“Your Guide to Medicare Drug Coverage” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048.

This product was produced at U.S. taxpayer expense.

Table of Contents

Section 1: The Basics

Medicare drug coverage adds to your Medicare health coverage

Pick the drug coverage that meets your needs

Get help with your choices

Section 2: How Medicare Drug Coverage Works

How is Part D coverage different from Part B coverage for certain drugs?

What plans are available in my area?

How much will my drug coverage cost?

How can I pay my plan premium?

When can I join, switch, or drop Medicare drug coverage?

How do I switch plans?

How do I join a plan?

What’s the Part D late enrollment penalty?

How much is the late enrollment penalty?

How do I avoid paying a penalty?

What information do I need to get Medicare drug coverage?

Will I get a separate card for my Medicare drug coverage?

What if I need to fill a prescription before I get my membership card?

Where can I fill my prescriptions?

Can I use an automatic refill mail-order service to get my drugs?

What if I have End-Stage Renal Disease (ESRD)?

Which drugs are covered?

What if I’m taking a drug that isn’t on my plan’s drug list when my drug coverage begins?

What if I join a plan, and then my doctor changes my prescription?

If I take medications for different medical conditions, am I eligible for Medication Therapy Management?

Section 3: How to Get Extra Help

What are the ways to qualify for Extra Help?

How do I apply for Extra Help?

How long will I get Extra Help if I qualify?

If I qualify for Extra Help, what can I do to make sure I pay the right amount?

What if my application for Extra Help is denied?

What if I don’t qualify for Extra Help?

Are there other ways to save if I don’t get Extra Help?

Section 4: Your Coverage Choices

Get help with drug coverage decisions

What else do I need to think about before I decide to get Medicare drug coverage?

I have only Part A and/or Part B and no drug coverage

I have Medicare and a Medicare Supplement Insurance (Medigap) policy without drug coverage

I have Medicare and a Medicare Supplement Insurance (Medigap) policy with drug coverage

I have Medicare and get drug coverage from a current or former employer or union

I have Medicare and a Federal Employee Health Benefits (FEHB) plan

I have Medicare and one of these that includes drug coverage: TRICARE, CHAMPVA, or benefits from the Department of Veterans Affairs (VA)

I have a Medicare health plan without drug coverage

I have a Medicare health plan with drug coverage

I have Medicare and Medicaid

I have Medicare and get Supplemental Security Income (SSI) benefits or belong to a Medicare Savings Program

I have Medicare and live in a nursing home or other institution

I have Medicare and benefits through Program of All-inclusive Care for the Elderly (PACE)

I have Medicare and get help from my State Pharmacy Assistance Program (SPAP) paying drug costs

I get help from an AIDS Drug Assistance Program (ADAP)

I have Medicare and get drug coverage from the Indian Health Service, Tribe or Tribal Health Organization, or Urban Indian Health Program

Section 5: 3 Steps to Choosing a Medicare Drug Plan

Step 1: Gather information about your current drug coverage and needs

Step 2: Compare Medicare drug coverage based on cost, coverage, and customer service

Step 3: Decide which plan is best for you, and join

Section 6: Tips for Using Your New Medicare Drug Coverage

If you have both Medicare and Medicaid or qualify for Extra Help

What if the pharmacist can’t confirm my Medicare drug coverage or Extra Help status?

Medicare’s Limited Income Newly Eligible Transition (NET) Program

Section 7: Rights & Appeals

How do I protect myself from fraud and identity theft?

What if I need help applying for Extra Help, joining Medicare drug coverage, or requesting a coverage determination or appeal?

What if my enrollment in a Medicare drug plan or health plan is denied?

What if my plan won’t cover a drug I need?

How do I appeal if I have Medicare drug coverage?

What’s the appeals process for Medicare drug coverage?

How do I file a complaint (grievance)?

What if I don’t agree with Medicare’s Part D late enrollment penalty?

Section 8: For More Information

Section 9: Definitions

Section 1: The Basics

Highlighted words are defined here.

Medicare drug coverage adds to your Medicare health coverage

Medicare drug coverage (Part D) helps you pay for both brand-name and generic drugs. Medicare drug plans are offered by insurance companies and other private companies approved by Medicare.

You can get coverage 2 ways:

Medicare drug plans (sometimes called Prescription Drug Plans, or PDPs) are separate drug plans that add Medicare drug coverage (Part D) to Original Medicare. Medicare drug plans can also add Medicare coverage to some Medicare health plans, like some Medicare Private Fee-for-Service (PFFS) Plans, some Medicare Cost Plans, and Medicare Medical Savings Account (MSA) Plans.

Some Medicare Advantage Plans or other Medicare health plans offer Medicare drug coverage. You generally get all of your Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and Part D through these plans. Medicare Advantage Plans that offer prescription drug coverage are sometimes called “MA-PDs.” If you join a Medicare Advantage Plan that doesn’t have drug coverage, in most cases, you won’t be able to add a separate Medicare drug plan. With a Medicare Cost Plan, you can either get your Medicare drug coverage from the plan (if offered), or you can join a separate Medicare drug plan to add drug coverage.

In this booklet, the term “Medicare drug coverage” means all Medicare drug plans and health plans that offer Medicare prescription drug coverage (Part D).

Joining a drug plan

To join a Medicare drug plan, Medicare Advantage Plan, or other Medicare health plan with drug coverage, you must be a United States citizen or lawfully present in the United States. To join a Medicare drug plan, you must have Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance).

To join a Medicare Advantage Plan or most other Medicare health plans with drug coverage, you must have Part A and Part B. You must also live in the service area of the Medicare health plan or drug plan you want to join. Generally, you need to join a Medicare Advantage Plan that includes drug coverage. If you join a separate Medicare drug plan, in most cases, you’ll lose your current Medicare Advantage Plan and go back to Original Medicare for your health coverage. With a Medicare Cost Plan, you can either get your drug coverage from the plan (if offered), or you can join a separate Medicare drug plan to add drug coverage.

All Medicare drug coverage must give at least a standard level of coverage set by Medicare. However, plans offer different combinations of coverage and cost sharing. Plans offering Medicare drug coverage may differ in the drugs they cover, how much you have to pay, and which pharmacies you can use.

If you decide to get Medicare drug coverage, compare plans in your area and choose one that meets your needs. If you don’t get drug coverage when you’re first eligible for Medicare, and you don’t have drug coverage that’s expected to pay, on average, at least as much as standard Medicare prescription drug coverage (called creditable prescription drug coverage), you may have to pay a lifetime late enrollment penalty if you join later. The penalty is in addition to your premium each month for as long as you have Medicare drug coverage.

Pick the drug coverage that meets your needs

Everyone with Medicare has to make a decision about drug coverage. If you don’t use a lot of prescription drugs now, you still may want to think about getting Medicare drug coverage to help lower your drug costs now and help protect against higher costs in the future. If you’re new to Medicare and already have other drug coverage, you have new options to consider. If you aren’t new to Medicare, you may want to look at your options to find drug coverage that meets your needs. You can join or switch Medicare plans between October 15–December 7 each year, with your coverage beginning January 1 of the following year.

Think about all your drug coverage options before you make a decision. Look at the drug coverage you may already have, like coverage from an employer or union, TRICARE, the Department of Veterans Affairs (VA), or the Indian Health Service. Compare your current drug coverage to Medicare drug coverage. Your current drug coverage may change because of Medicare drug coverage, so consider all your coverage options.

If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurance company or plan provider. Talk to your benefits administrator, insurance company, or plan provider before you make any changes to your current coverage.

Note: Prescription drug coverage is insurance. Doctor samples, discount cards, free clinics, or drug discount websites aren’t drug coverage.

See Section 4 for details about how Medicare drug coverage may affect other coverage.

Get help with your choices

Visit Medicare.gov/plan-compare to find plans in your area that cover your drugs and pharmacies that can fill your prescriptions.

Call your State Health Insurance Assistance Program (SHIP) for free personalized health insurance counseling. Visit shiphelp.org for the most up-to-date SHIP phone numbers.

Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Section 2: How Medicare Drug Coverage Works

Highlighted words are defined here.

Compare these things to find drug coverage that meets your needs:

Coverage

Medicare drug coverage covers generic and brand-name drugs. All plans must cover the same categories of drugs, but generally plans can choose which specific drugs are covered in each drug category. Check with the plan to see if it covers the prescriptions you take.

Cost

Plans have different monthly premiums. How much you pay for each drug depends on your plan. If you have limited income and resources, you may qualify for Extra Help to help pay your drug coverage costs. See Section 3 for more information on Extra Help.

Convenience

Check with the plan to make sure the pharmacies in the plan are convenient to you. Many plans also allow you to get your drugs by mail. If you spend part of the year in another state, see if the plan will cover you there.

Quality

Visit Medicare.gov/plan-compare to get quality Star Ratings for plans in different categories, like customer service. Or call 1-800-MEDICARE (1-800-633-4227) for quality Star Rating information. TTY users can call 1-877-486-2048.

How is Part D coverage different from Part B coverage for certain drugs?

Medicare Part B (Medical Insurance) includes limited drug coverage. It doesn’t cover most drugs you get at the pharmacy. You’ll need to join a Medicare drug plan or health plan with drug coverage to get Medicare coverage for prescription drugs for most chronic conditions, like high blood pressure.

Part B covers certain drugs, like injections you get in a doctor’s office, certain oral cancer drugs, and drugs used with some types of durable medical equipment—like a nebulizer or external infusion pump. Under very limited circumstances, Part B covers certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for these covered drugs. Part B also covers the flu and pneumococcal shots. Generally, Medicare drug plans cover other vaccines, like the shingles vaccine, needed to prevent illness.

Note: Medicare Part A (Hospital Insurance) or Part B generally don’t cover self-administered drugs you get in an outpatient setting like in an emergency room, observation unit, surgery center, or pain clinic. Your Medicare drug plan may cover these drugs under certain circumstances. You’ll likely need to pay out of pocket for the entire cost of these drugs and send in a claim to your drug plan for a refund of the portion your plan does cover. Call your plan if you have any questions. Visit Medicare.gov for more on how Medicare covers self-administered drugs you get in a hospital outpatient setting.

What plans are available in my area?

Get details about specific drug plans and health plans with drug coverage in your area by visiting Medicare.gov/plan-compare or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. See Section 5 for more information on how to compare plans and join one that meets your needs.

How much will my drug coverage cost?

Medicare drug plans and health plans with drug coverage have different coverage and costs, but all must offer at least a standard level of drug coverage set by Medicare. How much you actually pay for drug coverage depends on which prescription drugs you use, which Medicare plan you join, if you go to a pharmacy in your plan’s network, and if you get Extra Help paying for your drug costs. Contact the plan(s) you’re interested in to get specific cost information.

Your drug coverage costs are affected by:

Monthly premium

Yearly deductible

Copayments or coinsurance

Coverage gap (also called the “donut hole”)

Catastrophic coverage

Monthly premium

Most drug plans charge a monthly fee that differs from plan to plan. If you have Original Medicare, you pay this fee in addition to the premium you pay for Part B. If you have a Medicare Advantage Plan or a Medicare Cost Plan that includes drug coverage, the monthly premium may include an amount for drug coverage.

Some people with Medicare may pay a higher monthly premium based on their income. If you reported a modified adjusted gross income of more than $91,000 (individuals and married individuals filing separately) or $182,000 (married individuals filing jointly) on your 2020 IRS tax return (the most recent tax return information provided to Social Security by the IRS), you’ll have to pay an extra amount for your Medicare drug coverage, called the income-related monthly adjustment amount (IRMAA). You’ll pay this extra amount in addition to your monthly Part D premium.

Social Security will send you a letter if you have to pay this extra amount. Check the chart on the next page for the amount you’ll have to pay each month.

If your yearly income in 2020 was

File individual tax return

File joint
tax return

You pay each month
(in 2022)

$91,000 or less

$182,000 or less

Your plan premium

above $91,000
up to $114,000

above $182,000
up to $228,000

$12.40 + your plan premium

above $114,000
up to $142,000

above $228,000
up to $284,000

$32.10 + your plan premium

above $142,000
up to $170,000

above $284,000
up to $340,000

$51.70 + your plan premium

above $170,000 and less than $500,000

above $340,000 and less than $750,000

$71.30 + your plan premium

$500,000 or above

$750,000 or above

$77.90 + your plan premium

If your yearly income in 2020 was

File married & separate tax return

You pay each month (in 2022)

$91,000 or less

Your plan premium

above $91,000 and
less than $409,000

$71.30 + your plan premium

$409,000 or above

$77.90 + your plan premium

Your adjustment amount will get taken out of your monthly Social Security, Railroad Retirement, or Office of Personnel Management check, no matter how you usually pay your plan premium. If that amount is more than what’s in your check, you’ll get a bill from Medicare each month.

