Page header image

Medicare Coverage for Prescription Drugs

What is Medicare prescription drug coverage?

Medicare is a federal government program. It provides healthcare coverage for people 65 or older. It also provides coverage for people of any age who have certain disabilities. Medicare prescription drug coverage helps pay for prescription medicines. Everyone covered by Medicare can get this coverage.

When can I get Medicare prescription drug coverage?

You may sign up when you first become eligible for Medicare: 3 months before the month you turn 65 until 3 months after you turn 65. If you get Medicare because you have a disability, you can join from 3 months before to 3 months after your 25th month of cash disability payments. If you don't sign up when you are first eligible, you will pay a penalty. Your next opportunity to enroll will be from November 15 to December 31 of the current year.

If you join a Medicare prescription drug plan, you must keep that plan for the calendar year. You can change plans for the next year between November 15 and December 31. In some cases you can switch your plan at other times. For example, you may be able to change your plan if you move or enter a nursing facility. If you have both Medicare and Medicaid, you can change plans at any time.

How do Medicare drug plans work?

There are 2 ways to get Medicare drug coverage:

  • You can join a Medicare prescription drug plan.
  • You can join a Medicare Advantage Plan or other health plan that includes drug coverage.

A Medicare Advantage or other health plan, such as an HMO or PPO, often provides more benefits at a lower cost than a prescription-only drug plan (PDP).

You will pay a monthly premium and a yearly deductible. How much you pay depends on the plan you choose. You will also pay part of the cost of your medicines. Drug costs depend on which plan you choose. Some plans may offer more coverage and more medicines for a higher monthly premium.

If you qualify for Medicaid (through your state government) or for Supplemental Security Income, you may not have to pay a premium or deductible. You may qualify for help paying for Medicare drug coverage if your combined savings, investments, and real estate (other than your home) are below a limit set by the government. What the limit is depends on whether you are single or married.

What medicines are covered?

The list of medicines covered by a Medicare drug plan is called a formulary. Formularies include generic drugs and brand-name drugs. The formulary must include at least 2 drugs in each category and class of the most commonly prescribed drugs. For example, blood pressure medicines are a class of drugs. This makes sure that people with different medical problems can get the treatment they need.

If the plan does not cover the medicine you have been taking, your current medicine may be covered for a certain time while you work with your healthcare provider to one covered by the plan. If your provider decides that you should not change your medicine, you may be able to get an exception. This means the plan agrees to pay for the drug even if it is not in their formulary. If the plan refuses to give you an exception, you can appeal the plan's decision. If you don’t win the appeal, you will have to pay for the medicine yourself.

Where can I get help?

When you compare Medicare drug plans, think about what you need. Think about cost, coverage, convenience, and peace of mind now and in the future. Then use one of the resources below to help you find a plan that meets your needs.

  • Order or download the "Medicare & You" handbook from the Medicare Web site http://www.medicare.gov. You can also call 1-800-633-4227 to have it mailed to you. The handbook has drug plan information in it, including which plans are available in your area.
  • Use the Medicare Prescription Drug Plan Finder at the Medicare Web site (http://www.medicare.gov). To get personalized drug information, you will need to provide:
    • Information from your Medicare card
    • date of birth
    • last name
    • zip code.

    To get general drug plan information or to find out what plans are available in your area, you need to answer a few questions. You can also enter your current prescription drug information to get more detailed information.

  • Call Medicare at 1-800 MEDICARE (1-800-633-4227).

You can also call your State Health Insurance Assistance Program. Check the "Medicare & You" handbook for the telephone number in your state.

Developed by RelayHealth.
Published by RelayHealth.
Last modified: 2011-07-07
Last reviewed: 2011-07-05
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
© 2011 RelayHealth and/or its affiliates. All rights reserved.
Page footer image