Day 3 Chapter 4 - Prescription Drug Plans (Part D) Topics ... · Day 3 Chapter 4 - Prescription Drug Plans (Part D) Topics to Highlight Standard Plan Creditable Coverage Enrollment

Day 3 Chapter 4 - Prescription Drug Plans (Part D)

Topics to Highlight

□ Standard Plan

□ Creditable Coverage

□ Enrollment Periods

□ SHINE Pre-enrollment form

□ Extra Help

□ Prescription Advantage Handouts/Case Studies

□ Standard Medicare Part D Benefit

□ List of Mass. Stand-Alone PDPs □ Part D SEPs

□ Extra Help Chart and Fact Sheet & Extra Help Application

□ PA Rate Schedule Guide & PA Application (Not included)

□ SHINE (Part D) Pre-enrollment Form (Not included)

□ Case Study – Ann Apolis (Creditable coverage)

□ Case Study – Phil Harmonic (Pt. D drugs not covered)

□ Case Study – Stan Lee Steamer (Pt. D late enroll with creditable coverage)

□ Case Study – Mel O. Dee (PA & Pt. D)

□ Case Study – Manny Phestacion (Creditable coverage)

□ Medicare Part D Quiz

□ Case Study – Jean E. Ology (MA/Pt. D confusion)

□ Case Study – Bud Jet (Non-creditable coverage)

□ Case Study – Phil S Steen (PA & Pt. D)

□ Case Study – Will U. Help (Pt. D, PA, maybe LIS)

□ Medicare Drug Coverage under Part A, Part B, and Part D

□ How Medicare Covers Self-Administered Drugs at Outpatient Settings

□ How to Request a Coverage Determination, File an Appeal, of File a Complaint

□ Understanding Enrollment Periods

□ Preferred Pharmacies Chart □ Homework – Part D Question for Medicare & Read Chapter Five

2013 Standard Medicare Part D Benefit

52.5% PHARMACEUTICAL

DISCOUNT ON BRANDS (Counted toward Out of

Pocket Threshold)

100% ($325) DEDUCTIBLE $325

PLAN PAYS 75%

25%

COVERAGE PERIOD

47.5% FOR BRAND NAME

MEDICATIONS

COVERAGE GAP

CATASTROPHIC

INITIAL COVERAGE LIMIT DRUG COSTS = $2,970

OUT OF POCKET THRESHOLD $4,750

REACHED BY ADDING THE

AMOUNT THE MEMBER PAID

OUT OF POCKET AND THE

DISCOUNTED AMOUNT FOR

BRANDS

TOTAL DRUG COSTS = APPROXIMATELY $6,733

NO CAP Benefit restarts on

January 1st of each year.

79% FOR GENERIC MEDICATIONS

PLAN PAYS

21% FOR

GENERICS

DRUG PLAN AND MEDICARE PAY 95%

5%

2013 Standard Medicare Part D Benefit

Standard Coverage Levels

2013

Annual Deductible Beneficiary pays the first $325 of their drug costs before the plan starts to pay its share.

Initial Coverage Beneficiary pays 25% co-insurance; the plan pays 75% for each covered drug until the combined drug costs (plus the deductible) reach $2,970.

Coverage Gap Once the beneficiary and the plan have spent $2,970 for covered drugs, the coverage gap is reached. The beneficiary pays 47.5% of brand name drug costs and 79% of generic drug costs (plus a small dispensing fee) until they have spent $4,750* out of pocket. *In the gap, the full cost of brand name medications are counted towards the $4,750 out of pocket threshold

Catastrophic Coverage

If the beneficiary’s out-of-pocket costs reach $4,750 for the calendar year, they reach catastrophic coverage. For the rest of the calendar year the beneficiary will pay 5% coinsurance or $2.65 / $6.60 toward their medications, whichever is greater.

Organization Name Plan Name 2013

PremiumPremium Change

After Full LIS

Plan Deductible

Prescription Copays # 30 Day Supply - Retail

Prescription Copays # 90 Day Supply - Mail Gap coverage

Aetna Medicare 1-877-238-6211 Aetna CVS/pharmacy (S5810-036) $31.60 $5.60 $0* $325 2 / 5 / 45 / 38% / 25% 5 / 15 / 135 / 38% / 25%non-member 1-888-247-1028 Aetna Medicare Rx Premier(S5810-172) $109.60 $17.70 $78.20 $0 5 / 33 / 45 / 37% / 33% 5 / 99 / 135 / 37% / 33% many gen/some brandswww.aetnamedicare.com

Blue MedicareRx 1-888-543-4917 Blue Medicare Rx-Value Plus(S2893-001) $39.20 -$1.50 $7.80 $250** 6 / 12 / 45 / 95 / 26% 6 / 24 / 90 / 190non-member 1-866-832-9775 Blue Medicare Rx-Premier(S2893-003) $100.70 -$4.20 $69.30 $0 4 / 9 / 30 / 70 / 33% 4 / 18 / 60 / 140 many gen/few brandswww.rxmedicareplans.com

Cigna Medicare Rx 1-800-222-6700 CIGNA MedicareRx Plan 1 (S5617-008) $34.00 $3.40 $2.60 $325 0 / 8 / 35 / 85 / 25% 0 / 24 / 105 / 255 / 25%non-member 1-800-735-1459 CIGNA MedicareRx Plan 2 (S5617-172) $76.50 $8.70 $45.10 $0 0 / 10 / 45 / 90 / 33% 0 / 30 / 135 / 270 / 33% few genwww.cignamedicarerx.comEnvision Rx Plus 1-866-250-2005 EnvisionRxPlus Silver (S7694-002) $33.20 -$0.20 $1.80 $325 25%www.envisionrxplus.com EnvisionRxPlus Gold (S7694-073) $54.00 -$11.80 $22.60 $150 1% / 1% / 1% / 30% / 29% 1% / 1% / 1% / 30% some gen

Express Scripts Medicare 1-866-544-7086 Express Scripts Medicare Value (S5660-105) $47.80 $5.40 $16.40 $325 4 / 7 / 25% / 50% / 25% 12 / 21 / 25% 50%www.medcomedicare.com

First Health Part D 1-800-882-3822 First Health Part D Premier (S5768-038) $34.90 $4.80 $3.50 $325 1 / 25% / 42%

www.firsthealthpartd.com First Health Part D Value Plus (S5768-126) $31.00 $5.20 $18.70 $0 0 / 35 / 70 / 33%

First Health Part D Premier Plus (S5674-011) $92.40 $0.20 $61.00 $0 0 / 20 / 25% / 41 / 33% some gen/some brand

HealthMarkets Medicare 1-888-625-5531 Reader's Digest Value Rx (S0128-004) $33.60 n/a $2.20 $325 1 / 2.50 / 39 / 27% 3 / 7.50 / 111 / 27%www.hmic-medicare.comHealthSpring 1-800-331-6293 HealthSpring RX Drug Plan-Reg 2 (S5932-003) $37.70 $3.80 $6.30 $325 25% www.healthspring.comHumana 1-800-281-6918 Humana Walmart-Preferred Rx Plan (S5884-102) $18.50 $3.40 $0 $325 1 / 4 / 20% / 30% / 25% 0 / 0 / 20% / 30%non-member 1-800-706-0872 Humana Enhanced(S5884-002) $43.10 $4.20 $11.70 $0 2 / 5 / 44 / 90 / 33% 0 / 0 / 122 / 260www.humana-medicare.com Humana Complete(S5884-031) $114.00 $3.80 $82.60 $0 5 / 38 / 72 / 33% 0 / 104 / 206 some gen/some brand

SilverScript 1-866-235-5660 SilverScript Choice (S5601-111) $29.20 n/a $16.50 $0 0 / 34 / 35% / 33% 0 / 85 / 35% / 33%non-member 1-866-552-6106 SilverScript Basic (S5601-004) $30.50 -$0.20 $0 $325 2 / 22% / 43% / 25% 5 / 22% / 43% / 25%www.silverscript.com SilverScript Plus(S5601-005) $102.90 $17.70 $71.50 $0 0 / 34 / 35% / 33% 0 / 85 / 35% / 33% many gen/some brand

SmartD Rx 1-855-976-2781 SmartD Rx Saver (S0064-002) $32.40 n/a $0* $325 0 / 20 / 35 / 85 / 25%www.smartdrx.com SmartD Rx Plus (S0064-037) $69.00 n/a $37.60 $0 0 / 20 / 35 / 85 / 25% some gen

Unicare 1-800-928-6201 MedicareRx Rewards Standard (S5960-108) $52.50 $12.00 $21.10 $325 2 / 7 / 33 / 85 / 25% 3 / 10.50 / 82.50 / 212.50 / 25%non-member 1-866-552-6106www.medicarerxrewards.com

United American 1-866-524-4169 United American Select (S5755-074) $33.70 $1.80 $2.30 $325 1 / 4 / 40 / 95 / 25% 0 / 24 / 122 / 257 / 25%www.uamedicarepartd.com United American Enhanced(S5755-006) $51.20 $6.00 $19.80 $140** 1 / 7 / 40 / 95 / 29% 0 / 30 / 90 / 190 / 29%

UnitedHealthcare 1-888-867-5575 AARP MedicareRx Saver Plus (S5921-348) $15.00 n/a $0 $325 1 / 2 / 25 / 45 / 25% 0 / 2 / 60 / 120 / 25%non-member 1-888-867-5564 AARP MedicareRx Preferred(S5820-002) $37.70 $0.70 $6.30 $0 3 / 5 / 40 / 85 / 33% 0 / 5 / 105 / 240 / 33%www.partdcentral.com AARP MedicareRx Enhanced(S5921-183) $90.00 $4.70 $58.60 $0 2 / 5 / 40 / 76 / 33% 0 / 5 / 105 / 213 / 33% some gen/some brand

WellCare 1-888-550-5252 WellCare Classic(S5967-139) $30.80 -$2.90 $0 $0 6 / 44 / 94 / 33% 18 / 132 / 282non-member 1-888-293-5151 WellCare Extra (S5967-174) $39.00 n/a $24.40 $0 0 / 25% / 25% / 50% / 33% 0 / 25% / 25% / 50% many gen www.wellcarepdp.com

**Tier 1 medications not subject to plan deductible. Most plans have 5 tiers: preferred generic / non-preferred generic / preferred brand / non-preferred brand / specialty Late enrollment penalty based on 2013 National Base Premium of $31.17

2013 Massachusetts Stand Alone Medicare Drug PlansInformation as of 10/02/2012

Highlighted plans have a premium below 2013 benchmark of $31.35 or * the plan is participating in di-minimus (reducing the premium up to $2 for individuals with full LIS/Extra Help) Plan copayments listed above are for preferred pharmacies. Copayments may be higher at other network pharmacies. Contact plan for more details.

