What are my options if I want Medicare prescription drug coverage?
You can enroll in a stand-alone Medicare prescription drug plan if you have original (traditional) Medicare; or, you can enroll in a Medicare Advantage plan (which replaces original Medicare) that includes prescription drug coverage. Private insurance companies sell Medicare prescription drug plans and Medicare Advantage plans approved by Medicare. Everyone with Medicare is eligible to enroll in Medicare prescription drug coverage regardless of income or assets, and coverage is voluntary.
Federal assistance with premiums is available to Medicare beneficiaries who meet certain income requirements. If you think you may qualify, call the Social Security Administration at 1-800-SSA-1213 (1-800-772-1213). Medicare beneficiaries may seek assistance in reviewing options for coverage by contacting a SHINE (Serving the Health Information Needs of Everyone) counselor.
What to consider when choosing a plan?
- Are all of your prescriptions are on the plan's list of drugs (called a formulary)?
- Is your preferred pharmacy is on the plan's list?
- What co-payments will you be responsible for paying when filling a prescription?
- Can you afford the premium, deductible and cost-sharing requirements for your preferred plan?
- Is there a coverage gap where you are responsible for all of the costs? Can you afford this gap?
- How does enrollment in the new plan impact coverage you already have (including employer-sponsored or other retiree coverage or a Medicare supplement insurance plan) or your enrollment in original Medicare?
- Have you reviewed the network rules and provider list of the Medicare Advantage plan? Are your doctors and hospitals are covered?
What if I already have other prescription drug coverage?
A Medicare prescription drug plan might provide more coverage than a Medicare supplement insurance (Medigap) policy or your current employer-provided prescription drug coverage. If Medicare considers your existing coverage to be "creditable" - meaning, coverage that is as good as the standard Medicare prescription drug coverage benefit - you are permitted to keep your current coverage without incurring future penalties. However, if you do not enroll in a Medicare drug plan when you are first eligible for Medicare, and you do not have other creditable prescription drug coverage, you may be subject to a penalty if you decide to enroll at a later time. Check with your employer or Medigap plan before dropping an employer-provided prescription drug coverage or Medigap plan because you may not be able to get it back.
Plan features might change from year to year. Carefully examine all available plans during the annual enrollment period because your current plan may no longer best meet your needs.
Marketing Rules
State and federal rules are in place to protect consumers against abuses in the marketing and sales of Medicare prescription drug plans and Medicare Advantage plans. Legitimate agents who contact you about any type of private Medicare coverage must follow certain rules:
- Must be licensed by the state. Check with the Division of Insurance to make sure the salesperson is a licensed agent.
- Must have made an appointment before coming to your home.
- Must arrange in advance the type of products that will be discussed during a scheduled sales appointment. At the appointment, the salesperson may not try to sell you other types of insurance coverage other than the type(s) agreed upon in advance.
Agents are not allowed to:
- Make unsolicited contact such as door-to-door sales, cold calls or approaching you in a parking lot.
- Attempt to sell you non-health care related products (like a life insurance policy or an annuity) during a sales or marketing presentation of a Medicare prescription drug or Medicare Advantage plan.
- Attempt to sell you a plan in certain health care settings, such as in a doctor's office or in a pharmacy.
- Attempt to sell you a plan at an educational event.
- Offer you free meals at promotional or sales events.
- Offer you gifts or other promotional items whose value is in excess of $15.
Beware of Door-to-Door Sales People Remember, agents cannot solicit business at your home without an appointment. Do not allow uninvited agents into your home.
Legitimate plans cannot ask for payment over the Internet. They must send you a bill.
Do Not Give Out Personal Information Examples include Social Security numbers, bank account numbers or credit card numbers to anyone you have not verified as a licensed agent. People are not allowed to request such personal information in their marketing activities. Once you decide to purchase a plan and have verified that the agent is licensed, you may give the agent personal information to assist in enrollment and billing.
Verify that the plan you have chosen is an approved Medicare plan. All of the approved plans are available at Medicare.Gov or by calling 1-800-MEDICARE