If you don’t pay your entire Part D premium (and the extra amount), you may be disenrolled from your Medicare drug coverage. You must pay both the extra amount and your plan’s premium each month to keep Medicare drug coverage.

If you have to pay a higher amount for your Part D premium and you disagree, visit ssa.gov, or call 1-800-772-1213. TTY users can call 1-800-325-0778.

Yearly deductible

The deductible is what you pay for your drugs before your plan begins to pay. In 2022, $480 is the highest yearly deductible a plan can charge for Medicare drug coverage. Some plans don’t charge a deductible.

Copayments or coinsurance

You pay copayments or coinsurance for your prescription drugs after you pay the deductible. You pay your share, and your plan pays its share for covered drugs.

Usually, the amount you pay for a covered drug is for a one-month supply of a drug. However, you can request less than a one-month supply for most types of prescription drugs if you’re trying a new medication that’s known to have significant side effects, or you want to get the refills for all your drugs on the same refill schedule. If you do this, the amount you pay is reduced based on the quantity you actually get.

Coverage gap (also called the “donut hole”)

A gradual closing of the coverage gap has made Medicare drug coverage more reasonably priced for people with Medicare. Not everyone will reach the coverage gap. You reach the coverage gap once you and your plan have spent $4,430 (including the deductible)on covered drugs for 2022.

When you’re in the coverage gap, you may pay more out of pocket for your prescription drugs, up to an out-of-pocket limit of $7,050 in 2022. Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this limit. The limit doesn’t include the plan’s premium or what you pay for drugs that aren’t on your plan’s formulary (drug list), unless the plan covers the drug under an exception.

You won’t need to pay all out-of-pocket costs when you’re in the coverage gap. Your plan will cover at least 5% of the cost of covered brand-name drugs, and the drug manufacturer will give a 70% discount, for a combined savings of at least 75% on these brand-name drugs. The amount you pay (25%) and the 70% discount you get from the manufacturer both count as out-of-pocket spending that will help you get out of the coverage gap. Also, your plan will cover 75% of the price for generic drugs when you’re in the coverage gap. The 25% you’ll pay for generic drugs will also count toward getting you out of the coverage gap.

Each month that you fill a prescription, your plan mails you an “Explanation of Benefits” (EOB) notice, which tells you how much you’ve spent on covered drugs and if you’ve reached the coverage gap. Your EOB notice will also show the 75% your plan pays on covered generic drugs, and the 5% your plan pays and the 70% discount from the drug manufacturer on covered brand-name drugs you buy when you’re in the coverage gap.

Catastrophic coverage

Once you’ve spent $7,050 out of pocket in 2022, you’re out of the coverage gap and then automatically get “catastrophic coverage.” Under catastrophic coverage, you pay a small coinsurance percentage or copayment amount for covered drugs for the rest of the year.

This example shows the costs for covered drugs in 2022 for a Medicare drug plan that has a coverage gap:

Monthly premium—Ms. Smith pays a monthly premium throughout the year.

1. Yearly deductible

2. Copayment or coinsurance

3. Coverage gap

4. Catastrophic coverage

Ms. Smith pays the first $480 of her drug costs before her plan starts to pay its share.

Ms. Smith pays a copayment, and her plan pays its share for each covered drug until their combined amount (including the deductible) reaches $4,430.

Once Ms. Smith and her plan have spent $4,430 for covered drugs, she’s in the coverage gap. Ms. Smith pays a copayment or coinsurance for each covered drug. She gets a 70% discount from the drug manufacturer on covered brand-name prescription drugs that counts as out-of-pocket spending, and helps her get out of the coverage gap. She gets an additional 5% coverage from her plan on covered brand-name drugs and 75% coverage on covered generic drugs while in the coverage gap.

Once Ms. Smith has spent $7,050 out of pocket for the year, her coverage gap ends. Now, she pays only a small copayment amount or coinsurance percentage for each prescription drug until the end of the year.

Visit Medicare.gov/plan-compare to view estimated yearly costs for each plan and your costs per prescription drug for each month.

How can I pay my plan premium?

You can choose one of these options to pay your premium:

Sign up to have your plan deduct it from your checking or savings account.

Charge it to a credit or debit card.

Have your plan bill you each month directly. Some plans bill in advance for next month’s coverage. Send your payment to the plan—not to Medicare. Contact your plan for their payment address.

Have funds withheld from your Social Security payment. Contact your plan—not Social Security—to ask for this payment option. It may take up to 3 months to start, and it’s likely your plan will collect the first 3 months of premiums at one time.

If you get Extra Help to pay part of your drug coverage premium, Social Security may withhold your share of the monthly premiums. If you qualify for Extra Help, it will cover some or all of your drug coverage premiums. For more information, see Section 3.

Note: If you have an employer health plan and your plan pays part of your drug coverage premium, Social Security can’t withhold your share of the monthly premiums.

Example of Social Security withholding: Ms. Brown’s monthly drug coverage premium is $25, and her coverage begins in January. Her first premium payment of $75 is collected in March. It includes her premium for January, February, and March. Starting in April, only one month of premium payments ($25) will be withheld from her Social Security payment each month.

When can I join, switch, or drop Medicare drug coverage?

During your 7-month Initial Enrollment Period, when you first become eligible for Medicare. You can join Medicare drug coverage starting 3 months before you turn 65, and ending 3 months after you turn 65. Your coverage start date depends on the month you join.

Example: Mr. Lee’s birthday is May 19, so his 7-month Initial Enrollment Period is from February to August.

If he joins in February, March, or April, his coverage begins on May 1, the first day of his birth month.

If he joins in May, his coverage begins on June 1.

If he joins in June, July or August, his coverage begins the first day of the next month—July 1, August 1, or September 1.

During the 7-month period around your 25th month of getting disability benefits. If you get Medicare due to a disability, you can enroll in Medicare drug coverage starting 3 months before your 25th month of disability, and ending 3 months after your 25th month of disability. Your coverage start date depends on the month in which you join.

Example: Ms. Nguyen started getting disability benefits in February 2020. Her 25th month of disability is March 2022, so her 7-month period to join Medicare drug coverage runs from December 2021 to June 2022.

If she joins in December 2021, January 2022 or February 2022, her coverage begins on March 1, 2022.

If she joins in March, her coverage begins on April 1.

If she joins in April, May, or June, her coverage begins the first day of the next month—May 1, June 1, or July 1.

If you have a disability, you’ll have another chance to join when you turn 65 (see above).

During Open Enrollment, between October 15–December 7 each year. Your coverage begins January 1 the following year, as long as the plan gets your request during Open Enrollment.

If you currently have Medicare drug coverage, you may want to review your coverage each fall. If you’re happy with your coverage, cost, and customer service, and your Medicare drug coverage is still offered in your area, you don’t have to do anything to continue your coverage for another year. However, if you decide another plan will better meet your needs, you can switch to a different plan.

One time during each of these Special Enrollment Periods if you qualify for Extra Help: January–March, April–June, or July–September. This includes people who have Medicare and Medicaid, belong to a Medicare Savings Program, get Supplemental Security Income (SSI) benefits, and those who apply and qualify. You need to live in one of the 50 states or the District of Columbia to qualify for Extra Help. If you make a change, it will take effect on the first day of the following month. You’ll have to wait for the next period to make another change.

Note: In certain limited circumstances, you may be able to join, drop, or switch Medicare drug coverage at other times. For example, you may be able to switch at other times if:

You permanently move out of your plan’s service area.

You lose creditable prescription drug coverage.

You enter, live in, or leave a nursing home.

You want to switch to a plan with a 5-star overall quality Star Rating. Quality Star Ratings are available on Medicare.gov.

Your plan tells you that it’s leaving the Medicare Program or Medicare ended its contract.

How do I switch plans?

All you need to do is join a new plan. You don’t need to tell your current drug plan you’re leaving or send them anything, because joining a different plan, at the times listed above, disenrolls you from your current drug plan. Your new Medicare drug coverage should send you a letter telling you when your coverage with your new plan begins.

How do I join a plan?

Contact the company that offers the plan. You may be able to join on the plan’s website, or by mailing or faxing them a completed enrollment form.

You can also join a plan directly by visiting Medicare.gov/plan-compare, or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

To join Medicare drug coverage, you’ll need to give your Medicare Number and the date your Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) coverage started, which you’ll find on your Medicare card.

Note: Medicare plans aren’t allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this.

What’s the Part D late enrollment penalty?

The late enrollment penalty is an amount that’s permanently added to your Medicare drug coverage (Part D) premium. You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, there’s a period of 63 or more days in a row when you don’t have Medicare drug coverage or other creditable prescription drug coverage. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.

Note: If you get Extra Help, you don’t pay a late enrollment penalty.

How much is the late enrollment penalty?

Currently, the late enrollment penalty is calculated by multiplying the 1% penalty rate times the “national base beneficiary premium” ($33.37 in 2022) times the number of full, uncovered months you were eligible to join Medicare drug coverage but didn’t and went without other creditable prescription drug coverage.

The final amount is rounded to the nearest $.10 and added to your monthly premium. The “national base beneficiary premium” may go up each year, so the penalty amount may also go up each year.

Example:

Mrs. Martinez is currently eligible for Medicare, and her Initial Enrollment Period ended on May 31, 2019. She doesn’t have drug coverage from any other source. She didn’t join by May 31, 2019, and instead joined during the Open Enrollment Period that ended December 7, 2021. Her drug coverage was effective January 1, 2022.

Since Mrs. Martinez was without creditable prescription drug coverage from June 2019–December 2021, her penalty in 2022 is 31% (1% for each of the 31 months) of $33.37 (the national base beneficiary premium for 2022), or $10.34. Since the monthly penalty is always rounded to the nearest $0.10, she pays $10.30 each month in addition to her plan’s monthly premium.

Here’s the math:

.31 (31% penalty) × $33.37 (2022 base beneficiary premium) = $10.34

$10.34 rounded to the nearest $0.10 = $10.30

$10.30 = Mrs. Martinez’s monthly late enrollment penalty for 2022

When you join a Medicare drug plan or health plan with drug coverage, the plan will tell you if you owe a penalty and what your premium will be.

How do I avoid paying a penalty?

Join a Medicare drug plan or health plan with drug coverage when you’re first eligible (see here), or have other creditable prescription drug coverage at that time.

Don’t go 63 days or more in a row without Medicare drug coverage or other creditable prescription drug coverage. Creditable prescription drug coverage could include drug coverage from a former employer or union, TRICARE, the Department of Veteran Affairs (VA), Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), the Indian Health Service, or the Health Insurance Marketplace.® Your plan must tell you each year if your drug coverage is creditable. It may send you this information in a letter, or let you know in a newsletter or other piece of mail. Keep this information because you may need it if you join Medicare drug coverage later.

Tell your Medicare drug plan or health plan with drug coverage when you join if you have other creditable prescription drug coverage. When you join a Medicare drug plan or health plan, the plan may send you a letter asking if you have creditable prescription drug coverage if it believes you went 63 or more days in a row without other creditable prescription drug coverage. Complete the form and return it by the deadline in the letter. If you don’t tell your plan about your creditable prescription drug coverage, you may have to pay the late enrollment penalty.

What information do I need to get Medicare drug coverage?

Name, birth date, and permanent home address

Information found on your Medicare card (like your Medicare Number)

How you want to pay your plan premiums

Other insurance information and any creditable coverage notices

You may be asked for this information when you join a Medicare plan, but it’s optional and not required to process your enrollment:

Email address

Name and information for an emergency contact

Name, address, and phone number of nursing home or institution where you live (if applicable)

Once you join a plan, it will send you specific materials you’ll need, like a membership card, member handbook, formulary (drug list), pharmacy provider directory, and complaint and appeal procedures.

Will I get a separate card for my Medicare drug coverage?