MetroWest SHINE Program Revised 2/2013

Situation Your SEP is …

You belong to Prescription Advantage (a state pharmacy assistance program) or within the last 2 months lost participation in such a program.

One chance/year to join or switch your plan

You are eligible for Part D, even if you do not have a PDP or MA-PD now(5-Star SEP: December 8 through November 30 of the following year).

One chance/year to join or switch to 5-Star plan

You recently moved outside of the service area for your current plan. 2 - 14 months based on notification to plan

Due to a move, you have new plan options, even if you did not already have a PDP or MA-PD (Medicare Advantage plan with prescription drug coverage).

Up to two months after move

You recently returned to the United States after living permanently outside of the U.S. or you were recently released from incarceration.

Up to 2 months AFTER you move (3 mos. if IEP)

You are moving out of a Long Term Care Facility. Up to 2 months AFTER you move out of facility

You just moved to or are currently living in a Long Term Care Facility (e.g. a nursing home). Continuous monthly SEP

You have both Medicare & Medicaid (MassHealth Standard, PCA, Frail Elder, CommonHealth) or a Medicare Savings Program (Buy-ins: QMB, SLMB, QI-1). Continuous monthly SEP

You are currently receiving "extra help" (LIS). Continuous monthly SEP

You are no longer eligible for "extra help" (LIS) during the calendar year. Up to 2 months AFTER you lose "extra help"

You are no longer eligible for "extra help" (LIS) at the end of the calendar year. January 1 - March 31 of following year

You recently involuntarily lost your creditable drug coverage. Up to 2 months AFTER you lose coverage

You are leaving coverage from your employer or union (including COBRA or Retiree coverage) SEP EGHP.

Up to 2 months AFTER you drop plan

In the last 12 months, you joined a MA-PD when you turned 65 (MA SEP 65). You may drop MA-PD and enroll in PDP

In the last 12 months, you left a Medigap policy to join a MA-PD for the first time.You may drop MA-PD and enroll in PDP

You have had Medicare prior to now, but are now turning 65. 7 month IEP around 65th birthday

You have disenrolled from your MA plan during the MA disenrollment period (Jan 1 - Feb 14) regardless of whether you had drug coverage.

You may enroll in a PDP Jan 1 - Feb 14

In addition to the Initial Enrollment Period (IEP) for Medicare (7 months around beneficiary's 65th birthday) and the Annual Enrollment Period (October 15 - December 7 each year), there are several "special enrollment periods" (SEPs) when you may elect or change your current plan. If any of the statements below match your current situation, you may be eligible to join or switch your drug plan at this time. Note: Unless it is a 'continuous' SEP, the SEP ends when your enrollment in a new plan becomes effective or when the SEP time frame ends, whichever comes first. Most SEPS apply to PDPs and MA-PDs, except as noted .

PDP/MA-PD SEPs

Appendix G

MetroWest SHINE Program Revised 2/2013

Situation Your SEP is …

Your plan is not renewed for the next contract year. October 15 through last day of February

Your plan terminates its contract with Medicare during the contract year. Up to 1 month after contract ends (2 mos.if CMS terminates plan)

You recently left a Programs of All-inclusive Care for the Elderly (PACE) program. Up to 2 months AFTER you drop plan

You are being disenrolled from a Medicare special needs plan because you no longer have special needs status.

Up to 3 months AFTER disenrollment

You are disenrolling from a Medicare Cost plan and had Medicare prescription drug coverage from the Medicare Cost plan.

You may enroll in a PDP up to 2 months after

You are in a Medicare Cost plan that is not renewing its contract and had Medicare prescription drug coverage from the Medicare Cost plan.

Nov 1 of contract year - Jan 31 of following year

You were recently disenrolled from a MA-PD due to loss of Part B, but you still have Part A.

You may enroll in a PDP up to 2 months after

You are using the MA Open Enrollment Period for Institutionalized Individuals (OEPI) to disenroll from a MA-PD.

Up to 2 months after MA-PD disenrollment

CMS has determined your plan has violated its contract or you disenrolled due to a CMS sanction. Determined by CMS

You were not adequately notified of your creditable drug coverage status. Up to 2 months after CMS approval

You were enrolled or not enrolled due to an error by a federal employee. Up to 2 months after CMS approval

You are a member of a low-performing plan. Contact 1-800-MEDICARE

You already had Part A and you enrolled in Part B during the the General Enrollment Period (January - March, effective July 1).

April 1 - June 30, effective July 1 (MA-PD only)

You do not qualify for premium-free Part A and you enrolled in Part B during the General Enrollment Period (January - March, effective July 1).

April 1 - June 30, effective July 1 (PDP only)

You have a PDP and are switching to a SNP (special needs plan). Anytime, if eligible for SNP

You are enrolling in a Chronic Care SNP (special needs plan), regardless of whether you already have a Part D plan. Anytime, if eligible for SNP

You are disenrolling from a PDP or MA-PD to enroll in or maintain other creditable coverage (such as VA or TriCare). Anytime

You have retroactively been enrolled in Medicare. Up to 3 months after month of notification

Other Determined by CMS

PDP/MA-PD SEPs (continued)

Appendix G

(over)

Getting Extra Help With Medicare Prescription Drug Plan CostsResource And Income Limits

Getting Extra Help With Medicare Prescription Drug Plan Costs

Resource And Income Limits 2012

Social Security and the Centers for Medicare & Medicaid Services are working together

to get you Extra Help with your Medicare prescription drug plan costs. If you have limited resources and income, you may qualify for Extra Help with the costs—monthly premiums, annual deductibles, and prescription co-payments—related to a Medicare prescription drug plan. The Extra Help is estimated to be worth about $4,000 per year. To find out if you qualify, Social Security will need to know the value of your savings, investments, real estate (other than your home), and your income. If you are married and living with your spouse, we will need information about both of you.

By filing an Application for Extra Help with Medicare Prescription Drug Plan Costs (Form SSA-1020), Social Security will determine if you are eligible for the Extra Help. Most of the questions on the application are about resources and income. Social Security will not ask for proof to support the information you provide, but will match your information with data available from other government agencies.

What is the resource limit?To qualify for Extra Help, your resources

must be limited to $13,070 for an individual or $26,120 for a married couple living together. Resources include the value of the things you own. Some examples are:• Real estate (other than your primary residence);• Bank accounts, including checking, savings,

and certificates of deposit;• Stocks;• Bonds, including U.S. Savings Bonds;• Mutual funds;• Individual Retirement Accounts (IRAs); or• Cash at home or anywhere else.

What does not count as a resource?Social Security will not count:

• Your primary residence;• Your personal possessions;• Your vehicle(s);

• Resources you could not easily convert to cash, such as jewelry or home furnishings;

• Property you need for self-support, such as rental property or land you use to grow produce for home consumption;

• Non-business property essential to your self-support;

• Life insurance policies;• Burial expenses;• Interest earned on money you plan to use for

burial expenses; and• Certain other money you are holding is not

counted for nine months, such as: —Retroactive Social Security or Supplemental Security Income (SSI) payments; —Housing assistance; —Tax advances and refunds related to earned income tax credits and child tax credits; —Compensation you receive as a crime victim; and —Relocation assistance from a State or local government.

You should contact Social Security for other resource exclusions.

What is the income limit?To qualify for Extra Help, your annual

income must be limited to $16,755 for an individual or $22,695 for a married couple living together. Even if your annual income is higher, you still may be able to get some help. Some examples where your income may be higher include if you or your spouse: • Support other family members who live

with you;• Have earnings from work; or• Live in Alaska or Hawaii.

https://secure.ssa.gov/i1020/start




What does not count as income?Not all cash payments count as income. For

example, Social Security will not count:• Food stamp assistance;• Housing assistance;• Home energy assistance;• Medical treatment and drugs;• Disaster assistance;• Earned income tax credit payments;• Assistance from others to pay your

household expenses;• Victim’s compensation payments; and• Scholarships and education grants.

You should contact Social Security for other income exclusions.

How do I apply?It is easy to apply for Extra Help. Just

complete Social Security’s Application for Extra Help with Medicare Prescription Drug Plan Costs (Form SSA-1020). Here’s how:• Apply online at

www.socialsecurity.gov/extrahelp;• Call Social Security at 1-800-772-1213

(TTY 1-800-325-0778) to apply over the phone or to request an application; or

• Apply at your local Social Security office.

Can State agencies help with my Medicare costs?

When you file your application for Extra Help, you also can start your application process for the Medicare Savings Programs—State programs that provide help with other Medicare costs. Social Security will send information to your State unless you tell us not to on the Extra Help application. Your State will contact you to help you apply for a Medicare Savings Program.

These Medicare Savings Programs help people with limited resources and income pay for their Medicare expenses. The Medicare Savings Programs help pay for your Medicare Part B (medical insurance) premiums. For some people, the Medicare Savings Programs also may pay for Medicare Part A (hospital insurance) premiums, if any, and Part A and B deductibles and co-payments.

Printed on recycled paper

How can I get more information?For more information about getting Extra

Help with your Medicare prescription drug plan costs, visit www.socialsecurity.gov/extrahelp or call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Social Security representatives are available to help you complete your application. The sooner you apply the sooner you will begin receiving benefits.

If you need information about Medicare Savings Programs, Medicare prescription drug plans, how to enroll in a plan, or to request a copy of the Medicare & You handbook, please visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Your State Health Insurance Counseling and Assistance Program (SHIP) also can help answer Medicare questions. You can find your local SHIP contact information in the back of your Medicare handbook, online at www.medicare.gov under “Help & Support,” or you can request it when you call.

Social Security AdministrationSSA Publication No. 05-10115ICN 468740Unit of Issue - HD (one hundred)March 2012 (Recycle prior editions)

http://www.socialsecurity.gov/extrahelp

http://www.medicare.gov/default.aspx

http://www.medicare.gov/default.aspx




http://www.socialsecurity.gov/extrahelp

http://www.medicare.gov/publications/pubs/pdf/10050.pdf

Updated 2/2013

Limited/Low Income Subsidy – 2013 Extra Help with Medicare Prescription Drug Plan

Income/Asset Eligibility & Benefit

*Amount includes applicable $20 monthly disregard for unearned income.

