharing
-
Medigap plans
The Basic and Extended Basic benefits are available:
- When you enroll in Part B
- Regardless of your age or health problems
You’ll get another 6-month Medigap Open Enrollment Period if both of these apply:
- You return to work.
- You drop Part B to elect your employer's health plan.
You'll get this open enrollment period after you retire from that employer when you can elect Part B again.
Basic Plan
Covers:
- Basic benefits
- Part A: skilled nursing facility (SNF) coinsurance (provides 100 days of SNF care)
- 80% of foreign travel emergency
- 50% of outpatient mental health
- Medicare-covered preventive care
- 20% of physical therapy
- State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, and immunizations)
Doesn't Cover:
- Part A: inpatient hospital deductible
- Part B: deductible
- Usual and customary fees
- Coverage while in a foreign country
Extended Basic Plan
Basic benefits:
- Part A: inpatient hospital deductible
- Part A: skilled nursing facility (SNF) coinsurance (provides 120 days of SNF care)
- Part B: deductible
- 80%* of foreign travel emergency
- 50% of outpatient mental health
- 80%* of usual and customary fees
- Medicare-covered preventive care
- 20% of physical therapy
- 80%* of coverage while in a foreign country
- State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, and immunizations)
* The plan pays 100% after you spend $1,000 in out-of-pocket costs for a calendar year.
Back to TopWhat is a Medicare Advantage Plan?
A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:
- Health Maintenance Organizations
- Preferred Provider Organizations
- Private Fee-for-Service Plans
- Special Needs Plans
- Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and Medicare services aren’t paid for by Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
There are several types of Medicare Advantage plans available. Here are a few examples.
Health Maintenance Organization HMO
In most HMO Plans, you generally must get your care and services from providers in your plan's network, like, Doctors, Other health care providers, and Hospitals.
In HMO Plans, you generally must get your care and services from providers in the plan's network, except, emergency care, out-of-area urgent care, out-of-area dialysis.
In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.
In most cases, prescription drugs are covered in HMO Plans. You would want to ask the plan you choose. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. In most cases, yes, you need to choose or designate a primary care doctor in HMO Plans. In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral. If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan. If you get health care outside the plan's network , you may have to pay the full cost. It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.
Preferred Provider Organization PPO
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.
In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.
In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D).
You don't need to choose a primary care doctor in PPO Plans.
In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.
A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.
Special Needs Plans SNP’s
Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except in Emergency or urgent care situations, like care you get for a sudden illness or injury that needs medical care right away. Or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis. Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
All SNPs must provide Medicare prescription drug coverage. In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care. In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these, Yearly screening mammograms or An in-network pap test and pelvic exam (covered at least every other year).
An SNP plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time. Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders. If you have Medicare and Medicaid , your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid. If you live in an institution, make sure that plan providers serve people where you live.
Back to TopWhat is Drug Coverage (Part D)?
Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. If you decide not to get Medicare drug coverage when you're first eligible, you'll likely pay a late enrollment penalty if you join later, unless one of these applies. You have other creditable prescription drug coverage, or You get Extra Help. Generally, you'll pay this penalty for as long as you have Medicare prescription drug coverage.
To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.
Here are some ways to help you choose a Prescription Drug Plan. Look at drug plans that include your prescription drugs on their formulary (a list of prescription drugs covered by a drug plan). Then, compare costs. Look at drug plans offering coverage in the coverage gap, and then check with those plans to make sure they cover your drugs in the gap. Look at drug plans with no or a low deductible, or with additional coverage in the coverage gap. Look at Medicare drug plans with “tiers” that charge you nothing or low copayments for generic prescriptions. Look at Medicare drug plans with a low monthly premium for drug coverage. If you need prescription drugs in the future, all plans still must cover most drugs used by people with Medicare.
When you join a Medicare drug plan, you'll give your Medicare Number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies.
Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.
The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.
For 2019 and beyond, drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re taking these drugs, you’ll get information about the specific changes made to generic drug coverage afterwards.
You may need to change the drug you use or pay more for it. You can also ask for an exception. Generally, using drugs on your plan’s formulary will save you money. If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generic drugs instead of brand-name drugs may save you money.
To lower costs, many plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
In some cases, if your drug is in a higher (more expensive) tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment.
If you meet certain income and resource limits, you may qualify for a program called Extra Help from Medicare to pay the prescription costs, premiums, deductibles, and coinsurance of Medicare prescription drug coverage.
Back to Top