When you join a Medicare drug plan that works with Original Medicare, the plan will mail you a separate card to use when you fill your prescriptions. You’ll still use your Medicare card for hospital and doctor services. If you join a Medicare Advantage Plan or other Medicare health plan with drug coverage, you’ll also get a new card to use when filling your prescriptions and for hospital and doctor visits.

What if I need to fill a prescription before I get my membership card?

Within 2 weeks after your plan gets your completed application, you’ll get a letter letting you know it got your information. Within 5 weeks, you should get a welcome package with your membership card. If you need to go to the pharmacy before your membership card arrives, you can use any of these as confirmation of membership:

The acknowledgement, confirmation, or welcome letter you got from the plan

An enrollment confirmation number you got from the plan, and the plan name and phone number

A temporary card you may be able to print from your Medicare account at Medicare.gov

Don’t forget to bring your Medicare and/or Medicaid card and a photo ID, like your driver’s license. If you qualify for Extra Help, see here for more information about what you can use as confirmation of Extra Help. If you don’t have any of the items above that confirm your plan membership, and your pharmacist can’t get your drug coverage information any other way, you may have to pay out of pocket for the entire cost of your drugs. Save the receipts and contact your plan if you do pay for your drugs out of pocket—you may be able to get back some of the cost or have the amount credited toward your out-of-pocket costs.

Once you choose a plan, join it early in the month. This gives the Medicare plan time to mail you important information, like your membership card, before your coverage becomes effective. This way, even if you go to the pharmacy on your first day of coverage, you can fill your prescriptions without delay.

Where can I fill my prescriptions?

Each company that offers Medicare drug coverage has a list of pharmacies you can use. If you want to continue filling prescriptions at the same pharmacy you use now, check to see if the pharmacy is on the plan’s list. Visit Medicare.gov, or call the plan, your pharmacy, or 1-800-MEDICARE (1-800-633-4227) to see if your pharmacy works with the plan you want to join. TTY users can call 1-877-486-2048.

Medicare requires plans to have network pharmacies for you to choose from. Plans can’t make you use a mail-order pharmacy, but you may have this option if you want to use it. You may find using a mail-order pharmacy to be a cost effective and convenient way to fill prescriptions for drugs you take every day.

Can I use an automatic refill mail-order service to get my drugs?

Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription refills when you’re about to run out.

Plans should get your approval to deliver a prescription drug (new or refill) unless you ask for the refill or request the new prescription. Some plans may ask for your approval every year, so they can send your drugs without asking you before each delivery. Other plans may ask you before every delivery.

This policy doesn’t affect refill reminder programs where you go in person to pick up the prescription, and it doesn’t apply to long-term care pharmacies that give out and deliver prescription drugs.

Note: Be sure to tell your pharmacy the best way to reach you, so you don’t miss the refill confirmation call or other communication.

Contact your plan if you get any unwanted prescription drugs through an automated delivery program. You may be eligible for a refund for the amount your plan charged you. If you aren’t able to resolve the issue with the plan or wish to file a complaint, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

What if I have End-Stage Renal Disease (ESRD)?

If you have End-Stage Renal Disease (ESRD), you can get Medicare drug coverage. Medicare Part B (Medical Insurance) will pay for some of the drugs you need, like injectable drugs and their oral forms, and biologicals including erythropoiesis-stimulating agents used for dialysis. Part D will continue to cover most ESRD-related drugs that are available only in oral form.

Visit Medicare.gov for more information if you have ESRD. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Which drugs are covered?

Each plan may cover different drugs, so there’s no single formulary (drug list) that fits all plans. All Medicare drug plans and health plans with drug coverage must make sure the people in their plan can get medically- necessary drugs to treat their conditions. Drug lists, prior authorization, step therapy, and quantity limits are some of the coverage rules plans use to make sure certain drugs are used correctly and only when medically necessary. These coverage rules are described on the following pages.

Drug lists

Most Medicare drug plans and health plans with drug coverage have their own drug list. Plans cover both generic and brand-name prescription drugs. Although Medicare plans aren’t required to cover certain drugs (like drugs used for weight loss, weight gain, erectile dysfunction, or over-the-counter drugs), some plans may cover them as an added benefit.

All Medicare plans generally must cover at least 2 drugs per prescription drug category, but the plans can choose which specific drugs they cover. Plans are required to cover almost all drugs within these protected classes: antipsychotics, antidepressants, anticonvulsants, immunosuppressants, cancer drugs, and HIV/AIDS drugs.

A Medicare plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new prescription drugs are released, or new medical information becomes available.

Note: Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug, but you keep taking the brand- name drug.

Plans may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting 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, the coverage rules, or both, for brand-name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards.

For other changes involving a prescription drug you’re currently taking that will affect you during the year, your plan must do one of these:

Give you written notice at least 30 days before the date the change becomes effective; or

At the time you request a refill, provide written notice of the change and at least a month’s supply of the drug under the same plan rules as before the change.

You may need to change the prescription drug you use or pay more for it. You can also ask for an exception (see here).

Generally, using prescription drugs on your plan’s formulary (drug list) will save you money. All Medicare plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally 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. Also, using generics instead of brand-name drugs may save you money.

Generic drugs

The FDA says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. Generic drugs use the same active ingredients as brand-name drugs. Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber.

Tiers

To lower costs, many plans place prescription drugs into different “tiers” on their formularies (drug lists). 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.

Example of a drug plan’s tiers:

Tier 1–Most generic prescription drugs. Lowest copayment.

Tier 2–Preferred, brand-name prescription drugs. Medium copayment.

Tier 3–Non-preferred, brand-name prescription drugs. Higher copayment.

Specialty Tier–Very high cost prescription drugs. Highest copayment or coinsurance.

Your plan’s drug list might not include a prescription drug you take. However, in most cases, you can get a similar drug that’s just as effective.

Coverage rules

Plans may have coverage rules to make sure certain prescription drugs are used correctly and only when medically necessary. These rules may include prior authorization, step therapy, and quantity limits.

Prior authorization

You may need prescription drugs that require prior authorization. This means before the plan will cover a particular drug, you must show the plan you meet certain criteria for you to have that particular drug. Plans also do this to be sure these drugs are used correctly. Contact your plan about its prior authorization requirements, and talk with your prescriber.

Plans may also use prior authorization when they cover a medication for certain medical conditions, but not all medical conditions for which a drug is approved. When this occurs, plans will likely have alternative medications on their drug list for the other medical conditions for which the drug can be prescribed.

However, if your prescriber believes that it’s medically necessary for you to be on that particular drug even though you don’t meet the prior authorization criteria, you or your prescriber can contact the plan to request an exception. Your prescriber must give a statement supporting the request. If the request is approved, the plan will cover the particular drug, even if you didn’t get prior authorization for the drug.

Step therapy

Step therapy is a type of coverage rule. In most cases, you must first try a certain less-expensive drug on the plan’s formulary (drug list) that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, some plans may require you first try a generic drug (if available), then a less expensive brand-name drug on their drug list before they’ll cover a similar, more expensive, brand-name drug.

However, if your prescriber believes that because of your medical condition it’s medically necessary for you to be on a more expensive step therapy drug without trying the less expensive drug first, you or your prescriber can contact the plan to request an exception. Your prescriber can also request an exception if they believe you’ll have adverse health effects if you take the less expensive drug, or if your prescriber believes the less expensive drug would be less effective. Your prescriber must give a statement supporting the request. If the request is approved, the plan will cover the more expensive drug, even if you didn’t try the less expensive drug first.

Example:

Step 1: Dr. Smith wants to prescribe an ACE inhibitor to treat Mr. Mason’s heart failure. There’s more than one type of ACE inhibitor. Some of the drugs Dr. Smith considers prescribing are brand-name drugs that Mr. Mason’s plan covers. The plan rules require Mr. Mason to use a generic drug first. For most people, the generic drug works as well as the brand-name drugs.

Step 2: If Mr. Mason takes the generic drug but has side effects or limited improvement, Dr. Smith can provide that information to the plan to request approval to cover a brand-name drug that Dr. Smith wants to prescribe. If the plan approves Mr. Mason’s exception request, his Medicare plan will then move up a “step” to cover the requested brand-name drug.

Quantity limits

For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain time period. For example, most people prescribed heartburn medication take 1 tablet per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of heartburn medication.

If your prescriber believes that, because of your medical condition, a quantity limit isn’t medically appropriate (like if your doctor believes you need a higher dosage of 2 tablets per day), you or your prescriber can contact the plan to ask for an exception (see here).

Opioid pain medication safety checks

Safety reviews at the pharmacy

When you fill a prescription at the pharmacy, Medicare plans and pharmacists routinely check to make sure the prescription is correct, that there are no interactions, and that the medication is appropriate for you. They also conduct safety reviews to monitor the safe use of opioids and other frequently abused medications. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, the Medicare plan or pharmacist may need to talk to your doctor first before the prescription can be filled.

Your plan or pharmacist may do a safety review when you fill a prescription if you:

Take potentially unsafe opioid amounts as determined by the plan or pharmacist.

Take opioids with benzodiazepines like alprazolam (Xanax®), diazepam (Valium®), and clonazepam (Klonopin®).

Are taking opioids for the first time—you may be limited to an initial 7-day supply or less.

If your pharmacy can’t fill your prescription as written, the pharmacist will give you a notice explaining how you or your doctor can call or write to your plan to ask for a coverage decision, including an exception to a plan rule. If your health requires it, you can ask the plan for a fast coverage decision. You may also ask your plan for a decision before you go to the pharmacy, so you’ll know if your plan will cover the medication. Visit Medicare.gov/medicare-prescription-drug-coverage-appeals to learn how to ask for an exception.

Drug management programs

All Medicare plans have a drug management program in place to help you use these opioids and benzodiazepines safely. If your opioid use could be unsafe, your plan will contact the doctors who prescribed them for you to make sure they’re medically necessary and you’re using them appropriately. For example, your plan might do this if you’re getting opioid prescriptions from multiple doctors or pharmacies, or if you had a recent overdose from opioids.

If your Medicare plan decides your use of prescription opioids and benzodiazepines may not be safe, the plan will send you a letter in advance. This letter will tell you if the plan will limit coverage of these drugs for you, or if you’ll be required to get the prescriptions for these drugs only from a doctor or pharmacy that you select.

Before your Medicare plan places you in its drug management program, it will notify you by letter, and you’ll be able to tell the plan which doctors or pharmacies you prefer to use. You and your doctor can appeal if you disagree with your plan’s decision or think the plan made a mistake.

Note: The opioid safety reviews at the pharmacy and drug management programs generally don’t apply if you have cancer or sickle cell disease, are getting palliative or end-of-life care, are in hospice, or live in a long-term care facility.

What if I’m taking a drug that isn’t on my plan’s drug list when my drug coverage begins?

Generally, your plan will give you a one-time, temporary supply of your current prescription drug during your first 90 days in a plan. Plans must give you this temporary supply so that you and your prescriber have time to find another drug on the plan’s formulary (drug list) that will work as well as what you’re taking now, or you or your prescriber can contact the plan to ask for an exception. There may be different rules for people who move into or already live in an institution (like a nursing home or long-term care hospital).

However, if you already tried similar prescription drugs on your plan’s drug list and they didn’t work, or if your prescriber decides you need a certain drug because of your medical condition, you or your prescriber can contact your plan to ask for an exception as soon as your coverage begins. Also, you or your prescriber can ask for an exception if your prescriber thinks you need to have a coverage rule (like a quantity limit) waived. If the plan agrees to your request, it will cover the drug. If your plan doesn’t agree to the exception, you can appeal the plan’s decision. For more information on appeals, see here.

What if I join a plan, and then my doctor changes my prescription?

Your doctor or other prescriber may need to change your prescription or prescribe a new drug. If your doctor prescribes electronically, they can check which drugs your plan covers through their electronic prescribing system. If your doctor doesn’t prescribe electronically, give them a copy of your Medicare plan’s current formularies (drug lists).

If your doctor needs to prescribe a drug that isn’t on your Medicare plan’s formulary and you don’t have any other health coverage that covers outpatient prescription drugs, you or your doctor can ask the plan for an exception. For more information on exceptions, see here.

If your plan still won’t cover a specific prescription drug you need, you can file an appeal. If you want to get the prescription drug before you file an appeal, you may have to pay out of pocket for the entire cost of the drug. Keep the receipt and give a copy of it to the person deciding your appeal. If you win the appeal, the plan will pay you back. For more information about what to do if a plan won’t cover a prescription drug you need, see here.