Individuals with Extra Help may also apply and receive Prescription Advantage Benefits

Level of Extra Help

Benefits Monthly Income Limit Annual Income Limit Asset Limit

Full Extra Help 135% FPL

Premium below benchmark paid No deductible

copayments $2.65 - $6.60

If income below 100% FPL, copayments $1.15-$3.50

*$1,313 (individual) *$1,723 (couple)


$8,580 (individual) $13,620 (couple)

Partial Extra Help

150% FPL

25-75% subsidy in premium below benchmark

$66 deductible

Coinsurance of 15%

*$1,456(individual) *$1,959 (couple)


$13,300(individual) $26,580 (couple)

Understanding How Prescription Advantage and Extra Help Lower Prescription Costs

Smart D Rx Plan 2013

No Help

With Prescription Advantage

S3 or S4

With Prescription

Advantage S2

With Partial

Extra Help

With Partial Extra Help &

Prescription Advantage

S1

With Full Extra Help

With Full Extra Help & Prescription Advantage

S0

Premium $32.40 $32.40 $32.40 Reduced Reduced $0 $0

Deductible $325 $325 $325 $66

Generics: $7 Brands: $18

Until $66 deductible reached

$0 $0

Initial Coverage Period

Preferred Generics $0 $0 $0 Whichever is less:plan copay or 15%

Whichever is less:plan copay, 15% or $7

$2.65 $2.65

Non- Preferred Generics $20 $20 $20 Whichever is less:

plan copay or 15%


$2.65 $2.65

Preferred Brands $35 $35 $35 Whichever is less:plan copay or 15%


$6.60 $6.60

Non-preferred Brands $85 $85 $85 Whichever is less:plan copay or 15%


$6.60 $6.60

Coverage Gap

Generics 79% $12 $7 15% Whichever is less:15% or $7 $2.65 $2.65

Brands 47.5% $30 $18 15% Whichever is less:15% or $18 $6.60 $6.60

2013 – Day 3 1

Case Study - Ann Apolis

Ann meets with you at the SHINE office. She is very distraught about the Medicare Part D program. She currently has Medicare A & B and a retiree Medicare supplement plan through her former employer. She is very happy with her retiree plan. It provides coverage for all the deductibles and copays under Medicare and also provides unlimited drug coverage with $5-$15 co-pays for a 90-day supply of her medications. Her monthly premium for the retiree plan is $145.00. Her friend told her that she should have joined the Medicare Part D program during the initial open enrollment. The friend also told her she will face a penalty if the retiree plan should stop providing coverage and she wants to join Part D in the future. How would you help her?

2013 – Day 3 2

Case Study - Phil Harmonic

Phil calls you with questions about his Medicare Part D program. He tells you he enrolled in a Medicare Part D program because he takes several medications a few of which are expensive. He chose a plan with a low premium and was quite satisfied with it. However, he recently went to fill his prescriptions and was told he would have to pay 47.5% for three of his medications. He thought he was covered during the gap but learned that his plan only covers generics during the gap. Phil is very upset and wants to change plans. He tells you that he is single and has a monthly income of $1,590. Phil has Medicare A & B and a Medicare Supplement 1 plan. How would you help him?

2013 – Day 3 3

Case Study— Stan Lee Steamer Mr. Steamer meets with you at the SHINE office. He has been on Medicare A & B for the past 10 years and has been covered under his supplemental retiree plan. He just received notice that his retiree plan will no longer be providing prescription coverage. He tells you he takes 7 expensive medications and needs prescription coverage. His friend told him he will have to wait for open enrollment and pay a penalty of 10%. How would you help him?

2013 – Day 3 4

Case Study - Mel O. Dee

Mel calls you to get information about the Medicare drug program. He is assisting his mother who has finally decided to retire at age 72. His mother has already visited her local Social Security office and signed up for Medicare B. (She signed up for A when she turned 65.) He understands that she also needs to sign up for a Part D plan. Mel tells you that his mother takes minimal medication and he thinks her drug costs are not more than a few hundred dollars a year. Mel has heard that the Part D plans are expensive and don’t cover many medications. He has no idea how to go about helping her to choose a plan or whether she really needs one. He is concerned about the costs for Part D along with any other insurance or health care costs since her only income will be Social Security of $15,000/year. She owns her own home and has about $15,000 in assets and a $10,000 life insurance policy. She hopes she doesn’t have to spend that down on health care/insurance costs. How would you help him?

2013 – Day 3 5

Case Study — Manny Phestacion Manny meets with you at the SHINE office. He is 66 years old and still working full-time. Manny is covered by his group health plan. He enrolled in Medicare Part A when he turned 65. Manny understands that he does not need to enroll in Medicare Part B or a Medicare Prescription Drug Plan (Part D) until he stops working. He thinks he can enroll when he retires and will not have to pay a late penalty. Is he correct?

2013 – Day 3 6

Medicare Part D Quiz 1. Late enrollees in Part D will face a penalty of:

a) 10% per year c) 1% per month b) 5% per year d) l0% per month

2. To meet the out-of-pocket requirement for catastrophic coverage Part D enrollees can (select all that are correct):

a) Pay for their drugs themselves c) Buy drugs from Canada b) Use Prescription Advantage d) Get family members to help

3. Define “creditable coverage” as it pertains to the Medicare Prescription Drug Program. 4. Why is it important that a beneficiary know if she/he has creditable coverage? 5. What does the Limited/Low Income Subsidy (LIS) help pay for? 6. Who is eligible to receive it? 7. Who must apply and who is “deemed eligible”? 8. Minnie Sota meets with you at the SHINE office. She read about Part D and is not sure if she needs it. She will be retiring and will have a retiree plan from her employer with prescription coverage. How would you assist Minnie with her decision? 9. Pat E. Cake meets with you on November 20. She says she belongs to a Medicare Advantage plan. She tells you the prescription drug plan with her MA costs more than she wants to pay, so she has decided to take the Part D plan offered by the agent she met at CVS. How would you assist her?

2013 – Day 3 7

Case Study Jean E. Ology

Jean comes to see you at the SHINE office after previously reviewing her options with you over the phone. She is retiring in 2 months and wants to get your assurance that the options she chose will work. Jean takes 3 medications — two are generic and relatively inexpensive and one is an expensive brand. After hearing about the Part D program, she has decided to go with a Medicare Advantage (Medicare HMO) plan and join a Medicare Prescription Drug Plan (Part D) that provides coverage for generics during the gap (donut hole). How would you help her?

2013 – Day 3 8

Case Study - Bud Jet Bud meets with you at the SHINE office. Bud just retired last month. He has Medicare A & B and a retiree Medicare supplement plan from his former employer. He received a notice from his former employer that his drug plan coverage is not as good as the Medicare Part D drug coverage. His understanding is that he can stay with his employer plan or join Medicare Part D. After comparing the cost of his retiree plan with the Medicare Part D plan, he decided to stay with his employer plan as it fully meets his prescription needs and is less expensive. How would you help him?

2013 – Day 3 9

Case Study - Phil S. Steen

Phil meets with you at the SHINE office. He tells you he has Blue Cross/Blue Shield Supplement 1. He is also a member of Prescription Advantage. He has a Part D plan which had been working fine. However, his doctor just gave him a new medication that he discovered is not on the formulary of his plan. It’s an expensive medication, and he can’t afford to continue filling it. How would you help him?

2013 – Day 3 10

Case Study — Will U. Help

Mr. Help calls you at the SHINE office. He will be eligible for Medicare in 2 months and has already visited his local Social Security office to sign up for Medicare. The woman he met with at SS told him about Medicare A and B and also told him he must sign up for a Medicare Prescription Drug plan. He explained to her that he is a veteran and gets his prescriptions through the VA. She said that didn’t matter. He still needs to sign up or face a penalty. He tells you his income is a Social Security check for $1100/month and a pension of $200/month. He thought Medicare A+B and the VA would be all that he would need. He is worried about the Part D penalty and wants to know if you can help him figure out what Part D plan to join. How would you help Mr. Help?

2013 – Day 3 11

Homework: Question for Medicare

I will be 65 in November 2013. I plan to continue working until age 67 (2015) and will be covered by my employer health insurance. I will enroll in Medicare A when I turn 65 but won’t pick up B & D until I retire. I know that I have 8 months from termination of coverage under my active employment to pick up Part B. Is this also true for D? I will not face a penalty for not joining Part D as long as I’m covered under my employer plan while still actively working. Is that correct?

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Information Partners Can Use on:

Medicare Drug Coverage under Medicare Part A, Part B, and Part D

Revised May 2012

This tip sheet provides an overview of drug coverage under Medicare Part A (Hospital Insurance),Medicare Part B (Medical Insurance), and Medicare Part D (Medicare prescription drug coverage).

Does Medicare cover drugs under Part A?Generally, Part A doesn’t pay for outpatient prescription drugs. However, people with Medicaremay get drugs as part of their inpatient treatment during a covered stay in a hospital or skillednursing facility (SNF). Part A payments made to the hospital or SNF generally cover all drugsprovided during a covered stay.

Note: Some hospital services are provided in an outpatient setting, like an emergency department orhospital observation unit. See page 3 for information about Medicare drug coverage in these settings.

Does Medicare cover drugs under Part B?Yes, but Part B only covers limited types of drugs. Generally, Part B covers drugs that usually aren’tself administered and are given as part of a doctor’s service. Coverage usually is limited to drugs that aregiven by infusion or injection. If the injection usually is self administered or isn’t given as part of adoctor’s service, Part B generally won’t cover it.

In most cases, these drugs are subject to the yearly Part B deductible. This means that people withMedicare may have to pay the Part B deductible amount before Medicare pays its share.

Part B also covers:

• Shots (vaccinations):

– Flu shot: In general, 1 flu shot per flu season. Flu shots are usually given before the start of the flu season, in the late summer, fall, or winter, but some people may get the shot in the spring. This means people with Medicare can sometimes get this preventive shot twice in the same calendar year.

– Pneumococcal shot: A shot to help prevent pneumococcal infections (like certain types of pneumonia). Most people only need this shot once in their lifetime.

– Hepatitis B shots: A series of 3 shots covered only for people at high or medium risk for Hepatitis B. A person’s risk for Hepatitis B increases if the person has hemophilia, End-Stage Renal Disease (ESRD—permanent kidney failure requiring dialysis or a kidney transplant), or certain conditions that increase the person’s risk for infection. Other factors may also increase a person’s risk for Hepatitis B. To determine if he or she is eligible for coverage, a person with Medicare should check with his or her doctor to see if he or she is at high or medium risk for Hepatitis B.

