2018

PLAN
INFORMATION

Medicare Part D Overview

Medicare Part D is prescription drug coverage that is available to everyone with Medicare. Even if you don't take a lot of medications now, you may still want to join a Medicare Part D plan for protection against higher drug costs in the future.

To get Medicare Part D prescription drug coverage, you must join a plan offered by an insurance company or other private company approved by Medicare. You must also be a U.S. citizen or lawfully present in the United States.

Covered drugs

Each Medicare Part D drug plan has its own list of covered prescription drugs called a formulary. It's important to check a plan's formulary to see if your medications are covered by the plan. Learn more about covered drugs.

Medicare requires all Part D plans to cover at least two drugs in each therapeutic drug category. Certain types of drugs are not covered by Medicare Part D.

Medicare Part D drug coverage
These items are covered These items are not covered
Prescription drugs
  • Biological products
  • Certain vaccines
  • Insulin and supplies associated with the injection of insulin (syringes, needles, alcohol swabs and gauze)
  • Prenatal vitamins and fluoride preparations
  • Barbiturates
  • Benzodiazepines
Drugs for anorexia, weight loss or weight gain
Drugs that promote fertility
Drugs for the relief of coughs and colds
Drugs for cosmetic purposes or hair growth
Drugs for sexual or erectile dysfunction (ED)
Prescription vitamins and mineral products, except as noted within the plan's formulary
Over-the-counter medications
Certain outpatient drugs
Medicare Part D Pharmacy Network

In general, you must use pharmacies that are in the plan's network for your drugs to be covered. There are exceptions, such as in an emergency. In most cases, if you use a network pharmacy, you will not need to submit a claim form.

Network pharmacies include retail pharmacies and, in some cases, a home delivery pharmacy, such as the Express Scripts PharmacySM.* For some plans, there may be additional savings if you take advantage of preferred retail pharmacies (learn more about retail pharmacies with preferred cost-sharing) or home delivery.

Learn more about pharmacy networks.

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When to enroll in Medicare Part D

If you are new to Medicare, it's important to enroll in a Medicare Part D plan as soon as you become eligible (during your Initial Enrollment Period) to avoid paying any late enrollment penalties.

If you are already enrolled in a Medicare Part D plan, you can generally switch plans only during the Annual Enrollment Period, which runs from October 15 through December 7 each year.

Note: Some people, such as those who also receive Medicaid, may be allowed to enroll at other times of the year without penalty.

Learn more about when to enroll or switch plans.

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Medicare Part D plan costs

As a member of a Medicare Part D plan, you will pay a monthly premium in addition to any premiums you pay for Medicare Parts A and B. You may also be responsible for paying part of your prescription drug costs. Your actual drug plan costs will vary, depending on the following criteria:

  • Amount of coverage your plan offers
  • Region where you live (View premiums by state)
  • Medications you use
  • Pharmacies you use (retail or home delivery; in-network or out-of-network) and if the pharmacy offers standard or preferred cost-sharing
  • Whether your drugs are on the plan's formulary (list of covered drugs)
  • Whether you qualify for Extra Help paying your Part D prescription drug costs

Compare plans and see your costs based on where you live, the drugs you take and the pharmacy you use.

Find a Plan

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Medicare Part D coverage stages

Drug costs vary throughout a plan year based on your current stage of coverage. The following information is for the 2018 plan year:

Stage 1: Deductible Stage
  • The deductible is the amount you must pay out-of-pocket before the plan begins covering your drugs.
  • Medicare's standard benefit plan deductible is $405.
  • Some plans, including our Saver and Choice plans, have no deductible on generic drugs (Tiers 1 & 2), but include a deductible for all other drugs.
Stage 2: Initial Coverage Stage
  • This stage begins after you have met any deductible and continues until your year-to-date total drug costs (the amount that both you and your plan pay) reach $3,750.
  • During this stage, you will generally pay a portion of your drug costs and the plan will pay the rest.
Stage 3: Coverage Gap Stage ("Donut Hole")

Unless your Medicare Part D plan provides some coverage in the Coverage Gap:

  • This stage begins when your year-to-date total drug costs exceed $3,750 and continues until your year-to-date out-of-pocket costs reach $5,000.
  • In this stage, you pay only 44% of the cost of generic drugs.
  • During this stage, you pay 35% of the cost of brand-name drugs.
Stage 4: Catastrophic Coverage Stage
  • You will reach this stage after your year-to-date out-of-pocket costs exceed $5,000.
  • During this stage, you pay a low copayment or coinsurance for your drugs.