Plans can change their drug list and costs for drugs. Call your plan or look on their website to find the most up-to-date Medicare drug list and costs.

If I take medications for different medical conditions, am I eligible for Medication Therapy Management?

Plans with Medicare drug coverage must offer additional Medication Therapy Management (MTM) services if you meet certain requirements or are in a program to help members use their opioids safely. If you qualify, you can get these MTM services to help you understand how to manage and safely use your medications. MTM services may vary in some plans, are free, and usually include a discussion with a pharmacist or health care provider to review your medications. The pharmacist or health care provider may talk with you about:

How well your medications are working and any problems you’re having related to your medications

Whether your medications have side effects

If there might be interactions between the drugs you’re taking

Whether you can get lower costs

How to safely dispose of unused medications

Contact your plan for specific details and to see if you’re eligible for a Medication Therapy Management program.

Section 3: How to Get Extra Help

Highlighted words are defined here.

“Extra Help” is a program to help people with limited income and resources pay Medicare drug program costs, like premiums, deductibles, and coinsurance. Some people automatically qualify for Extra Help because they have both Medicare and Medicaid, they’re in a Medicare Savings Program, or they get Supplemental Security Income (SSI) benefits. Other people who think they may qualify for Extra Help will need to apply.

What are the ways to qualify for Extra Help?

The chart on the next page shows different ways you may qualify for Extra Help, depending on your situation. It includes many, but not all, of the types of letters that Medicare sends, by color and name. You need to live in one of the 50 states or the District of Columbia to qualify for Extra Help.

If you get one or more of these letters, keep them in case you need to show them to your plan as confirmation that you qualify for Extra Help.

Note: Although people living in U.S. territories aren’t eligible for Extra Help, these territories have programs to help people with limited income and resources pay their Medicare costs. U.S. territories include Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Programs vary in these areas. Call or visit your Medicaid office to learn more.

Visit Medicare.gov/basics/forms-publications-mailings for more information about each type of letter described in the chart below.

When you

Medicare will mail you a ...

Automatically qualify for Extra Help because of any of these:

You have both Medicare and Medicaid

You’re in a Medicare Savings Program

You get Supplemental Security Income (SSI) benefits

Purple

“Deemed Status Notice”
(See here.)

Automatically qualify for Extra Help because you qualify for Medicare and full Medicaid coverage, currently get benefits through Original Medicare, and you’re not enrolled in a Medicare drug plan.

Yellow

“Auto-Enrollment Notice”
(See here.)

Continue to automatically qualify for Extra Help, but you’ll have different copayment levels next year

Orange

“Change in Extra Help Copayment

Notice” (See here.)

Qualify for Extra Help because of one of these below and you’re not enrolled in a Medicare drug plan:

You belong to a Medicare Savings Program

You get SSI

You applied and qualified for Extra Help

Green

“Facilitated Enrollment Notice”
(See here.)

Already get Extra Help, you joined a Medicare drug plan on your own, and your plan’s premium is changing

Tan

“LIS Choosers Notice”

Already get Extra Help and Medicare reassigned you into a new Medicare drug plan for the coming year

Blue

“Reassign Formulary Notice”

No longer automatically qualify for Extra Help next year

Gray

“Loss of Deemed Status Notice”

If you automatically qualify for Extra Help, you don’t need to apply.
Medicare mails purple “Deemed Status Notices” to people who automatically qualify for Extra Help. You don’t need to apply for Extra Help if you get this purple notice, but keep it as confirmation that you qualify.

You automatically qualify for Extra Help if you get any of these:

Full coverage from a state Medicaid program

Help from your state Medicaid program paying your Medicare Part B premiums through a Medicare Savings Program

Supplemental Security Income (SSI) benefits

You must already be in or join Medicare drug coverage to get this Extra Help. If you don’t join Medicare drug coverage on your own, Medicare will enroll you in a Medicare drug plan, unless you have certain retiree drug coverage from a former employer or union. If Medicare enrolls you in a drug plan, we’ll send you a yellow “Auto-Enrollment Notice” (if you get full Medicaid coverage) or a green “Facilitated Enrollment Notice” (if you belong to a Medicare Savings Program or get SSI) letting you know when your coverage begins. Check to see if the plan covers the drugs you use and if you can go to the pharmacies you want.

If Medicare enrolls you in a drug plan that doesn’t meet your needs, you can switch plans one time each during January–March, April–June, and July–September, and your new plan will begin the first day of the next month. You can also switch drug plans during Medicare Open Enrollment, from October 15–December 7, and the new plan will take effect on January 1. If you don’t want to join a separate Medicare drug plan (for example, because you want only your employer or union coverage), call the plan listed in your letter. Tell them you don’t want to join a Medicare drug plan (you want to “opt out”).

Note: If you have employer or union coverage and you enroll in Medicare drug coverage, you may lose your employer or union coverage (for you and your dependents) even if you qualify for Extra Help. Call your employer’s benefits administrator before you enroll in Medicare drug coverage.

Medicare drug plan costs if you automatically qualify for Extra Help in 2022

If you have Medicare and...

Your monthly premium*

Your yearly deductible

Your cost per drug at the pharmacy (until $7,050**)

Your cost per drug at the pharmacy (after $7,050**)

Full Medicaid coverage for each full month you live in an institution, like a nursing home

$0

$0

$0

$0

Full Medicaid coverage, and you get home- and community-based services

$0

$0

$0

$0

Full Medicaid coverage and have a yearly income at or below $13,590 (single) or $18,310 (married)

$0

$0

Generic and certain preferred drugs: No more than $1.35
Brand-name drugs: No more than $4.00

$0

Full Medicaid coverage and have a yearly income above $13,590 (single) or $18,310 (married)

$0

$0

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

$0

Help from Medicaid paying your Medicare Part B premiums

$0

$0

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

$0

Supplemental Security Income (SSI)

$0

$0

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

$0

Notes: *There are plans you can join and pay no premium. There are other plans where you’ll have to pay part of the premium even when you automatically qualify for Extra Help. Tell your plan you qualify for Extra Help and ask how much you’ll pay for your monthly premium. You can also visit Medicare.gov/plan-compare to look for plans whose monthly premium is $0.

** Your cost per drug generally decreases once the amount you pay and Medicare pays in Extra Help for your cost sharing reaches $7,050 in 2022.

The cost sharing, income levels, and resources listed are for 2022 and may increase each year. Income levels are higher if you live in Alaska or Hawaii, or you or your spouse pays at least half of the living expenses of dependent family members who live with you, or you work.

If you apply and qualify for Extra Help

If you think you qualify for Extra Help, you can do one of these:

Visit ssa.gov/i1020 to apply online, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

Apply at your State Medical Assistance (Medicaid) office.

Visit Medicare.gov/talk-to-someone, or call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid” to get the phone number. TTY users can call 1-877-486-2048.

There’s no risk or cost to apply. Remember, even if you qualify, you still need to join a Medicare drug plan to get the Extra Help. For more information on what income and resources count when you apply, see here.

If you apply and qualify for Extra Help, in most cases, Medicare will enroll you in a Medicare drug plan if you don’t join one on your own. This makes sure you get help paying for your drug costs. Medicare will mail you a green letter letting you know when your coverage begins. Check to see if the plan covers the drugs you use and if you can go to the pharmacies you want. If not, you can change plans. If Medicare enrolls you in a drug plan that doesn’t meet your needs, you can switch plans one time during January–March, April–June, or July–September, and your new plan will begin the first day of the next month. You can also switch drug plans during Medicare Open Enrollment, from October 15–December 7, and the new plan will take effect on January 1.

If you don’t want Medicare to enroll you in a Medicare drug plan (for example, because you want to keep your employer or union coverage), call the plan listed in the green letter. Tell them you don’t want to be in a Medicare drug plan and want to “opt out” of (decline) enrollment. Or, call 1-800-MEDICARE.

Note: When you apply for Extra Help, you can also begin the application process for a Medicare Savings Program. These state programs provide help with other Medicare costs. Social Security will send information to your state unless you tell them not to on the Extra Help application.

Medicare drug plan costs if you apply and qualify for Extra Help in 2022

If you have Medicare and...

Your monthly premium*

Your yearly deductible

Your cost per drug at the pharmacy (until $7,050**)

Your cost per drug at the pharmacy (after $7,050**)

A yearly income below
$18,346.50 (single) or
$24,718.50 (married) with resources of no more than
$9,900 (single) or
$15,600 (married)

$0

$0

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.20

$0

A yearly income below
$18,346.50 (single) or
$24,718.50 (married)
with resources between
$9,900 – $15,510 (single) or
$15,600 – $30,950 (married)

$0

$99

Up to 15% of the cost of each drug

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

A yearly income between
$18,346.50 – $19,026 (single) or
$24,718.50 – $25,634 (married)
with resources up to
$15,510 (single) or
$30,950 (married)

25%

$99

Up to 15% of the cost of each drug

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

A yearly income between
$19,026 – $19,705.50 (single) or
$25,634 – $26,549.50 (married)
with resources up to
$15,510 (single) or
$30,950 (married)

50%

$99

Up to 15% of the cost of each drug

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

A yearly income between
$19,705.50 – $20,385 (single) or
$26,549.50 – $27,465 (married)
with resources up to
$15,510 (single) or
$30,950 (married)

75%

$99

Up to 15% of the cost of each drug

Generic and certain preferred drugs: No more than $3.95
Brand-name drugs: No more than $9.85

* and **: See the notes below the table here for more information.

How do I apply for Extra Help?

Whose income and resources count?

Your own income and resources count.

If you’re married and live with your spouse, both of your incomes and resources count, even if only one of you applies for Extra Help.

If you’re married and don’t live with your spouse when you apply, only your income and resources count.

Note: Married couples living together who both apply for Extra Help through Social Security can use the same application (SSA-1020), available at ssa.gov/i1020.

What income counts?

“Income” means any cash, goods, or services you can use to meet your needs for food or shelter. Examples include (but aren’t limited to):

Income counted

Alimony

Annuities

Earnings from self-employment

Pensions

Railroad Retirement Board (RRB)
benefits

Rental income

Social Security benefits

Veterans’ benefits

Wages

Worker’s compensation

Income not counted

Assistance from others to pay for household expenses

Disaster assistance

Earned income tax credit payments

Home energy assistance

Housing assistance

Medical treatment and drugs

Scholarships and education grants

Supplemental Nutrition Assistance Program (SNAP)

Victim’s compensation payments

What resources count?

Social Security or your state must count your resources to decide if you qualify for Extra Help. Resources include the value of the things you own. Your resources include cash and other things you normally can convert to cash within 20 workdays. Examples include (but aren’t limited to):

Resources counted

Cash at home or anywhere else

Bank accounts (checking, savings, and certificates of deposit)

Stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRA), or other similar investments

Value of real estate other than your primary residence (the home you live in)

Resources not counted

Your primary residence (the home you live in) and the land it’s on

Your personal possessions

Your car(s) or vehicle(s)

Things you couldn’t easily convert to cash, like jewelry or furniture

Burial expenses, burial plots, and interest earned on money you plan to use for burial expenses

Life insurance policies

Property needed for self-support, like rental property or land used to grow produce for home consumption

Contact Social Security at 1-800-772-1213 to find out which other types of income and resources count and which are excluded. TTY users can call 1-800-325-0778.

How long will I get Extra Help if I qualify?

If you automatically qualify for Extra Help

To automatically qualify for Extra Help for the coming year, you must continue to qualify for Medicaid, get help from your state Medicaid program to pay Medicare Part B premiums (in a Medicare Savings Program), or get Supplemental Security Income (SSI).

If you won’t automatically qualify the next year, you’ll get a notice (on gray paper) in the mail by early fall. If the amount of Extra Help you get is changing so that your copayment amounts change for next year, you’ll get a notice (on orange paper) in the mail with the new copayment amounts. If you don’t get a notice, you’ll get the same level of Extra Help next year that you have this year.

Even if you get the notice on gray paper because you don’t automatically qualify, you may still be able to save on your Medicare drug coverage costs. You need to apply for Extra Help to find out.

If you apply and qualify for Extra Help

If you qualify for Extra Help, you’ll get the Extra Help for the calendar year as long as you have a Medicare drug plan and there aren’t changes to your income, resources, or family size.