– Other shots: Some other vaccines when they’re directly related to the treatment of an injury or illness (like a tetanus shot after stepping on a nail).

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Does Medicare cover drugs under Part B? (continued)• Durable Medical Equipment (DME) supply drugs: Some drugs used with DME, like

infusion pumps and nebulizers, if considered reasonable and necessary.

• Injectable drugs: Most injectable drugs given by a licensed medical provider if the drug isconsidered reasonable and necessary for treatment and usually isn’t self-administered.

• Osteoporosis drugs: An injectable drug for women with osteoporosis who meet the criteriafor the Medicare home health benefit and have a bone fracture that a doctor certifies wasrelated to post-menopausal osteoporosis. A doctor must certify that the woman is unable tolearn how to or unable to give herself the drug by injection. The home health nurse or aidewon’t be covered to provide the injection unless family and/or caregivers are unable orunwilling to give the woman the drug by injection.

• Some antigens: If they’re prepared by a doctor and given by a properly-instructed person(who could be the patient) under doctor supervision.

• Erythropoiesis-stimulating agents: For people undergoing dialysis and, if given as part of adoctor’s service, for certain other conditions.

• Blood Clotting factors: For people with hemophilia who give themselves the drug byinjection.

• Immunosuppressive drugs: Drug therapy for transplant patients if the transplant meetsMedicare coverage requirements, the patient has Part A at the time of the transplant, andthe patient has Part B at the time the drugs are dispensed.

• Oral anti-cancer drugs: Some oral anti-cancer drugs if the same drug is available ininjectable form for the same use and covered under Part B. As new oral anti-cancer drugsbecome available, Part B may cover them.

• Oral anti-nausea drugs: Used as part of an anti-cancer chemotherapeutic regimen. The drugs must be administered immediately before, at, or within 48 hours after theadministration of the chemotherapy drug and must be used as a full therapeuticreplacement for the intravenous anti-nausea drugs that would otherwise be given.

• Oral End-Stage Renal Disease (ESRD) drugs: Some oral ESRD drugs if the same drugis available in injectable form and covered under the Part B ESRD benefit.

• Parenteral and enteral nutrition (intravenous and tube feeding): Certain nutrients forpeople who can’t absorb nutrition through their intestinal tracts or can’t take food bymouth.

• Intravenous Immune Globulin (IVIG) provided in the home: For people with adiagnosis of primary immune deficiency disease. A doctor must decide that it’s medicallyappropriate for the IVIG to be given in the patient’s home. Part B covers the IVIG itself,but Part B doesn’t pay for other items and services related to the patient getting theIVIG in his or her home.

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Does Part B cover self-administered drugs given in anoutpatient setting, like an emergency department orhospital observation unit?Generally, Part B doesn’t cover self-administered drugs a person gets in outpatient settings. A person’s Medicare drug plan (Part D) may cover these drugs under certain circumstances. A person might need to pay out-of-pocket for these drugs and submit a claim to his or her Part D plan for a refund. He or she should call the plan for more information.

For more information, visit www.medicare.gov/publications to view the fact sheet, “HowMedicare Covers Self Administered Drugs Given in Hospital Outpatient Settings (CMS ProductNo. 11333).” You can also call 1-800-MEDICARE (1-800-633-4227) to find out if a copy canbe mailed to you. TTY users should call 1-877-486-2048.

Which drugs does Part D cover?Medicare offers comprehensive prescription drug coverage to people with Medicare underPart D. In general, a Part D-covered drug must meet all of these conditions:

• The drug is available only by prescription

• The drug is approved by the Food and Drug Administration (FDA)

• The drug is used and sold in the U.S.

• The drug is used for a medically-accepted indication, as defined under the Social Security Act

• The drug isn’t covered under Part A or Part B

• The drug is covered by the person’s Part D plan or coverage is obtained through the exceptionsor appeals process

Does Part D cover shots (vaccinations)?Yes. All Medicare drug plans must include all commercially available vaccines (like theshingles vaccine) on their drug formularies (except vaccines that are covered under Part B,like the flu or pneumococcal shot). The plan member or provider can contact the Medicaredrug plan for more information about coverage.

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http://www.medicare.gov/publications

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Are there certain drugs that Part D doesn’t cover?Yes. By law, Part D can’t pay for drugs when they would be covered under Part A or Part B. In addition, the following drugs can’t be included in basic Part D coverage:

• Benzodiazepines• Barbiturates• Drugs for weight loss or gain• Drugs when used for treatment of sexual or erectile dysfunction, unless such agents are used

to treat a condition, other than sexual or erectile dysfunction, for which the agents have beenapproved by the FDA

• Drugs for relief of cough and colds• Non-prescription drugs• Drugs used for cosmetic purposes or hair growth• Drugs used to promote fertility• Prescription vitamins and minerals, except prenatal vitamins and fluoride preparation products

Some Medicare drug plans may choose to cover these drugs as part of the plan’s supplementalbenefits. However, any amount spent for these drugs isn’t counted toward the person’s share ofthe costs, like the deductible or out-of-pocket limit.

Can people appeal a drug coverage decision?Yes. People with Medicare have certain guaranteed rights. One of these is the right to a fairprocess to appeal decisions about coverage or payment of health care services. How people filean appeal will depend on the type of Medicare plan they have. People with Medicare shouldreview their coverage decision notices carefully for instructions on how to file an appeal.

Where can people get more information or help?• Visit www.medicare.gov.

– Look for more information on appeals in the “Help & Support” section. Select “Filing a Complaint or Grievance.”

– Look for more information on Medicare drug coverage by selecting “Health & Drug Plans.”

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

• Contact your State Health Insurance Assistance Program (SHIP) to get free personalizedhealth insurance counseling. To get the phone number, visit www.medicare.gov/contacts, orcall 1-800-MEDICARE.

CMS Product No. 11315-P4

http://www.medicare.gov

http://www.medicare.gov/contacts

How Medicare Covers Self-AdministeredDrugs Given in Hospital Outpatient SettingsMedicare Part B (Medical Insurance) generally covers care you get in a hospitaloutpatient setting, like an emergency department, observation unit, surgery center,or pain clinic. Part B only covers certain drugs in these settings, like drugs giventhrough an IV (intravenous infusion).

Sometimes people with Medicare need “self-administered drugs” while in hospitaloutpatient settings. “Self-administered drugs” are drugs you would normally takeon your own. Part B generally doesn’t pay for self-administered drugs unless theyare required for the hospital outpatient services you’re getting.

If you get self-administered drugs that aren’t covered by Medicare Part B while in ahospital outpatient setting, the hospital may bill you for the drug. However, if youare enrolled in a Medicare drug plan (Part D), these drugs may be covered.

What you should know about Medicare drug plans(Part D) and self-administered drugs • Generally, your Medicare drug plan only covers prescription drugs and won’t pay

for over-the-counter drugs, like Tylenol® or Milk-of-Magnesia®.

• Any drug you get needs to be on your Medicare drug plan’s formulary (orcovered by an exception).

• You can’t get your self-administered drugs in an outpatient or emergencydepartment setting on a regular basis.

• Your Medicare drug plan will check to see if you could have gotten these self-administered drugs from an in-network pharmacy.

• Since most hospital pharmacies don’t participate in Medicare Part D, you mayneed to pay up front and out-of-pocket for these drugs and submit the claim toyour Medicare drug plan for a refund. Check with your hospital to see if theyparticipate in Part D.

If possible, bring any drugs (or a list of drugs you are taking) with you to thehospital and show them to the staff. It helps the hospital staff to know what drugsyou take at home.

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CENTERS FOR MEDICARE & MEDICAID SERVICES

Here are some common questions and answers about how Medicare drugplans (Part D) cover self-administered drugs.

What should I do if I get a bill for self-administereddrugs that aren’t covered by Part B in a hospitaloutpatient setting?• Follow the instructions in your Medicare drug plan’s enrollment materials on

how to submit an out-of-network claim, or call your plan for information abouthow to submit a claim.

• Your plan will ask you to send certain information, like the emergency room billthat shows what self-administered drugs you were given. You may also need toexplain the reason for your hospital visit. Keep copies of any receipts and anypaperwork you send your plan.

What will my Medicare drug plan do?• Your Medicare drug plan will check to see if the drug is on your Medicare drug

plan’s formulary; otherwise, you may need to file an exception.

• Your plan may ask you if you could have reasonably gotten any of the drugs froma participating network pharmacy. For example, if you could have taken a dose ofa drug that you got from your network pharmacy before your outpatient hospitalappointment, your Medicare drug plan may not pay you back for that drug.

• If the drug is covered by your Medicare drug plan, your plan may only reimburseyou the in-network cost for the drug minus any deductibles, copayments, orcoinsurance that you would normally be charged for the drug.

What will I have to pay for self-administered drugs thataren’t covered by Part B?• If the drug is covered by your Medicare drug plan, you may need to pay the

difference between what the hospital charged and what the plan paid in addition toany deductibles, copayments, or coinsurance you would normally pay. This amountcounts towards your Part D out-of-pocket costs. You must submit the claim to yourplan for it to count towards your out-of-pocket costs.

• If the drug isn’t covered by your Medicare drug plan, you need to pay what thehospital charges for the drug. As mentioned above, you can always request anexception if your plan tells you a drug isn’t on their formulary.

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Where can I get more help?• Call your State Health Insurance Assistance Program (SHIP). Every state and

territory, plus Puerto Rico, the Virgin Islands and the District of Columbia, has a SHIP with counselors who can give you free health insurance informationand help. To get the telephone number for your SHIP, visitwww.medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

• For information on how to appeal any decision made by your Medicare drugplan, check your plan’s enrollment materials or call your plan.

• Call 1-800-MEDICARE.

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http://www.medicare.gov/contacts

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CMS Product No. 11333Revised February 2011

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5Section 5: How do I Appeal if I have Medicare Prescription Drug Coverage?

If you have Medicare prescription drug coverage through a Medicare Prescription Drug Plan, a Medicare Advantage Plan with prescription drug coverage (MA-PD), or other Medicare plan, your plan will send you information that explains your rights (called an “Evidence of Coverage”). Call your plan if you have questions about your “Evidence of Coverage.”

You have the right to request an appeal to resolve differences with your plan. You have the right to ask your plan to provide or pay for a drug you think should be covered, provided, or continued.

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

What if my plan won’t cover a drug I think I need? If your pharmacist tells you that your Medicare drug 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 the following options:

1 . Talk to your prescriber .