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Getting Extra Help with Medicare Part D costs

Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you could get help paying for any Medicare drug plan's monthly premium, yearly deductible, and prescription drug copayments or coinsurance. This Extra Help also counts toward your out-of-pocket costs.

To see if you qualify for getting Extra Help, call:

  • 1.800.MEDICARE (1.800.633.4227). TTY users, call 1.877.486.2048, 24 hours a day, 7 days a week.
  • The Social Security Office at 1.800.772.1213 between 7 a.m. and 7 p.m. Eastern, Monday through Friday. TTY users, call 1.800.325.0778.
If you qualify for Extra Help

If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium, deductible and drug costs may be lower. When you join Express Scripts Medicare, Medicare will tell us how much Extra Help you will get. Then we will let you know the amount you will pay. To see what your monthly premium would be if you qualify for Extra Help, please see the attached chart.

Best Available Evidence (BAE)

In some cases, you may not get the full amount of Extra Help you deserve because your income status information is out of date. Under the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy, if you show proof that you qualify for additional Extra Help, the plan sponsor must adjust the amount that you pay.

For more information on the BAE policy, please visit the CMS website at:
http://www.cms.gov/
Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovContra/
Best_Available_Evidence_Policy.html
.

If you qualify for both Medicare and Medicaid ("dual eligible")

You, your pharmacist, advocate, representative, a family member, or another person acting on your behalf may submit any one of the following items as proof that you are eligible for both Medicare and Medicaid:

  • A copy of your Medicaid card that includes your name and an eligibility date during any month after June of the previous calendar year
  • A copy of a state document that confirms your active Medicaid status during any month after June of the previous calendar year
  • A printout from your state's electronic enrollment file showing your Medicaid status during any month after June of the previous calendar year
  • A screen print from your state's Medicaid system showing your Medicaid status during any month after June of the previous calendar year
  • Other documentation provided by your state showing your Medicaid status during any month after June of the previous calendar year
  • A letter from the Social Security Administration (SSA) showing that you receive Supplemental Security Income (SSI)
  • An application filed by deemed eligible confirming that the beneficiary is "…automatically eligible for Extra Help…"
If you do not qualify for Medicaid (are not "dual eligible")

A copy of the award letter you received from the Social Security Administration (SSA) stating that you qualify for Extra Help may be submitted by you, your pharmacist, advocate, representative, a family member, or another person acting on your behalf.

If you are in a long-term care facility

You or your pharmacist may submit any one of the following items as proof that you qualify to pay $0 toward your drug benefit:

  • A remittance from the facility that shows Medicaid payment for a full calendar month during any month after June of the previous calendar year
  • A copy of a state document that confirms Medicaid payment to the facility on your behalf for a full calendar month after June of the previous calendar year
  • A screen print from the state's Medicaid systems showing your status at the facility based on at least a full calendar-month stay for Medicaid payment purposes during a month after June of the previous calendar year

Please fax documents to:
Express Scripts Medicare (PDP)
1.855.297.7271

If you have any questions, please call Customer Service toll free at the numbers on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week, except Thanksgiving and Christmas.

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Resources

For general information about Medicare programs, please refer to the following Centers for Medicare & Medicaid Services (CMS) and Social Security Administration resources:

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Need help?

Call 1.866.477.5703 TTY users: 1.800.716.3231
8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas

*Other pharmacies are available in our network.

Available from manufacturers that agreed to pay a 50% discount on the negotiated price, excluding the dispensing fee and any vaccine administration fee. The plan pays 15%.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.
Enrollment in Express Scripts Medicare depends on contract renewal.