You’ll also get the Extra Help for the calendar year as long as you don’t have a change in your marital status, like:

Marriage

Divorce

Annulment

Separation (not temporary)

Spouses resume living together after separating

Death of spouse (in this situation, the change in your Extra Help may be delayed for one year)

If you applied to Social Security for Extra Help and you qualified, notify them if your marital status changes, because it could raise, lower, or stop the amount of Extra Help you get. The change in Extra Help you get starts the month after you report the change in your marital status.

You can report changes in your income, resources, or family size to Social Security to review at any time. Any changes affecting your Extra Help start January 1 of the following year.

If you applied and qualified for Extra Help through your state, your state’s rules may require you to tell them about changes in your circumstances. Contact your State Medical Assistance (Medicaid) office for more information. You can get the phone number for your state Medicaid office by visiting Medicare.gov/talk-to-someone, or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

If I qualify for Extra Help, what can I do to make sure I pay the right amount?

You should get a purple, yellow, orange, or green notice from Medicare that you can show to your plan as confirmation that you qualify for Extra Help (see the chart here). If you applied for Extra Help, you can show your plan your “Notice of Award” letter from Social Security as confirmation that you qualify. If you have Supplemental Security Income (SSI), you can use your award letter from Social Security as confirmation that you have SSI.

You can also give your plan any of the documents below as proof. Each item must show you were eligible for Medicaid during a month after June 2022.

Forms that confirm you have Medicaid and live in an institution or get home- and community-based services

Other forms that confirm you have Medicaid

A bill from an institution (like a nursing home) or a copy of a state document showing Medicaid paid for your stay for at least a month

A print-out from your state’s Medicaid system showing you lived in the institution for at least a month

A document from your state that shows you have Medicaid and are getting home- and community-based services

A copy of your Medicaid card (if you have one)

A copy of a state document that shows you have Medicaid

A print-out from a state electronic enrollment file, or screen print from your state’s Medicaid systems that shows you have Medicaid

Any other document from your state that shows you have Medicaid

Your plan must accept any of these documents as confirmation that you qualify for Extra Help. As soon as you have given them any one of these documents, your plan must make sure you pay no more than the right amount to fill your prescriptions.

If you qualify for Extra Help because you have Medicaid, but you don’t have or can’t find any of the documents on the previous page, ask your plan for help. Your plan must also contact Medicare so Medicare can get confirmation that you qualify, if it’s available. You should expect your request to take anywhere from several days to up to 2 weeks, depending on the circumstances. Be sure to tell your plan how many days of medication you have left. Your plan and Medicare will work to process your request before you run out of medication, if possible.

If you paid for prescription drugs since you qualified for Extra Help, you may be able to get back part of what you paid. Keep your receipts, and call Medicare’s Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307 for more information. TTY users can call 711. See here for more information about Medicare’s Limited Income NET Program.

If your plan doesn’t correct a problem to help you pay the right amount for your prescription drugs, doesn’t respond to your request for help, or takes longer than expected to get back to you, call 1-800-MEDICARE (1-800-633-4227) to file a complaint. TTY users can call 1-877-486-2048.

What if my application for Extra Help is denied?

You have the right to appeal the decision. If you applied for Extra Help through Social Security, they’ll give you a hearing by phone unless you choose a case review. Either way, Social Security will review those parts of the decision that you believe are wrong and will look at any new information you provide. Social Security may also review those parts which you believe are correct. Someone who wasn’t involved in the first decision will decide your case.

To request an appeal, call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. You can also get a copy of form SSA-1021 (“Appeal of Determination for Help with Medicare Prescription Drug Costs”) and instructions on filling it out by visiting ssa.gov/forms.

If you want to file an appeal, keep in mind:

You have 60 days to ask for an appeal.

The 60 days start the day after you get a letter from Social Security denying your application. Social Security will assume you got the letter 5 days after the date on it, unless you show them you didn’t get it within the 5-day period.

You can have a lawyer, friend, or someone else help you. Call Social Security at 1-800-772-1213 for a list of groups that can help you with your appeal. Visit ssa.gov/locator to find your local Social Security office.

If you apply for Extra Help with your state, your decision letter should include appeal rights and procedures. Call your State Medical Assistance (Medicaid) office for information on your state’s appeals process. Visit Medicare.gov/talk-to-someone or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state Medicaid office. TTY users can call 1-877-486-2048.

What if I don’t qualify for Extra Help?

You can still choose and join a Medicare drug plan that meets your needs. You’ll have to pay the monthly premium, yearly deductible (some plans don’t have a deductible), and a share of the cost of your prescription drugs.

Even if you don’t qualify for Extra Help now, you can apply or reapply later if your income and resources change.

Are there other ways to save if I don’t get Extra Help?

When you’re ready to shop for Medicare drug coverage, consider choosing a plan that offers additional coverage during the Medicare drug coverage gap (which you enter once you and your plan have spent $4,430 (including the deductible) on covered drugs for 2022. Plans with additional gap coverage for prescriptions may charge a higher monthly premium, so check with the drug plan first to see if your drugs would be covered during the gap. Visit Medicare.gov/plan-compare to shop for Medicare drug coverage.

Here are more ways to lower your drug costs:

Switch to generic or other lower-cost drugs. There may be generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now. Talk to your doctor to find out if these are an option for you. You might also be able to lower prescription costs by using mail-order pharmacies.

Look at State Pharmaceutical Assistance Programs (SPAPs) to see if you qualify. Many states and the U.S. Virgin Islands offer some type of coverage to help people with Medicare with paying drug plan premiums and/or cost sharing. Find out if your state has an SPAP at Medicare.gov/pharmaceutical-assistance-program. See here to find more information about SPAPs. SPAP contributions may count toward your Medicare drug coverage out-of-pocket threshold (or limit), which is $7,050 in 2022. Once you’ve spent more than the limit, you automatically get “catastrophic coverage.” It assures you only pay a small coinsurance percentage or copayment for covered drugs for the rest of the year.

Look into Manufacturer’s Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs, or PAPs). Many of the major drug manufacturers offer assistance programs for people with Medicare drug coverage. Find out whether the manufacturers of the drugs you take offer a PAP at Medicare.gov/pharmaceutical-assistance-program/#state-programs. Any help you get from this type of program won’t count toward your out-of-pocket costs.

Your state may have programs to help you pay your prescription drug costs. Contact your state Medicaid office or State Health Insurance Assistance Program (SHIP) for more information. Visit shiphelp.org or call 1-800-MEDICARE (1-800-633-4227) for the phone number of your SHIP. TTY users can call 1-877-486-2048.

Section 4: Your Coverage Choices

Highlighted words are defined here.

Read about the choices you have with Medicare drug coverage. More than one situation may apply to you.

Get help with drug coverage decisions

If you need help with your Medicare drug coverage decisions, call your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number of your SHIP. TTY users can call 1-877-486-2048.

Medicare works with other government representatives, community- and faith-based groups, employers and unions, doctors, pharmacies, and other people and organizations to educate people about prescription drug coverage choices. Look for information on social media, in your local newspaper, or listen for information on the radio, about events in your community.

What else do I need to think about before I decide to get Medicare drug coverage?

Before you make a decision, get answers to these questions:

If I have drug coverage now, should I keep it? Is it creditable prescription drug coverage? Your current plan can tell you if your drug coverage is creditable prescription drug coverage.

How will joining a Medicare drug or health plan and keeping my current drug coverage affect my current coverage? Your current plan can tell you.

How would joining a particular Medicare drug or health plan affect my out-of-pocket costs?

Would my premium be higher later if I wait to join a Medicare drug or health plan because I have to pay a Part D late enrollment penalty? Would my coverage start when I want it to?

Does a Medicare drug or health plan in my area cover the prescription drugs I take? Find out by visiting Medicare.gov/plan-compare.

Can I get Extra Help paying for my drug costs if I join a Medicare drug plan? You may qualify for Extra Help if you have limited income and resources. See Section 3.

Is there a particular pharmacy I want to use? Does it belong to a network of a Medicare drug or health plan in my area?

Do I spend part of each year in another state? This may be important if a plan you want to join requires you to use certain pharmacies.

What are a particular Medicare drug plan’s quality Star Ratings? Compare Medicare drug plans at Medicare.gov/plan-compare.

I have only Part A and/or Part B and no drug coverage

If you have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) and live in a Medicare drug plan’s service area, you can join that plan. Visit Medicare.gov/plan-compare or call 1-800-MEDICARE (1-800-633-4227) for a list of plans in your area. TTY users can call 1-877-486-2048. You can also look in your “Medicare & You” handbook. Not sure if you have Part A and/or Part B? Check your red, white, and blue Medicare card.

I have Medicare and a Medicare Supplement Insurance (Medigap) policy without drug coverage

You can join a Medicare drug plan by:

Keeping your current Medigap policy and enrolling in a Medicare drug plan.

Joining a Medicare Advantage Plan in your area that includes drug coverage. You’d get all your health care benefits and drug coverage from the plan.

If you join a Medicare Advantage Plan, you don’t need a Medigap policy. If you already have a Medigap policy, you can’t use it to pay for out-of-pocket costs under your Medicare Advantage Plan. You may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you might not be able to get the same Medigap policy back if you leave the Medicare Advantage Plan and then go back to Original Medicare, or you may end up paying higher premiums for the Medigap policy.

You have a legal right to keep your Medigap policy, but rights to buy a Medigap policy may vary by state. For more information about your Medigap policy, contact your Medigap insurance company or visit Medicare.gov.

If you’re joining a Medicare Advantage Plan for the first time, you may get a 12-month trial period during which you can drop the Medicare Advantage Plan and get back your Medigap policy, or if it isn’t available, buy another Medigap policy.

I have Medicare and a Medicare Supplement Insurance (Medigap) policy with drug coverage

Before 2006, some Medigap policies included drug coverage. If you still have a Medigap policy with drug coverage, your Medigap insurance company must send you a detailed notice each year describing your choices for drug coverage and stating whether its drug coverage is creditable prescription drug coverage. Some of your choices for drug coverage include:

Joining a Medicare drug plan and keeping your current Medigap policy without the drug coverage.

Joining a Medicare Advantage Plan that includes drug coverage. You’d get all your health care coverage, including drug coverage, from this plan, and you wouldn’t need a Medigap policy. If you join a Medicare Medical Savings Account (MSA) Plan (a type of Medicare Advantage Plan), you can continue to use your Medigap drug coverage, since MSAs can’t offer Medicare drug coverage.

Keeping your current Medigap policy with the drug coverage included. If the drug coverage your Medigap plan offers isn’t creditable, you may have to pay a late enrollment penalty if you later decide to get your coverage through a Medicare drug plan.

Information you get from your Medigap insurance company describes these choices in detail. You can also check with your State Insurance Department to find out what other options you may have for drug coverage. Visit Medicare.gov/talk-to-someone or call 1-800-MEDICARE (1-800-633-4227) to get the number of your State Insurance Department. TTY users can call 1-877-486-2048.

Note: If you join a Medigap policy and a Medicare drug plan offered by the same company, you may need to make 2 separate premium payments for your coverage. Contact your insurance company for more details.

Tip: Contact your Medigap insurance company before you make any changes to your drug coverage.

If you decide to join a Medicare drug plan, you can keep your current Medicare Supplement Insurance (Medigap) policy without the drug coverage. You’ll need to tell your Medigap insurance company when your Medicare drug coverage starts. They must remove the drug coverage from your Medigap policy and adjust your premium based on this change. Also, you may have to pay a lifetime late enrollment penalty to join a Medicare drug plan if the drug coverage you’ve had under your Medigap policy isn’t creditable prescription drug coverage. You may have to pay this higher premium for as long as you’re in a Medicare drug plan.

For more information about Medigap policies, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also call your State Health Insurance Assistance Program (SHIP) for more information about Medigap. Visit shiphelp.org or call 1-800-MEDICARE to get the phone number of your SHIP.

I have Medicare and get drug coverage from a current or former employer or union

Before making a decision about whether to get Medicare drug coverage, find out how your employer or union drug coverage works with Medicare, because your coverage may change if you get Medicare drug coverage. Your employer or union (or the plan that administers your drug coverage) will send you a Notice of “Creditable Coverage” each year, letting you know if your drug coverage is creditable prescription drug coverage and how it compares to Medicare drug coverage. Read carefully, and save all materials from your employer or union to know your options. If you don’t get this information, ask your employer or union for it.