Ask your prescriber if you meet prior authorization or step therapy requirements. For more information on these requirements, visit www.medicare.gov/Publications to view or print the fact sheet “How Medicare Prescription Drug Plans and Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) Use Pharmacies, Formularies, and Common Coverage Rules,” or call 1-800-MEDICARE (1-800-633-4227) and ask for a free copy. TTY users should call 1-877-486-2048. 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.

Words in red are defined on pages 51–54.

www.medicare.gov/Publications

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5 How do I Appeal if I have Medicare Prescription Drug Coverage?

2 . 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 you need. You can request a coverage determination if your pharmacist or plan tells you one of the following: — A drug you believe should be covered isn’t covered. — A drug is covered at a higher cost than you think you should

have to pay. — You have to meet a plan coverage rule (such as 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 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, such as 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 the plan’s non-preferred drug tier because the other treatment options in your plan’s preferred drug tier 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 the supporting statement is required and if it must be made in writing. The plan’s decision-making time period begins once your plan gets the supporting statement.


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5How do I Appeal if I have Medicare Prescription Drug Coverage?

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

You can either file a standard request or a fast request for the coverage determination. See timeframes below.

How do I file a standard coverage determination? You, your representative, your doctor, or other prescriber can request a coverage determination (including an exception) by following the instructions that your plan sends you. Once your plan has gotten your request, it has 72 hours to notify you its decision.

You can call your plan, write them a letter, or send them a completed “Model Coverage Determination Request” form to ask your plan for a coverage determination or exception. This form is available at www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp, or call your plan and ask for a copy. Your plan must accept any written request for a coverage determination from you, your doctor, or your other prescriber.

How do I file a fast coverage determination? You, your representative, your doctor, or other prescriber can call or write your plan to request that a fast decision be made within 24 hours of your request. You will get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that your life or health may be at risk waiting 72 hours for a decision. You won’t get a fast decision if you’ve already paid for and gotten the drug.

You can call your plan, write them a letter, or send them a completed “Model Coverage Determination Request” form to ask your plan for a fast coverage determination or exception. This form is available at www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp, or call your plan and ask for a copy.

www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp


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What if I disagree with the decision? Your Medicare drug plan will send you a written decision. If you disagree with this decision, you have the right to appeal.

What is the appeals process? The appeals process has five 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 will be given instructions on how to move to the next level of appeal.

Level 1: Redetermination from your plan

If you disagree with your plan’s initial denial, you can request a redetermination.

You must request the redetermination within 60 days from the date of the coverage determination.

How do I request a redetermination? Follow the directions in the plan’s initial denial notice and plan materials to do this. You, your representative, your doctor, or other prescriber can request a standard or fast redetermination. Standard requests must be made in writing, unless your plan allows you to file a standard request by phone. You will get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that your life or health may be at risk by waiting for a standard decision.

Your plan must accept any written request for a redetermination from you, your representative, your doctor, or other prescriber. A written request to appeal should include the following: ■ Your name, address, and the Medicare claim number (your Medicare number) shown on your Medicare card.

■ The name of the drug you want your plan to cover. ■ Reason(s) why you’re appealing. ■ Your signature. If you’ve appointed a representative, include the name and signature of your representative. For more information on appointing a representative, see Section 2.

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Send your request along with any other information that may help your case, including medical records. Your plan’s address and phone number is in your plan materials and will also be in any written plan decision you get.

Your plan will respond in a “Redetermination Notice” within the timeframes below: ■ Standard redetermination decision—7 days ■ Fast redetermination decision—72 hours

If you disagree with the plan’s redetermination decision in level 1, you have 60 days from the date of the decision to request a reconsideration by an Independent Review Entity (IRE).

Level 2: Reconsideration by an Independent Review Entity (IRE)

If your Medicare drug plan decides against you in level 1, it will send you a written decision. If you disagree with the plan’s redetermination, you can request a standard or fast reconsideration by an IRE.

How do I request a reconsideration? To request a reconsideration by an IRE, follow the directions in the plan’s “Redetermination Notice.” If your plan issues an unfavorable redetermination, it should also send you a “Request for Reconsideration” form that you can use to ask for a reconsideration. If you don’t get this form, call your plan and ask for a copy. This form is also available at www.cms.gov/MedPrescriptDrugApplGriev/13_Forms.asp.

Important: If you want your doctor, other prescriber, or another person to request a reconsideration from the IRE for you, you will need to submit an “Appointment of Representative” form or other documentation to show that the person has the authority to act on your behalf. For more information on appointing a representative, see Section 2.


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Send your request to the IRE at the address or fax number listed in the plan’s redetermination decision letter that’s mailed to you. You will get a fast reconsideration decision if the IRE determines, or your prescriber tells the IRE, that your life or health may be at risk by waiting for a standard decision.

Once the IRE gets the request for review, it will send you its decision in a “Reconsideration Notice” within the timeframes below: ■ Standard reconsideration decision—7 days ■ Fast reconsideration decision—72 hours

If you disagree with the IRE’s decision in level 2, you have 60 days from the date of the IRE’s decision to request an Administrative Law Judge (ALJ) hearing.

Level 3: Hearing before an Administrative Law Judge (ALJ)

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-tele-conference, or in some cases, in person. You can also ask the ALJ to make a decision without a hearing.

At the ALJ hearing, you will have the chance to explain why your Medicare drug plan should cover your drug or pay you back. You can also ask your doctor or other prescriber to join the hearing and explain why he or she believes the drug should be covered.

To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2011, the required amount is $130. The “Reconsideration Notice” will include a statement that tells you if your case meets this minimum dollar amount. However, it’s up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.

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How do I request a hearing? Follow the directions on the IRE’s reconsideration notice to request a hearing before an ALJ. Your request must be sent to the appropriate Office of Medicare Hearings and Appeals (OMHA) field office. The address of the appropriate field office is listed in the reconsideration notice. You or your representative can file a request in one of the following ways: 1. Fill out a “Request for Hearing by an Administrative Law

Judge” form (CMS Form Number 20034 A/B) available at www.cms.gov/cmsforms/downloads/cms20034ab.pdf, or call 1-800-MEDICARE and ask for a free copy.

2. Submit a letter to the OMHA office that will handle your ALJ hearing. Your letter must include the following: — Your name, address, phone number, Medicare number,

and the name of your Medicare Prescription Drug Plan. If you’ve appointed a representative, include the name and address of your representative.

— The appeal case number included on the reconsideration notice.

— The prescription drug in dispute. See your redetermination or reconsideration notice for this information.

— An explanation of why you disagree with the reconsideration decision.

— Any other information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you will submit it.

— If you’re requesting a fast decision, include a statement that indicates this.

3. If you’re requesting a fast hearing, you can make an oral request. Follow the instructions in the IRE’s decision notice to do this. The ALJ will give you a fast decision if your doctor or other prescriber indicates, or the ALJ determines, that your life or health may be at risk waiting 90 days for a decision. You won’t get a fast decision if you already got the drug.


www.cms.gov/cmsforms/downloads/cms20034ab.pdf

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Once the ALJ gets the request for review, you will get a decision within the timeframes below: ■ Standard ALJ decision—90 days ■ Fast ALJ decision—10 days

To learn more about the ALJ hearing process, visit www.hhs.gov/omha and select “Coverage and Claims Appeals.” If you need help filing an appeal with an ALJ, call 1-800-MEDICARE.

If you disagree with the ALJ’s decision in level 3, you have 60 days after you get the ALJ’s decision to request a review by the Medicare Appeals Council (MAC).

Level 4: Review by the Medicare Appeals Council (MAC)

You can request that the MAC review your case. You can request a review for a claim of any amount of money.

How do I request a review? To request that the MAC review the ALJ’s decision in your case, follow the directions in the ALJ’s hearing decision you got in level 3. Your request must be sent to the MAC at the address listed in the ALJ’s hearing decision. You or your representative can file a request for MAC review in one of the following ways: 1. Fill out a “Request for Review of an Administrative Law

Judge (ALJ) Medicare Decision/Dismissal” form (DAB-101) available at www.hhs.gov/dab/divisions/dab101.pdf, or call 1-800-MEDICARE and ask for a free copy.

2. Submit a letter to the MAC that includes the following: — Your name, address, phone number, Medicare number, and

the name of your Medicare Prescription Drug Plan. If you’ve appointed a representative, include the name and address of your representative.

— The prescription drug in dispute. See your IRE reconsideration notice or your ALJ hearing decision for this information.


www.hhs.gov/omha

www.hhs.gov/dab/divisions/dab101.pdf

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— A statement identifying the parts of ALJ’s decision with which you disagree and an explanation of why you disagree.

— The ALJ appeal case number. — If you’re requesting a fast decision, include a statement

that indicates this.— Your signature. If you’ve appointed a representative,

include the signature of your representative. 3. If you’re requesting a fast review, you can make an oral

request. Follow the instructions in the ALJ’s decision notice to do this. The MAC will give you a fast decision if your doctor or other prescriber indicates, or the MAC determines, that your life or health may be at risk waiting 90 days for a decision. You won’t get a fast decision if you already got the drug.

Once the MAC gets the request for review, you will get a decision within the timeframes below: ■ Standard MAC decision—90 days ■ Fast MAC decision—10 days

To learn more about the MAC review process, visit www.hhs.gov/dab and select “Medicare Appeals Council.” If you need help filing a request for MAC review, call 1-800-MEDICARE.

If you disagree with the MAC’s decision in level 4, you have 60 days after you get the MAC’s decision to request judicial review by a Federal district court.

www.hhs.gov/dab

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Level 5: Judicial review by a Federal district court

If you disagree with the decision issued by the MAC, you can request judicial review in Federal district court. To get a review, the amount of your case must meet a minimum dollar amount. For 2011, the minimum dollar amount is $1,300. You may be able to combine claims to meet this dollar amount.

How do I request a review? Follow the directions in the MAC’s decision letter to file you got in level 4 in order to a complaint in Federal district court. You should check with the clerk’s office of the Federal district court for instructions about how to file the appeal. The court location will be listed in the MAC’s decision notice.

For more information on the appeals process: ■ Visit www.medicare.gov/appeals. ■ Call 1-800-MEDICARE. ■ Call your State Health Insurance Assistance Program (SHIP) for free personalized health insurance counseling. To get the phone number for the SHIP in your state, visit www.medicare.gov/contacts or call 1-800-MEDICARE.

How do I file a grievance or complaint? 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”). You must file your complaint within 60 days of the date of the event that led to the issue.

Some examples of why you might file a complaint include the following: ■ You believe your plan’s customer service hours of operation should be different.

■ You have to wait too long for your prescription. ■ The company offering your plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan.

www.medicare.gov/appeals

www.medicare.gov/contacts

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■ The plan didn’t make a timely decision about a coverage determination in level 1 and didn’t send your case to the IRE.

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

■ The plan didn’t provide the required notices. ■ The plan’s notices don’t follow Medicare rules.

If you want to file a complaint, you should know the following: ■ 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 decision generally no later than 30 days after the plan gets the complaint.

■ If the complaint relates to a plan’s refusal to make a fast coverage determination or redetermination and you haven’t yet purchased or received the drug, the plan must notify you of its decision no later than 24 hours after it gets the complaint.

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

If the plan doesn’t take care of your complaint, call 1-800-MEDICARE.

For more information on filing a complaint: ■ Visit www.medicare.gov/appeals. ■ Call your SHIP for free personalized counseling and help filing a complaint. To get the phone number of the SHIP in your state, call 1-800-MEDICARE or visit www.medicare.gov/contacts.


www.medicare.gov/appeals

www.medicare.gov/contacts

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T I P S H E E T

Understanding Medicare Part C & D Enrollment Periods

Revised October 2012

It’s important to know when you can enroll in the different parts of Medicare. This tip sheet is designed to help you learn more about enrolling in Medicare Advantage Plans (Part C) and Medicare Prescription Drug Plans (Part D), including who can sign up, when you can sign up, and how the timing, including signing up late, can increase your costs.

Note: For information about signing up for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), visit www.medicare.gov/publications to view the booklet “Enrolling in Medicare Part A & Part B.”

When can I sign up? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Initial Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Enrollment periods that happen each year . . . . . . . . . . . . . . . 5

Special Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Get more information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

http://www.medicare.gov/publications

2

When can I sign up? There are specific times when you can sign up for a Medicare Advantage Plan (like an HMO or PPO) or Medicare prescription drug coverage, or make changes to coverage you already have: 1. When you first become eligible for Medicare or when you turn 65, during

your Initial Enrollment Period. See page 3. 2. During certain enrollment periods that happen each year. See page 5.3. Under certain circumstances that qualify you for a Special Enrollment Period

(SEP), like: ■ You move. ■ You’re eligible for Medicaid. ■ You qualify for Extra Help with Medicare prescription drug costs. ■ You’re getting care in an institution, like a skilled nursing facility or long‑term care hospital.

See the charts beginning on page 7 for a list of different SEPs, including rules about how to qualify.

Note about joining a Medicare Advantage Plan You must have Medicare Part A and Part B to join a Medicare Advantage Plan. In most cases, if you have End‑Stage Renal Disease (ESRD), you can’t join a Medicare Advantage Plan.

Extra Help is available! If you have limited income and resources, you may be able to get Extra Help paying your prescription drug coverage costs. People who qualify may be able to get their prescriptions filled and pay little or nothing out of pocket. You can apply for Extra Help at any time. There’s no cost to apply for Extra Help, so you should apply even if you’re not sure if you qualify. To apply online, visit www.socialsecurity.gov/i1020. Or, call Social Security at 1‑800‑772‑1213 to apply by phone or to get a paper application. TTY users should call 1‑800‑325‑0778.

http://www.socialsecurity.gov/i1020

3

Initial Enrollment Periods If this describes you... You can... At this time... You’re newly eligible for Medicare because you turn 65.

Sign up for a Medicare Advantage Plan (with or without prescription drug coverage) or a Medicare Prescription Drug Plan.

During the 7‑month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

You’re newly eligible for Medicare because you’re disabled and under 65.


Starting 21 months after you get Social Security or RRB benefits. Your Medicare coverage begins 24 months after you get Social Security or Railroad Retirement Board (RRB) disability benefits. Your chance to sign up lasts through the 27th month after you get Social Security or RRB benefits.

You’re already eligible for Medicare because of a disability, and you turn 65.

■ Sign up for a Medicare Advantage Plan (with or without prescription drug coverage) or a Medicare Prescription Drug Plan.

■ Switch from your current Medicare Advantage or Medicare Prescription Drug Plan to another plan.

■ Drop a Medicare Advantage or Medicare Prescription Drug Plan completely.

During the 7‑month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you sign up for a Medicare Advantage Plan during this time, you can drop that plan at any time during the next 12 months and go back to Original Medicare.

You DON’T have Medicare Part A coverage, and you enroll in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).

Sign up for a Medicare Prescription Drug Plan.

Between April 1–June 30.

You HAVE Medicare Part A coverage, and you enroll in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).


Between April 1–June 30.

4

Part D late enrollment penalty The late enrollment penalty is an amount that’s added to your 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 Part D or other creditable prescription drug coverage. Creditable prescription drug coverage is 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. If you’re subject to the penalty, you may have to pay it each month for as long as you have Medicare drug coverage. For more information about the late enrollment penalty, visit www.medicare.gov or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

5

Enrollment periods that happen each year Each year, you have a chance to make changes to your Medicare Advantage or Medicare prescription drug coverage for the following year. There are 2 separate enrollment periods each year. See the chart below for specific dates.

Enrollment Period What you can do

October 15–December 7

Medicare Open Enrollment Period (Changes will take effect on January 1.)

■ Change from Original Medicare to a Medicare Advantage Plan.

■ Change from a Medicare Advantage Plan back to Original Medicare.

■ Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.

■ Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage.

■ Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage.

■ Join a Medicare Prescription Drug Plan. ■ Switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan.

■ Drop your Medicare prescription drug coverage completely.

January 1–February 14 ■ If you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. Your Original Medicare coverage will begin the first day of the following month.

■ If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your prescription drug coverage will begin the first day of the month after the plan gets your enrollment form.

Note: During this period, you can’t: ■ Switch from Original Medicare to a Medicare Advantage Plan.

■ Switch from one Medicare Advantage Plan to another. ■ Switch from one Medicare Prescription Drug Plan to another.

■ Join, switch, or drop a Medicare Medical Savings Account Plan.

6

Special Enrollment Periods You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs) and are in addition to the regular enrollment periods that happen each year. Rules about when you can make changes and the type of changes you can make are different for each SEP.

The SEPs listed on the next pages are examples. The list doesn’t include every situation. For more information about SEPs, call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

7

Changes in where you live If this describes you… You can… At this time... You move to a new address that isn’t in your plan’s service area.

Switch to a new Medicare Advantage or Medicare Prescription Drug Plan.

If you tell your plan before you move, your chance to switch plans begins the month before the month you move and continues for 2 full months after you move. If you tell your plan after you move, your chance to switch plans begins the month you tell your plan, plus 2 more full months.If you tell your plan after you move, your chance to switch plans begins the month you tell your plan, plus 2 more full months.

You move to a new address that’s still in your plan’s service area, but you have new plan options in your new location.

You move back to the U.S. after living outside the country.

Join a Medicare Advantage or Medicare Prescription Drug Plan.

Your chance to join lasts for 2 full months after the month you move back to the U.S.

You just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital).

■ Join a Medicare Advantage or Medicare Prescription Drug Plan.

■ Switch from your current plan to another Medicare Advantage or Medicare Prescription Drug Plan.

■ Drop your Medicare Advantage Plan and return to Original Medicare.

■ Drop your Medicare prescription drug coverage.

Your chance to join, switch, or drop coverage lasts as long as you live in the institution and for 2 full months after the month you move out of the institution.

You’re released from jail. Join a Medicare Advantage or Medicare Prescription Drug Plan.

Your chance to join lasts for 2 full months after the month you’re released from jail.

8

Changes that cause you to lose your current coverage

If this describes you… You can… At this time... You’re no longer eligible for Medicaid.





Your chance to change lasts for 2 full months after the month you find out you’re no longer eligible for Medicaid.

You find out that you won’t be eligible for Extra Help for the following year.





Your chance to change is between January 1–March 31.

You leave coverage from your employer or union.


Your chance to join lasts for 2 full months after the month your coverage ends.

You involuntarily lose other drug coverage that’s as good as Medicare drug coverage (creditable coverage), or your other coverage changes and is no longer creditable.

Join a Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

Your chance to join lasts for 2 full months after the month you lose your creditable coverage or are notified of the loss of creditable coverage, whichever is later.

You have drug coverage through a Medicare Cost Plan and you leave the plan.

Join a Medicare Prescription Drug Plan.

Your chance to join lasts for 2 full months after the month you drop your Medicare Cost Plan.

You drop your coverage in a Program of All-inclusive Care for the Elderly (PACE) plan.


Your chance to join lasts for 2 full months after the month you drop your PACE plan.

9

You have a chance to get other coverage

If this describes you … You can… At this time... You have a chance to enroll in other coverage offered by your employer or union.

Drop your current Medicare Advantage or Medicare Prescription Drug Plan to enroll in the private plan offered by your employer or union.

Whenever your employer or union allows you to make changes in your plan.

You have or are enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage).

Drop your current Medicare Advantage Plan with drug coverage or your Medicare Prescription Drug Plan.

Anytime.

You enroll in a Program of All-inclusive Care for the Elderly (PACE) plan.

Drop your current Medicare Advantage or Medicare Prescription Drug Plan.

Anytime.

You live in the service area of one or more Medicare Advantage or Medicare Prescription Drug Plans with an overall quality rating of 5 stars.

Join a Medicare Advantage, Medicare Cost, or Medicare Prescription Drug plan with an overall quality rating of 5 stars.

One time between December 8, 2012–November 30, 2013.

Changes in your plan’s contract with Medicare

If this describes you… You can… At this time... Medicare takes an official action (called a “sanction”) because of a problem with the plan that affects you.

Switch from your Medicare Advantage or Medicare Prescription Drug Plan to another plan.

Your chance to switch is determined by Medicare on a case‑by‑case basis.

Your plan’s contract ends (terminates) during the contract year.

Switch from your Medicare Advantage or Medicare Prescription Drug Plan to another plan.

Your chance to switch starts 2 months before and ends 1 full month after the contract ends.

Your Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan’s contract with Medicare isn’t renewed for the next contract year.

Join another Medicare Advantage or Medicare Prescription Drug Plan.

Between October 15 and the last day in February.

10

Changes due to other special situations

If this describes you… You can... At this time... You’re eligible for both Medicare and Medicaid.

Join, switch, or drop a Medicare Advantage Plan or Medicare prescription drug coverage.

Anytime.

You qualify for Extra Help paying for Medicare prescription drug coverage.

Join, switch, or drop Medicare prescription drug coverage.

Anytime.

You’re enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility.

Join either a Medicare Prescription Drug Plan or a Medicare Advantage Plan with prescription drug coverage.