You may have to make choices about your employer/union drug coverage and Medicare drug coverage:

During your 7-month Initial Enrollment Period, when you first become eligible for Medicare (see here for details)

During Open Enrollment, between October 15–December 7 each year

When your employer/union coverage changes or ends

Some important questions to answer before making a decision:

Is your employer or union drug coverage creditable (on average, does it expect to pay at least as much as standard Medicare drug coverage)? If not, in most cases, you’ll have to pay a late enrollment penalty if you don’t get Medicare drug coverage when you’re first eligible.

Will you, your spouse, or dependents lose all of your employer or union health coverage if you get Medicare drug coverage?

How do out-of-pocket drug costs with your employer or union drug coverage compare to out-of-pocket drug costs with Medicare drug coverage?

How will your costs change if you get Extra Help with your Medicare drug coverage costs?

If your (or your spouse’s) employer or union tells you your current coverage is creditable prescription drug coverage:

You can keep this coverage as long as your employer or union still offers it.

You won’t have to pay a late enrollment penalty if your employer or union stops offering drug coverage, or stops offering creditable prescription drug coverage, as long as you join a Medicare drug plan or health plan with drug coverage within 63 days after the coverage ends.

Note: Keep materials your employer or union sends you that tell you your drug coverage is creditable. You may need to show it to your Medicare plan as confirmation of creditable prescription drug coverage if you decide to get Medicare drug coverage later.

If your (or your spouse’s) employer or union tells you your current coverage isn’t creditable prescription drug coverage:

If you want Medicare drug coverage, in most cases, you must join when you’re first eligible to avoid a late enrollment penalty. If you don’t enroll when you’re first eligible, you may have to wait until Open Enrollment (October 15–December 7) to add Medicare drug coverage.

Find out about your options from your benefits administrator. You may be able to do one of these:

Keep your current employer or union drug coverage, and get Medicare drug coverage for more complete drug coverage.

Keep only your current employer or union drug coverage. If you sign up for Medicare drug coverage later, you may have to pay a late enrollment penalty if your current drug coverage isn’t creditable.

Drop your current coverage and join a Medicare plan that covers prescription drugs. (Note: If your current coverage changes, and is no longer creditable, you’ll be eligible to get Medicare drug coverage during a Special Enrollment Period. See here for more information.)

Caution: If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependents. Medicare doesn’t have information about how your current employer or union drug coverage will be affected by you getting Medicare drug coverage. Talk to your employer or union’s benefits administrator before you make any decisions about your drug coverage.

I have Medicare and a Federal Employee Health Benefits (FEHB) plan

Contact your FEHB plan before making any changes. It’s almost always to your advantage to keep your current coverage without any changes. It isn’t cost effective for most people covered under a FEHB plan to get Medicare drug coverage unless they qualify for Extra Help. Caution: You can’t drop FEHB drug coverage without also dropping FEHB plan coverage for hospital and medical services, which may mean higher costs for these services.

If you qualify for Extra Help paying Medicare drug costs, see how your costs with a Medicare plan and any Extra Help would compare to your FEHB plan drug coverage.

If you ever lose your FEHB coverage and need to get Medicare drug coverage, in most cases, you won’t have to pay a late enrollment penalty, if you join within 63 days of losing FEHB coverage.

If you join a Medicare plan with drug coverage, you can keep your FEHB plan. In most cases, your Medicare drug coverage pays first.

For more information about how your FEHB plan works with Medicare, visit opm.gov/healthcare-insurance/healthcare/medicare/ or call the Office of Personnel Management at 1-888-767-6738. TTY users can call 711. You can also call your plan.

I have Medicare and one of these that includes drug coverage: TRICARE, CHAMPVA, or benefits from the Department of Veterans Affairs (VA)

As long as you still qualify, you can keep your TRICARE, Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), or VA drug coverage. TRICARE, CHAMPVA, or your VA provider should send you information each year about your coverage and whether it’s creditable prescription drug coverage. Read this information carefully, and save these materials.

Before making any changes, contact your benefits administrator for information about your TRICARE, CHAMPVA, or VA coverage. It’s almost always to your advantage to keep your current coverage without any changes. For most people with TRICARE, CHAMPVA, or VA coverage, unless you qualify for Extra Help, it isn’t cost effective to get Medicare drug coverage.

If you qualify for Extra Help paying Medicare drug costs, compare costs with your TRICARE, CHAMPVA, or VA drug coverage.

If you ever lose your TRICARE, CHAMPVA, or VA coverage and need to join a Medicare plan, in most cases, you won’t have to pay a Part D late enrollment penalty, if you join within 63 days of losing TRICARE, CHAMPVA, or VA coverage.

If you get Medicare drug coverage and already have VA coverage, you can’t use both types of coverage for the same prescription.

If you have TRICARE and join a Medicare drug plan, your Medicare drug plan pays first, and TRICARE pays second.

If you have CHAMPVA and join a Medicare drug plan, you won’t be able to use the Meds by Mail program, which can give your maintenance medications at no charge to you (no premiums, no deductibles and no copayments).

If you join a Medicare Advantage Plan with drug coverage, you must get prescription drugs through the Medicare Advantage Plan. The Medicare Advantage Plan is the primary payer. TRICARE may cover some or all of the claim unpaid by the Medicare Advantage Plan if the plan’s pharmacy is a TRICARE network pharmacy that participates in the online coordination of benefits.

For more information on VA benefits, visit va.gov/health-care/, call the VA Health Benefits Service Center at 1-877-222-VETS (1-877-222-8387), or visit your local VA medical facility. TTY users can call 711.

For more information on the TRICARE Pharmacy Program, visit tricare.mil/pharmacy or call 1-877-363-1303. TTY users can call 1-877-540-6261.

For more information on CHAMPVA, visit va.gov/communitycare/programs/dependents/champva/ or call CHAMPVA at 1-800-733-8387.

I have a Medicare health plan without drug coverage

If you have a Medicare Advantage Plan or another Medicare health plan that doesn’t include drug coverage, you may want to think about other ways to get Medicare drug coverage during a valid enrollment period. (See here for more information about when you can join, switch, or drop a drug plan or health plan with drug coverage.)

See if your current Medicare Advantage Plan offers a Medicare drug coverage option. If so, you can switch to that option.

If your current plan doesn’t offer Medicare drug coverage, you can switch to another Medicare health plan in your area that offers it.

If your current plan doesn’t offer Medicare drug coverage, you can switch to Original Medicare and join a Medicare drug plan.

Only some Medicare Private Fee-for-Service (PFFS) Plans (a type of Medicare Advantage Plan) offer Medicare drug coverage. If your Medicare PFFS Plan doesn’t offer Medicare drug coverage, you can also join a Medicare drug plan to get this coverage.

Medicare Medical Savings Account (MSA) Plans (a type of Medicare Advantage Plan) don’t offer Medicare drug coverage. If you have a Medicare MSA Plan, you can also join a Medicare drug plan to get drug coverage.

If you have a Medicare MSA Plan and a Medicare drug plan, any money you use from your MSA Plan account on Medicare drug plan deductibles or cost sharing counts toward your drug plan out-of-pocket costs (see here).

If you have a Medicare MSA Plan and don’t have a Medicare drug plan, you can use money in your MSA account for prescription or non-prescription drugs. These expenses don’t count toward the MSA Plan deductible.

If your Medicare Cost Plan doesn’t offer Medicare drug coverage, you can also join a separate Medicare drug plan to add drug coverage.

If you stay in a plan that doesn’t offer drug coverage and you don’t join a Medicare drug plan or have other creditable prescription drug coverage, you may have to pay a late enrollment penalty if you want Medicare drug coverage later. See here to learn more about the late enrollment penalty.

Contact your plan for more information about your choices.

I have a Medicare health plan with drug coverage

If you have drug coverage from a Medicare Advantage Plan or other Medicare health plan, in most cases, you’ll need to get your Medicare drug coverage from your plan.

If you have a Medicare Advantage Plan and you join a separate Medicare drug plan, in most cases, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

If you’re in a Medicare Private Fee-for-Service (PFFS) Plan or a Medicare Medical Savings Account (MSA) Plan that doesn’t offer Medicare drug coverage, you can join a separate Medicare drug plan to add drug coverage.

With a Medicare Cost Plan, you can either get your Medicare drug coverage from the plan (if offered), or you can join a separate Medicare drug plan to add drug coverage.

Contact your plan for more information about your choices.

I have Medicare and Medicaid

Medicare helps pay for your prescription drugs instead of Medicaid. Because you have Medicaid, Medicare automatically gives you Extra Help with your Medicare drug plan costs, and will mail you a purple notice. Keep this notice as confirmation that you qualify for Extra Help. See here for information about your costs.

Unless you choose a Medicare Advantage Plan with drug coverage or a Medicare drug plan on your own, Medicare automatically enrolls people with both Medicare and full Medicaid coverage living in institutions into Medicare drug plans. If you live in a nursing home and have full Medicaid coverage, you pay nothing for your covered drugs after Medicaid has paid for your stay for at least one full calendar month.

If you haven’t joined a Medicare drug plan, Medicare will enroll you in a drug plan to make sure you have drug coverage (unless you already have certain retiree drug coverage). Medicare sends you a yellow notice telling you what drug plan you’re in and when your coverage starts. Check to see if the plan covers the drugs you take and includes the pharmacies you use. Since you qualify for Extra Help, you have chances to switch your Medicare drug plan during the year.

If you filled any covered prescriptions before your Medicare drug plan coverage started, you may be able to get back some of the money you spent. Call Medicare’s Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307 for more information. TTY users can call 711. See here for more information about Medicare’s Limited Income NET Program.

If you don’t want Medicare drug coverage and you don’t want Medicare to enroll you in a Medicare drug plan (like if you have other creditable prescription drug coverage), call 1-800-MEDICARE (1-800-633-4227) and tell them you want to “opt out” of (decline) Medicare drug coverage. TTY users can call 1-877-486-2048.

Caution: If you call 1-800-MEDICARE and opt out of a Medicare drug plan, you could be left without any drug coverage. As long as you continue to qualify for Extra Help, you can change your mind and join a Medicare drug plan during the next available enrollment period without paying a late enrollment penalty.

If you continue to qualify for Medicaid, Medicaid will still cover the other health care costs that Medicare doesn’t cover. If you aren’t sure whether you still qualify for Medicaid, call your State Medical Assistance (Medicaid) office. To get the phone number, visit Medicare.gov/talk-to-someone or call 1-800-MEDICARE.

I have Medicare and get Supplemental Security Income (SSI) benefits or belong to a Medicare Savings Program

If you have Medicare and get SSI or belong to a Medicare Savings Program, Medicare will send you a purple notice letting you know you automatically qualify for Extra Help paying your Medicare drug coverage costs. You get it automatically when you join a Medicare drug plan. See here for more information about your costs.

If you don’t get Medicare drug coverage on your own, Medicare will enroll you in a Medicare drug plan, to make sure you have coverage, unless you already have certain retiree drug coverage. Medicare sends you a yellow or a green notice letting you know when your coverage begins. As long as you qualify for Extra Help, you have chances to switch Medicare drug plans during the year.

If you don’t want Medicare drug coverage, and you don’t want Medicare to enroll you in a Medicare drug plan (like if you have other creditable prescription drug coverage), call 1-800-MEDICARE (1-800-633-4227) and tell them you want to “opt out” of (decline) Medicare prescription drug coverage. TTY users can call 1-877-486-2048.

Caution: If you call 1-800-MEDICARE and tell them you don’t want to join a Medicare drug plan, you could be left without drug coverage. As long as you continue to qualify for Extra Help, you can change your mind and join a Medicare drug plan during the next available enrollment period without paying a Part D late enrollment penalty.

I have Medicare and live in a nursing home or other institution

While you’re living in an institution, you can switch Medicare drug plans at any time.

If you move into or out of a nursing home or other institution, you can switch Medicare drug plans at that time.

If you’re in a skilled nursing facility getting Medicare-covered skilled nursing care, Medicare Part A (Hospital Insurance) will generally cover your drugs.

If you live in a nursing home or other institution, you’ll get your covered drugs from a long-term care pharmacy that works with your Medicare drug plan. This long-term care pharmacy usually contracts with (or is owned and operated by) your institution.

Note: For the purposes of this publication, institutions don’t include assisted living, adult living facilities, residential homes, or any kind of nursing home that Medicare or Medicaid hasn’t certified.