Once during the calendar year.

You dropped a Medicare Supplemental Insurance (Medigap) policy the first time you joined a Medicare Advantage Plan.

Drop your Medicare Advantage Plan and enroll in Original Medicare. You’ll have special rights to buy a Medigap policy.

Your chance to drop your Medicare Advantage Plan lasts for 12 months after you join the Medicare Advantage Plan for the first time.

You have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with your condition.

Join a Medicare Chronic Care Special Needs Plan (SNP) that serves people with your condition.

You can join anytime, but once you join, your chance to make changes using this SEP ends.

You joined a plan, or chose not to join a plan, due to an error by a federal employee.

■ Join a Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

■ Switch from your current plan to another Medicare Advantage Plan with drug coverage or a Medicare Prescription Drug Plan.

■ Drop your Medicare Advantage Plan with drug coverage and return to Original Medicare.


Your chance to change coverage lasts for 2 full months after the month you get a notice of the error from Medicare.

11

If this describes you… You can... At this time... You weren’t properly told that your other private drug coverage wasn’t as good as Medicare drug coverage (creditable coverage).


Your chance to join lasts for 2 full months after the month you get a notice of the error from Medicare.

You weren’t properly told that you were losing private drug coverage that was as good as Medicare drug coverage (creditable coverage).


Your chance to join lasts for 2 full months after the month you get a notice of the error from Medicare.

Get more information For more detailed information about signing up, including instructions on how to join, visit www.medicare.gov. You can also call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

http://www.medicare.gov

12

CMS Product No. 11219

Rev. 10/22/12

Preferred Pharmacies for 2013 Medicare Prescription Drug Plans

Many of the Medicare Prescription Drug Plans (PDP) for 2013 have preferred pharmacy pricing—meaning members will pay a reduced (or sometimes no) co‐payment for prescriptions filled at one of the plan’s preferred pharmacies. Below you will find the plans that have preferred pharmacy pricing, the corresponding preferred pharmacies, and breakdowns of how co‐payments differ between preferred and non‐preferred pharmacies. If a PDP is not listed below, it does not use preferred pharmacy pricing. When referencing SHINE’s Massachusetts Stand Alone Medicare Drug Plans chart, please note that the co‐payments given reflect the preferred pharmacy pricing if the plan has preferred pharmacies. All AARP Plans Preferred Pharmacies: Walgreens, Safeway, Kroger, Target, Stop and Shop, Publix, Hannaford, Wegmans

AARP MedicareRx Preferred Preferred Pharmacies

Other Network Pharmacies

Tier 1: Preferred Generic $3 $6

Tier 2: Non‐Preferred Generic $5 $10

Tier 3: Preferred Brand $40 $45

Tier 4: Non‐Preferred Brand $85 $95

Tier 5: Specialty 33% 33%

AARP MedicareRx Saver Plus Preferred Pharmacies







AARP MedicareRx Enhanced Preferred Pharmacies







Rev. 10/22/12

Aetna CVS/Pharmacy Preferred Pharmacies: CVS pharmacies

Aetna CVS/Pharmacy Preferred Pharmacies





Tier 4: Non‐Preferred Brand 38% 38%


EnvisionRx Plus Gold Preferred Pharmacies: COSTCO, Wal‐Mart, Walgreens, Stop and Shop, and some independent pharmacies

EnvisionRx Plus Gold Preferred Pharmacies


Tier 1: Preferred Generic 1% 25%

Tier 2: Non‐Preferred Generic 1% 25%

Tier 3: Preferred Brand 1% 25%



First Health Part D Preferred Pharmacies: Walgreens, Target, Wal‐Mart, KMART

First Health Part D Value Plus Preferred Pharmacies


Tier 1: Generic 0 7

Tier 2: Preferred Brand 35 45

Tier 3: Non‐Preferred Brand 70 95


Rev. 10/22/12

Humana Note: Each Humana Plan uses a different network of preferred pharmacies Humana Walmart Preferred Pharmacies: Walmart & Sam’s Club

Humana Walmart Preferred Preferred Pharmacies




Tier 3: Preferred Brand 20% 25%



Humana Enhanced Preferred Pharmacies: Walgreens, Wal‐Mart, Sam’s Club

Humana Enhanced Preferred Pharmacies

Other network pharmacies






Humana Complete Preferred Pharmacies: Most pharmacies

Humana Complete Preferred Pharmacies


Tier 1: Generic $5 $10




Rev. 10/22/12

SilverScript Preferred Pharmacies: CVS/pharmacy, Wal‐Mart, and select independent pharmacies

SilverScript Choice Preferred Pharmacies






SilverScript Plus Preferred Pharmacies






SmartD Rx Preferred Pharmacies: RxAlly alliance of independent pharmacies

SmartD Rx Saver Preferred Pharmacies







SmartD Rx Plus Preferred Pharmacies







Rev. 10/22/12

United American Preferred Pharmacies: CVS/pharmacy, Walmart, Sam’s Club, Kroger

United America Select Preferred Pharmacies







United America Enhanced Preferred Pharmacies







COSTCO

CVS/ pharmacy

Hannaford Kmart Kroger Publix Safeway Sam’s Club

Stop & Shop

Target Walgreens Walmart Wegmans

AARP MedicareRx Preferred

AARP MedicareRx Saver Plus

AARP MedicareRx Enhanced

Aetna CVS/pharmacy Envision Rx Plus Gold First Health Part D Value Plus

Humana Walmart Preferred

Humana Enhanced Humana Complete Most pharmacies

SilverScript Choice SilverScript Plus SmartD Rx Saver

Rx Ally alliance of independent pharmacies SmartD Rx Plus

United American Select

United American Enhanced

Form SSA-1020B-OCR-SM-INST (01-2013) Recycle prior editions

THIS COVER LETTER IS FOR INFORMATION ONLY. DO NOT COMPLETE THE FOLLOWING PAGES.

THIS IS NOT AN APPLICATION.

Social Security Administration Important Information

You may be eligible to get Extra Help paying for your prescription drugs.

The Medicare prescription drug program gives you a choice of prescription plans that offer various types of coverage. In addition, you may be able to get Extra Help to pay for the monthly premiums, annual deductibles, and co-payments related to the Medicare prescription drug program.

But before we can help you, you must fill out this application, put it in the enclosed envelope and mail it today. Or you may complete an online application at www.socialsecurity.gov. We will review your application and send you a letter to let you know if you qualify for Extra Help. To use the Extra Help, you must enroll in a Medicare prescription drug plan.

If you need help completing the application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You can find more information at www.socialsecurity.gov.

You also may be able to get help from your State with other Medicare costs under the Medicare Savings Programs. By completing this form, you will start your application process for a Medicare Savings Program. We will send information to your State who will contact you to help you apply for a Medicare Savings Program unless you tell us not to by answering question 15 on this form.

If you need information about Medicare Savings Programs, Medicare prescription drug plans or how to enroll in a plan, call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) or visit www.medicare.gov. You also can request information about how to contact your State Health Insurance Counseling and Assistance Program (SHIP). The SHIP offers help with your Medicare questions.

Please mail your application today.

Carolyn W. Colvin Acting Commissioner

Form SSA-1020B-OCR-SM-INST (01-2013) Page 1

DO NOT COMPLETE. THIS IS NOT AN APPLICATION.

General Instructions for Completing the Application for Extra Help with Medicare Prescription Drug Plan Costs

If You Are Assisting Someone Else With This Application Answer the questions as if that person were completing the application. You must know that person’s Social Security number and financial information. Also, complete Section B on page 6.

Do you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid?If the answer is YES, do not complete this application because you automatically will get the Extra Help. Does your State Medicaid program pay your Medicare premiums because you belong to a Medicare Savings Program?If the answer is YES, contact your State Medicaid office for more information. You could get the Extra Help automatically and may not need to complete this application.

How To Complete This Application • Use BLACK INK only;• Keep your numbers, letters and inside the boxes; use only CAPITAL letters;• Do not add any handwritten comments on the application;• Do not use dollar signs when entering money amounts; and• Cents can be rounded to the nearest whole dollar.

E X A M P L E

Place an X in the box. DO NOT fill in or use check marks in boxes.

CORRECT

XINCORRECT

E X A M P L E

Use capital letters when entering answers

A B C D

Completing Your Application You may complete the online application at www.socialsecurity.gov or use the enclosed pre-addressed stamped envelope to return your completed and signed application to:

Social Security Administration Wilkes-Barre Data Operations Center P.O. Box 1020 Wilkes-Barre, PA 18767-9910

Return this application package in the enclosed envelope. Do not include anything else in the envelope. If we need more information, we will contact you.

NOTE: To apply, you must live in one of the 50 States or the District of Columbia.

If You Have Questions Or Need Help Completing This Application You can call us toll-free at 1-800-772-1213, or if you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778.


— —

— —

— —

— —

Form ApprovedOMB No. 0960-0696


Application for Extra Help with Medicare Prescription Drug Plan CostsTHIS IS AN APPLICATION FOR EXTRA HELP AND DOES NOT ENROLL YOU IN A MEDICARE PRESCRIPTION DRUG PLAN.

1. Applicant’s Name: Print name as it appears on your Social Security card. Use one box for each letter.

FIRST NAME MI

LAST NAME SUFFIX (Jr., Sr., etc.)

APPLICANT’S SOCIAL SECURITY NUMBER APPLICANT’S DATE OF BIRTH (MM-DD-YYYY)

2. If you are married and living with your spouse, please provide the following information as itappears on your spouse’s Social Security card. If you are not currently married, do not live withyour spouse or are widowed, skip to question 3 and do not include any information about yourspouse on this application.

FIRST NAME MI

LAST NAME SUFFIX (Jr., Sr., etc.)

SPOUSE’S SOCIAL SECURITY NUMBER SPOUSE’S DATE OF BIRTH (MM-DD-YYYY)

If your spouse has Medicare, does he or she also wish to apply for the Extra Help? YES NO

3. If you are married and live with your spouse, do you have savings, investments or real estate worthmore than $26,580? If you are not married or you do not live with your spouse, is the value more than$13,300? Do NOT count your home, vehicles, personal possessions, life insurance, burial plots,irrevocable burial contracts or back payments from Social Security or SSI.

YES If you place an in the YES box, you are not eligible for the Extra Help. But,your State may be able to help you with your Medicare costs through their Medicare Savings Programs. To start the application process for Medicare Savings Programs, skip to page 6, sign this application and return it to us. If you are not interested in Medicare Savings Programs, skip to question 15 on page 5.