I have Medicare and benefits through Program of All-inclusive Care for the Elderly (PACE)

Program of All-inclusive Care for the Elderly (PACE) is a joint Medicare and Medicaid option in some states. PACE gives you your Medicare drug coverage, so you don’t need to join a separate Medicare drug plan.

Caution: Joining a Medicare drug plan will disenroll you from your PACE plan. Your PACE plan gives you all of your health care services, not only your drug coverage. If you join a Medicare drug plan, you’ll become disenrolled from your PACE plan, and you’ll no longer get other health care benefits through PACE. Contact your PACE plan for more information. Visit Medicare.gov/plan-compare/#/pace/ to find contact information for your PACE plan.

If you have both Medicare and full Medicaid coverage, you get drugs through your PACE plan, at no cost to you.

If you have Medicare and a PACE plan, but don’t have Medicaid coverage, you get all of your health care benefits, including drug coverage, through your PACE plan. You pay a reduced monthly PACE premium because it doesn’t include prescription drugs. However, you’ll also pay a separate Medicare prescription drug premium to your PACE organization or plan to cover the cost of your drugs.

You may still qualify for Extra Help paying for Medicare drug coverage, even if you don’t have Medicaid coverage. See Section 3 for more information about Extra Help.

I have Medicare and get help from my State Pharmacy Assistance Program (SPAP) paying drug costs

Several states have programs to help certain people pay for prescription drugs. Depending on your state, the State Pharmacy Assistance Program (SPAP) will have different ways to help you pay your drug costs. Some SPAPs may require you to get Medicare drug coverage, and then they’ll cover the prescription drug costs that Medicare doesn’t cover. Find your SPAP’s contact information by visiting Medicare.gov/pharmaceutical-assistance-program/state-programs.aspx. SPAP contributions may count toward your Medicare drug coverage out-of-pocket threshold (or limit), which is $7,050 in 2022. Once you’ve spent more than the limit, you automatically get “catastrophic coverage.” It assures you only pay a small coinsurance percentage or copayment for covered drugs for the rest of the year.

If you belong to an SPAP, you may have another opportunity each year to join a plan in addition to the October 15–December 7 Open Enrollment Period. You can switch one time in a calendar year to a different plan from the one your SPAP enrolled you in. If you lose your SPAP benefits, you’re allowed to choose different Medicare drug coverage at any time during the month you lose your benefits and through the following 2 months.

Your SPAP will give you more information on how Medicare drug coverage affects the help you get now.

I get help from an AIDS Drug Assistance Program (ADAP)

Most AIDS Drug Assistance Programs (ADAPs) only cover HIV/AIDS-related medications. If they don’t cover other drugs, they aren’t creditable prescription drug coverage. If you don’t have creditable prescription drug coverage and delay joining Medicare drug coverage, you may have to pay a Part D late enrollment penalty to join later.

All Medicare plans with drug coverage cover all antiretroviral medications. Your ADAP may require you to have Medicare drug coverage to get ADAP benefits. An ADAP can cover Medicare drug coverage premiums, deductibles, coinsurance, and/or copayments to help with your drug costs. Check with your ADAP to see if it requires you to join or if it will help pay for these costs.

ADAPs vary by state, so contact your ADAP to learn how it will work with Medicare’s drug coverage. ADAP contributions count toward your Medicare drug coverage out-of-pocket threshold (or limit), which is $7,050 in 2022.

I have Medicare and get drug coverage from the Indian Health Service, Tribe or Tribal Health Organization, or Urban Indian Health Program

You and your community may benefit if you join a Medicare plan. Ask your health provider or benefits coordinator if joining a plan is right for you. If you decide to join, they can help you find a plan.

If you get prescription drugs through an Indian health pharmacy, you pay nothing.

Joining a Medicare plan may be helpful to your Indian health provider because the Medicare drug coverage pays part of the cost of your prescription drugs. This helps the Indian health provider with the cost of services.

If you have full coverage from Medicaid and live in a nursing home, you pay nothing for your Medicare drug coverage. See your Indian health provider or check with the benefits coordinator at your local Indian health pharmacy to get more information on how to join a Medicare plan.

If you get health care from the Indian Health Service, Tribal Health Program, or Urban Indian Health Program, you have creditable prescription drug coverage. You won’t have to pay a Part D late enrollment penalty to join a Medicare plan later. Ask your Indian health care provider for a letter stating you have creditable prescription drug coverage.

Section 5: 3 Steps to Choosing a Medicare Drug Plan

Highlighted words are defined here.

Follow these 3 steps to choose Medicare drug coverage, whether you’re joining for the first time or reviewing your plan options for coverage next year. Use the personal worksheets here to help decide which plan meets your needs:

Step 1: Gather information about your current drug coverage, prescriptions, and needs

Step 2: Compare Medicare drug coverage based on cost, coverage, and customer service

Step 3: Decide which plan is best for you, and join

Tip: Check out how your current health coverage could affect your drug coverage choices before you consider which Medicare plan you join. See Section 4.

Step 1: Gather information about your current drug coverage and needs

Before choosing Medicare drug coverage, gather information about any drug coverage you may currently have, as well as a list of the drugs and doses you currently take. Also, gather any notices you get from Medicare, Social Security, or your current Medicare drug coverage about changes to your plan.

If you have drug coverage, you need to find out whether it’s creditable prescription drug coverage. Your current insurance company or plan provider is required to notify you each year whether your coverage is creditable prescription drug coverage. If you haven’t heard from your insurance company or plan, call the insurance company, your plan, or your benefits administrator to find out.

Request a notice about whether your coverage is creditable prescription drug coverage if you didn’t get one. Also, you may want to consider keeping your creditable prescription drug coverage rather than choosing Medicare drug coverage.

Tip: Log into Medicare.gov/plan-compare to quickly enter, update, and print your drug list from data about prescriptions you filled within the last 12 months. (Visit Medicare.gov/account to log into (or create) your secure Medicare account, if you don’t already have one.)

Prescription drugs I take:Today’s date: _____________________

Drug name

Dosage
(ml, mg)

Number of times a day I take my prescription drug

Amount I pay each month

Step 2: Compare Medicare drug coverage based on cost, coverage, and customer service

Use Medicare.gov/plan-compare to compare plans based on what’s most important to your situation and your drug needs. You may want to ask yourself:

Which plan(s) cover the drugs I take?

Which plan gives me the best overall price on all of my drugs?

What’s the monthly premium, yearly deductible, and the coinsurance, or copayment(s)?

Which plan(s) allows me to use the pharmacy I want?

Which plan(s) allows me to get drugs through the mail?

Which plan(s) give me coverage in multiple states (if I need it)?

What are the plans’ quality Star Ratings?

Will I have to pay a penalty because I waited to join?

Can my coverage start when I want it to?

Is it likely that I’ll need protection against unexpected drug costs in the future?

If I already have Medicare drug coverage, am I satisfied with my plan’s service?

If you need help with your Medicare drug coverage decisions, call your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org, or call 1-800-MEDICARE (1-800-633-4227) for the phone number of your SHIP. TTY users can call 1-877-486-2048.

Step 3: Decide which plan is best for you, and join

Visit Medicare.gov/plan-compare, or call 1-800-MEDICARE (1-800-633-4227) for lists of the specific plans available in your area. TTY users can call 1-877-486-2048. You can also look in your “Medicare & You” handbook.

After you pick a plan that meets your needs, you may be able to join through Medicare.gov/plan-compare. If not, use the plan’s contact information in “Plan Details” or your handbook to find out how to join. You may be able to join by phone, paper application, or online.

Section 6: Tips for Using Your New Medicare Drug Coverage

Highlighted words are defined here.

There are some things you can do to make sure your first visit to the pharmacy goes smoothly if you’ve just joined a Medicare drug plan or health plan with drug coverage for the first time, or you switched to a new plan.

Come to the pharmacy with as much information as possible the first time you use your new Medicare drug coverage. Bring:

Your red, white, and blue Medicare card. Visit Medicare.gov to log into (or create) your secure Medicare account to print an official copy of your Medicare card.

Photo ID (like a state driver’s license or passport).

Your plan membership card.

If you don’t have a plan membership card, also bring these to the pharmacy:

An acknowledgement or confirmation letter from the plan, if you have one.

An enrollment confirmation number from the plan, if you have one.

The name of the Medicare drug plan or health plan you joined. (Note: If you haven’t gotten a plan membership card or any plan enrollment materials, tell your pharmacist the name of your plan. This can help them confirm your plan enrollment and get the information they need to bill your plan. The pharmacist may have to search for your plan information, and it may take extra time for them to fill your prescription.)

If you have both Medicare and Medicaid or qualify for Extra Help

If you have both Medicare and Medicaid or qualify for Extra Help with drug plan costs, you should also bring confirmation of your enrollment in Medicaid or confirmation that you qualify for Extra Help with you to the pharmacy. This is to help make sure you pay the right amount for your prescription drugs. See here for a list of some of the letters that confirm you qualify for Extra Help. See here for a list of documents that confirm you have Medicaid.

You don’t need to have all of these items, but anything you can bring will help the pharmacist confirm your Medicare drug plan enrollment and/or that you qualify for Medicaid or Extra Help, to make sure you pay no more than the right amount to fill your prescriptions.

What if the pharmacist can’t confirm my Medicare drug coverage or Extra Help status?

In some rare cases, the pharmacist may not be able to confirm your plan enrollment or that you qualify for Medicaid or Extra Help. If this happens, your doctor may be able to give you a sample of your prescription drug to help until your coverage is confirmed. You can also pay out-of-pocket for the drug. You should save the receipts and work with your new Medicare plan to get paid back for the drugs that your plan normally would cover.

Medicare’s Limited Income Newly Eligible Transition (NET) Program

Medicare’s Limited Income NET Program gives immediate prescription drug coverage if you’re at the pharmacy counter and qualify for Extra Help, but you aren’t enrolled in a Medicare drug plan. This program covers all Part D covered drugs, and there are no network pharmacy restrictions. You’ll be charged a reduced copayment based on your level of Extra Help. Also, if you’re eligible for this program, it will cover prescriptions you filled within the last 30 days.

If you paid for prescription drugs out of pocket before you were enrolled in a Medicare drug plan but after you qualified for both Medicare and Medicaid or SSI, you may be able to get paid back for those costs. Call Medicare’s Limited Income NET Program at 1-800-783-1307 to see if you qualify. TTY users can call 711.

Section 7: Rights & Appeals

Highlighted words are defined here.

How do I protect myself from fraud and identity theft?

Help protect yourself by knowing whether Medicare drug plans and Medicare health plans with drug coverage are marketing to you properly. These plans and people who work with Medicare aren’t allowed to:

Charge you a fee to enroll in a plan.

Send you unwanted emails.

Come to your home uninvited to get you to join a Medicare plan.

Call you, unless you’re already a plan member. If you’re a member, the agent who helped you join can call you.

Offer you money to join their plan or give you free meals while trying to sell you a plan.

Enroll you into Medicare drug coverage over the phone unless you call them and ask to enroll.

Ask you for payment over the phone or online. The plan must send you a bill.

Sell you a non-health related product, like an annuity or life insurance policy, while trying to sell you a Medicare health or drug plan.

Make an appointment to tell you about their plan unless you agree (in writing or through a recorded phone call) to the products being discussed. During the appointment, they can only try to sell you the products you agreed to hear about.

Talk to you about their plan in areas where you get health care, like an exam room, hospital patient room, or at a pharmacy counter.

Try to sell you their plans or enroll you during an educational event, like a health fair or conference.

Independent agents and brokers working for plans must be licensed by the state. The plan must tell the state which agents are selling its plans.

If you have Medicare drug coverage and you think the plan may be breaking these rules, call the Medicare Drug Integrity Contractor (MEDIC) at 1-877-7SAFERX (1-877-772-3379).

Identity theft

Identity theft happens when someone uses your personal information without your permission to commit fraud or other crimes. Personal information includes things like your name, or your Social Security, Medicare, bank account, or credit card numbers.

If you think someone is misusing your personal information, call the Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 to make a report. TTY users can call 1-866-653-4261. For more information about identity theft or to file a complaint online, visit ftc.gov/identitytheft.

What if I need help applying for Extra Help, joining Medicare drug coverage, or requesting a coverage determination or appeal?

You may have a legal representative who, by state or federal law, has the legal right (like through a Power of Attorney or a court order) to act on your behalf. You can also appoint a family member, friend, advocate, attorney, doctor, or someone else to act as your representative.

A representative can help you (or act on your behalf) apply to see if you qualify for Extra Help paying for Medicare drug coverage, or file a request for a coverage determination, complaint (also called a “grievance”), or appeal. Your doctor or other prescriber can request a coverage determination or first or second
level appeal for you without being your appointed representative. A representative can’t enroll you in Medicare drug coverage unless they’re also your legal representative according to the laws of your state.

A representative can be any of these:

The person who acts on your behalf if you’re incapacitated or can’t make decisions for yourself.

Anyone you choose to act as your representative (like your spouse, your child, or a caregiver).

Your “representative payee” (sometimes called a “rep payee”). This is a person, agency, organization, or institution that Social Security selects to act on your behalf.

If you want Medicare to be able to give your personal information to someone other than you, you can:

Fill out an “Appointment of Representative” form (CMS Form Number 1696) at CMS.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207. You can also get the form when you log into (or create) your secure Medicare account at Medicare.gov/account. Or call 1-800-MEDICARE (1-800-633-4227) and ask for a free copy. TTY users can call 1-877-486-2048.

Submit a letter that includes:

Your name, address, and phone number

Your Medicare Number (found on your red, white, and blue Medicare card) or plan identification card

A statement appointing someone as your representative

The name, address, and phone number of your representative

The professional status of your representative or their relationship to you

A statement authorizing the release of your personal and identifiable health information to your representative

A statement explaining why you’re being represented and to what extent

Your signature and the date you signed the letter

Your representative’s signature and the date they signed the letter

Your representative must send the form or letter with your appeal request. See here for how to request an appeal. The person helping you must send a copy of the form or letter each time you file a coverage determination or appeal, so keep a copy of everything you send to Medicare as part of your appeal. If you have questions about appointing a representative, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

What if my enrollment in a Medicare drug plan or health plan is denied?

Medicare drug plans and health plans generally have to accept all eligible applicants who live in their service area, regardless of the applicant’s age or health status. If your enrollment form is denied, the company will send you a letter explaining why. You may contact the plan for more information about your options.

What if my plan won’t cover a drug I need?

If your Medicare drug plan or health plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you should have to pay, you have these options:

Talk to your prescriber (the professional who wrote your prescription).

Ask your prescriber if you meet prior authorization or step therapy requirements. Contact your plan for more information on these requirements. You can also ask your prescriber if there are generic, over-the-counter, or less expensive brand-name drugs that could work just as well as the ones you’re taking now.

Request a coverage determination (including an “exception”).

You, your representative, your doctor, or other prescriber can request (orally or in writing) that your plan cover the prescription drug you need. You can request a coverage determination if your pharmacist or plan tells you one of these:

A drug you believe should be covered isn’t.

A drug is covered at a higher cost than you think you should have to pay.

You have to meet a plan coverage rule (like prior authorization) before you can get the drug you requested.

It won’t cover a drug on the formulary because the plan believes you don’t need the drug.

You, your representative, your doctor, or other prescriber can request a coverage determination called an “exception” if:

You think your plan should cover a drug that’s not on its formulary (drug list) because the other treatment options on your plan’s formulary won’t work for you.

Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, like prior authorization, step therapy, or quantity or dosage limits.

You think your plan should charge a lower amount for a drug you’re taking on a higher-cost drug tier because the other treatment options in your plan’s lower-cost drug tier(s) won’t work for you.

If you request an exception, your doctor or other prescriber will need to give a supporting statement to your plan explaining why you need the drug you’re requesting. Check with your plan to find out if it requires the supporting statement in writing. The plan’s decision-making time period begins once your plan gets the supporting statement.

You can either request a coverage determination before you pay for or get your prescription drug, or you can decide to pay for the drug, save your receipt, and request that the plan pay you back by requesting a coverage determination.

For details on filing a coverage determination, visit Medicare.gov/appeals. If you disagree with the coverage determination decision, you have the right to appeal.

How do I appeal if I have Medicare drug coverage?

If your plan denies your request, it will send you a letter explaining why the drug you requested isn’t covered and instructions on how to file an appeal. You also can find information about your appeal rights in the plan’s “Evidence of Coverage” (EOC). The EOC is a document your plan sends you each year that explains what the plan covers and how it works. Call your plan if you have questions about your EOC.

If you decide to appeal, ask your doctor or other prescriber for any information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.

What’s the appeals process for Medicare drug coverage?

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll be given instructions on how to move to the next level of appeal. For details on the appeals process, visit Medicare.gov/appeals.

How do I file a complaint (grievance)?

If you have a concern or a problem with your plan that isn’t a request for coverage or reimbursement for a drug, you have the right to file a complaint (also called a “grievance”).

Some examples of why you might file a complaint include:

You believe your plan’s customer service hours of operation should be different.

You have to wait too long for your prescription drug.

The company offering your plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan.

The plan didn’t make a timely decision about a coverage determination or didn’t send your case to the Independent Review Entity (IRE) when it should have.

You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or first-level appeal (called a “redetermination”).

The plan didn’t provide you with the required notices.

The plan’s notices don’t follow Medicare rules.

If you want to file a complaint, you should know:

You must file your complaint within 60 days from the date of the event that led to the complaint.

You can file your complaint with the plan over the phone or in writing.

You must be notified of the plan’s decision generally no later than 30 days after the plan gets the complaint.

If the complaint relates to a plan’s refusal to make an expedited (fast) coverage determination or redetermination and you haven’t yet bought or gotten the drug, the plan must notify you of its decision within 24 hours after it gets the complaint.

If you think you were charged too much for a drug, call the company offering your plan to get the most up-to-date price.

If the plan doesn’t address your complaint, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

More information on filing a complaint

Visit Medicare.gov/appeals.

Call your State Health Insurance Assistance Program (SHIP) for free, personalized counseling, and help filing a complaint. To get the phone number of the SHIP in your state, visit shiphelp.org or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

What if I don’t agree with Medicare’s Part D late enrollment penalty?

If you don’t join a Medicare plan with drug coverage when you’re first eligible, you may have to pay a Part D late enrollment penalty unless you had other creditable prescription drug coverage. In some cases, you have the right to ask Medicare to review your late enrollment penalty. This is called a “reconsideration.”

Some reasons why you may ask for a reconsideration include:

You think Medicare didn’t count all your previous creditable prescription drug coverage.

You didn’t get a notice that clearly explained whether your previous drug coverage was creditable.

Your Medicare plan will give you a reconsideration request form when it sends you the letter telling you that you have to pay a late enrollment penalty. Mail the completed form to the address, or fax it to the number listed on the form within 60 days from the date on the letter. You should also send copies of any documents that support your case, like information about previous creditable prescription drug coverage.

If you need more information about requesting a reconsideration of your late enrollment penalty, call your Medicare plan. You can also visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users can call 1-877-486-2048.

Section 8: For More Information

Highlighted words are defined here.

For more information about Medicare drug coverage, visit Medicare.gov/plan-compare to get personalized information. Enter and save your current drug information to get more detailed cost information.

You also can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, including weekends, to get information you need. TTY users can call 1-877-486-2048.

If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing. You can fill out a “Medicare Authorization to Disclose Personal Health Information” form (CMS Form Number 10106) at CMS.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS1193148. You can also get the form when you log into (or create) your secure Medicare account at Medicare.gov/account. Or call 1-800-MEDICARE to get a copy of the form.

For more information about your current drug coverage, contact your benefits administrator, insurance company, or plan.

For more information about applying for Extra Help with your Medicare drug coverage costs, call Social Security at 1-800-772-1213, or visit ssa.gov. TTY users can call 1-800-325-0778.

For free personalized counseling on your coverage choices, contact your State Health Insurance Assistance Program (SHIP). Visit shiphelp.org or call 1-800-MEDICARE for the phone number of your SHIP.

Section 9: Definitions

Coinsurance—An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

Copayment—An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug.

Coverage determination (Part D)—The first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits, including:

Whether a particular drug is covered

Whether you have met all the requirements for getting a requested drug

How much you’re required to pay for a drug

Whether to make an exception to a plan rule when you request it

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests). If you disagree with the plan’s coverage determination, the next step is an appeal.

Coverage gap (Medicare prescription drug coverage)—A period of time in which you may pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year.

Creditable prescription drug coverage—Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Deductible—The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

Drug list—A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. This list is also called a formulary.

End-Stage Renal Disease (ESRD)—Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

Exception—A type of Medicare prescription drug coverage determination. A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that is on its non-preferred drug tier. You or your prescriber can request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

Extra Help—A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

Institution—For the purposes of this publication, an institution is a facility that provides short-term or long-term care, like a nursing home, skilled nursing facility (SNF), or rehabilitation hospital. Private residences, like an assisted living facility or group home, aren’t considered institutions for this purpose.

Medicaid—A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medicare—The federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare Advantage Plan (Part C)—A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all 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, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Cost Plan—A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services or urgently needed services).

Medicare drug coverage (Part D)—Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Medicare drug plan—Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare drug plans.

Medicare health plan—Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans. PACE plans can be offered by public or private companies and provide Part D and other benefits in addition to Part A and Part B benefits.

Medicare Medical Savings Account (MSA) Plan—MSA Plans combine a high deductible Medicare Advantage Plan and a bank account. The plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins.

Medicare Part A (Hospital Insurance)—Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)—Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medicare Private Fee-for-Service (PFFS) Plan—A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when you get care. A Private Fee-For-Service Plan is very different than Original Medicare, and you must follow the plan rules carefully when you go for health care services. When you’re in a Private Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits than in Original Medicare.

Medicare Savings Program—A Medicaid program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance.

Medigap policy—Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage. Some Medigap policies sold before January 1, 2006, have prescription drug coverage. Policies sold on or after January 1, 2006, don’t have prescription drug coverage.

Original Medicare—Original Medicare is a fee-for-service health plan that has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

Penalty—An amount added to your monthly premium for Part B or a Medicare drug plan (Part D), if you don’t join when you’re first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions.

Premium—The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Program of All-inclusive Care for the Elderly (PACE)—A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.

State Health Insurance Assistance Program (SHIP)—A state program that gets money from the federal government to give free local health insurance counseling to people with Medicare.

State Medical Assistance (Medicaid) office—A state or local agency that can give information about, and help with applications for, Medicaid programs that help pay medical bills for people with limited income and resources.

State Pharmaceutical Assistance Program (SPAP)—A state program that provides help paying for drug coverage based on financial need, age, or medical condition.

CMS Accessible Communications

The Centers for Medicare & Medicaid Services (CMS) provides free auxiliary aids and services, including information in accessible formats like braille, large print, data or audio files, relay services and TTY communications. If you request information in an accessible format from CMS, you won’t be disadvantaged by any additional time necessary to provide it. This means you’ll get extra time to take any action if there’s a delay in fulfilling your request.

To request Medicare or Marketplace information in an accessible format you can:

Call us:
For Medicare: 1-800-MEDICARE
(1-800-633-4227)
TTY: 1-877-486-2048

Send us a fax:
1-844-530-3676

Send us a letter:
Centers for Medicare & Medicaid Services
Offices of Hearings and Inquiries (OHI)
7500 Security Boulevard
Mail Stop S1-13-25
Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Staff

Your request should include your name, phone number, type of information you need (if known), and the mailing address where we should send the materials. We may contact you for additional information.

Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan, contact your plan to request its information in an accessible format. For Medicaid, contact your State or local Medicaid office.

Nondiscrimination Notice

The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by CMS directly or through a contractor or any other entity with which CMS arranges to carry out its programs and activities.

You can contact CMS in any of the ways included in this notice if you have any concerns about getting information in a format that you can use.

You may also file a complaint if you think you’ve been subjected to discrimination in a CMS program or activity, including experiencing issues with getting information in an accessible format from any Medicare Advantage Plan, Medicare drug plan, State or local Medicaid office, or Marketplace Qualified Health Plans. There are three ways to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:

Online:
hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html.

By phone:
Call 1-800-368-1019.
TTY users can call 1-800-537-7697.

In writing:
Send information about your complaint to:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201

U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES

Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Official Business
Penalty for Private Use, $300

CMS Product No. 11109
Revised July 2022

To get this booklet in Spanish, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

¿Necesita usted una copia de esta guía en Español?
Llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY pueden llamar al 1-877-486-2048.