NO or NOT SURE

If you place an in the NO or NOT SURE box, complete the rest of this application and return it to us.



If you placed an in the NO or NOT SURE box in question 3, answer all of thefollowing questions. If you are married and living with your spouse, you must answer all of the questions for both of you.4. Enter below money amounts of all bank accounts, investments or cash that you, your spouse, if

married and living together, or both of you own. Also include items that either of you own withanother person. Include only dollar figures not account numbers. If you or your spouse do not ownany item listed, alone or with another person, place an in the NONE box. Do NOT include aback payment from Social Security or SSI received in the last 10 months.

• Combined total of all bank accounts(checking, savings and certificateof deposit)

NONE

• Combined total of all stocks, bonds,savings bonds, mutual funds,Individual Retirement Accounts orother similar investments

NONE

• Any other cash at home oranywhere else NONE

5. Will some money from the sources listed in question 4 be used to pay for funeral or burial expenses?

If YES, skip to question 6.

If NO, place an in the NO box, then go to question 6.

YOU: NO SPOUSE: NO

6. Other than your home and the property on which it is located, do you or your spouse, if marriedand living together, own any real estate? Examples of other real estate are summer homes, rentalproperties or undeveloped land you own which is separate from your home.

7. For this question, a relative is someone related to you by blood, adoption, or marriage (but notincluding your spouse). How many relatives live with you and depend on you or your spouse for atleast one-half of their financial support?

Please do not include yourself or your spouse in the number you enter. If your household consistsonly of you or you and your spouse, place an in the ZERO box. Place an in only one box.

ZERO 9 or more87654321

NOYES



8. If you or your spouse, if married and living together, receive income from any of the sources listedbelow, you must answer the questions for both of you. Please enter the total amount you receiveeach month. If the amount changes from month to month or you do not receive it every month,enter the average monthly income for the past year for each type in the appropriate boxes. Donot list wages and self-employment, interest income, public assistance, medical reimbursements orfoster care payments here. If you or your spouse do not receive income from a source listed below,place an in the NONE box for that source.

Monthly Benefit

• Social Security benefit NONEbefore deductions

• Railroad Retirement benefit NONEbefore deductions

• Veterans benefits before deductions NONE

• Other pensions or annuities beforedeductions. Do not include money you NONEreceive from any item you included inquestion 4.

• Other income not listed above,including alimony, net rental income,workers compensation, unemployment, NONEprivate or State disability payments, etc.(Specify): _______________________

9. Have any of the amounts you included in question 8 decreased during the last two years?

If you have worked in the last two years, you need to answer questions 10-14. If you are married and living with your spouse and either one of you has worked in the last two years, you need to answer questions 10-14. Otherwise, skip to question 15.

NOYES

10. What do you expect to earn in wages before taxes and deductions this calendar year?

YOU: NONE

SPOUSE: NONE



11. What do you expect your net earnings from self-employment to be this calendar year?Place an in the NONE box if you are not self-employed and go to question 12.

YOU: NONE

SPOUSE: NONE

Place an in the box(es) if you or your spouse expect a net loss. SPOUSE:YOU:

12. Have the amounts you included in questions 10 or 11 decreased in the last two years?

YES NO

13. If you or your spouse, stopped working in 2012 or 2013, or plan to stop working in 2013 or 2014,enter the month and year.

E X A M P L E

For January – September, place a zero (0) in the first box. May 2013 should read:

0 5 3102M M Y Y Y Y

YOU:M M Y Y Y Y

SPOUSE:M M Y Y Y Y

If you are younger than age 65, answer question 14. If you are married and living with your spouse and either one of you is younger than age 65, continue to question 14. Otherwise, skip to question 15.14. Do you or your spouse have to pay for things that enable you to work? We will count only a part

of your earnings toward the income limit if you work and receive Social Security benefits basedon a disability or blindness and you have work-related expenses for which you are not reimbursed.Examples of such expenses are: the cost of medical treatment and drugs for AIDS, cancer,depression or epilepsy; a wheelchair; personal attendant services; vehicle modifications, driverassistance or other special work-related transportation needs; work-related assistive technology;guide dog expenses; sensory and visual aids; and Braille translations.

YOU: SPOUSE: YES NOYES NO

15. Information about Medicare Savings Programs: You may be able to get help from your Statewith your Medicare costs under the Medicare Savings Programs. To start your application processfor the Medicare Savings Programs, Social Security will send information from this form to yourState unless you tell us not to. If you want to get help from the Medicare Savings Programs, donot complete this question. Just sign and date the application and your State will contact you.

If you are not interested in filing for the Medicare Savings Programs, place an in the box below.

No, do not send the information to the State.



Signatures IMPORTANT INFORMATION - PLEASE READ CAREFULLY

I/We understand that the Social Security Administration (SSA) will check my/our statements and compare its records with records from Federal, State, and local government agencies, including the Internal Revenue Service (IRS) to make sure the determination is correct. By submitting this application, I am/we are authorizing SSA to obtain and disclose information related to my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy laws. This information may include, but is not limited to, information about my/our wages, account balances, investments, benefits, and pensions. Unless I/we answered “No” to Question 15, I am/we are authorizing SSA to disclose to the State the financial information listed above and other individually identifiable information from my/our file, such as my/our name(s), date of birth, gender and Social Security number(s) to start the application process for Medicare Savings Programs.I/We declare under penalty of perjury that I/we have examined all the information on this form and it is true and correct to the best of my/our knowledge. Please complete Section A. If you cannot sign, a representative may sign for you. If someone assisted you, complete Section B as well.

Section AYour Signature: Date: Phone Number:

Spouse’s Signature: Date:

Your Mailing Address: Apt. #:

City: State: Zip Code:

If you changed your mailing address within the last three months, place an here:

If you would prefer that we contact someone else if we have additional questions, please provide the person’s name and a daytime phone number.

Phone Number:Print First Name: Print Last Name:

Section BIf someone assisted you, place an in the box that describes that person and provide the rest of the information requested below.

Family Member Attorney Other Advocate Other Specify:

Friend Agency Social Worker

Print First Name: Print Last Name: Phone Number:

Address: Apt. #:

City: State: Zip Code:



Privacy Act / Paperwork Reduction NoticeSection 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you provide to determine if you are eligible for help paying your share of the cost of a Medicare prescription drug plan.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from making an accurate and timely decision on your application.

We rarely use the information you supply for any purpose other than to determine your eligibility for Extra Help with Medicare Prescription Drug Plan Costs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to SocialSecurity benefits and/or coverage;

2. To comply with Federal laws requiring the release of information from Social Security records(e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at theFederal, State, and local level; and,

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrityand improvement of Social Security programs (e.g., to the Bureau of the Census and privateconcerns under contract to Social Security).

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information are available in Systems of Records Notices entitled, Master Beneficiary Record, 60-0090, and Medicare Database File, 60-0321. These notices, additional information regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answerthese questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0696. We estimate that it will take 30 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE ENCLOSED PRE-ADDRESSED, POSTAGE-PAID ENVELOPE:

Social Security Administration Wilkes-Barre Data Operations Center P.O. Box 1020 Wilkes-Barre, PA 18767-9910

Prescription Advantage Customer Service l 1-800-AGE-INFO (1-800-243-4636); Press 2 l TTY (toll free) for the deaf and hard of hearing 1-877-610-0241 SIDE 1

Prescription Advantage Rate Schedule Guide for Members Eligible for Medicare Effective April 1, 2013

Medicare provides ‘Extra Help’ to lower costs for beneficiaries with limited income and resources. Prescription Advantage requires all applicants who may qualify for Extra Help to apply for this benefit. You may qualify for Extra Help if your income is at or below the S1 income and your resources (other than your home) are no more than the current Medicare limits of $13,300 single, $26,580 married. Please note: these limits are subject to change.

Co-payment Assistance: Once co-payment assistance begins, you pay no more than the co-payments listed above for covered drugs. Prescription Advantage pays any additional amount. Prescription Advantage only pays for drugs covered by a drug plan.

Out-of-Pocket Spending Limit: When your total spending for deductibles (if any) and co-payments reaches the annual out-of-pocket spending limit, Prescription Advantage will cover 100% of all co-payments for the remainder of the plan year. Note: Benefits for new members begin on the effective date of Prescription Advantage coverage. Any costs incurred prior to the effective date cannot be applied towards the out-of-pocket spending limit.

Note: If you are under age 65 and disabled, your income cannot exceed the S2 income limits listed on the chart above.

Category S0 - Members receive FULL Extra Help from Medicare. Category S1 - Members receive PARTIAL Extra Help from Medicare and immediate co-payment assistance from Prescription Advantage.

Category Income if single Income if married Generic co-payments

per 30-day supplyBrand name co-payments

per 30-day supplyAnnual out-of-pocket

spending limitYearly $ Monthly $ Yearly $ Monthly $

S0 0 - 15,512 0 - 1,293 0 - 20,939 0 - 1,745 No more than $2.65 No more than $6.60 N/A

S1 0 - 17,235 0 - 1,436 0 - 23,265 0 - 1,939 No more than $7 No more than $18 $1,510

Categories S2, S3, S4 - Members pay their drug plan’s deductible (if any) and co-payments until the total retail costs of covered prescription drugs reaches $2,970. - After the cost of covered drugs reaches $2,970, co-payments are no more than the amounts listed below.





S2 0 - 21,601 0 - 1,800 0 - 29,159 0 - 2,430 $7 $18 $1,675

S3 21,602 - 25,853 1,801 - 2,154 29,160 - 34,898 2,431 - 2,908 $12 $30 $2,100

S4 25,854 - 34,470 2,155 - 2,873 34,899 - 46,530 2,909 - 3,878 $12 $30 $2,515

Category S5 - Members pay a $200 annual enrollment fee to Prescription Advantage. - Members pay their drug plan’s deductible (if any) and co-payments until their out-of-pocket costs for covered prescription drugs total $3,355 as a Prescription Advantage member in the calendar year 2013. Once members spend $3,355, they will pay $0 for prescription drugs covered by their plan.





S5 34,471 - 57,450 2,874 - 4,788 46,531 - 77,550 3,879 - 6,463 Drug plan co-payment Drug plan co-payment $3,355

Prescription Advantage may be able to offer primary prescription drug coverage to Massachusetts residents not eligible for Medicare.• If you are under age 65 and disabled, your income cannot exceed the Category 2 income limits listed on the chart below.• If you become eligible for Medicare, it is your responsibility to inform Prescription Advantage.•

Category

Income if single Income if married Annual out-of-pocket

spendinglimit

Individualquarterly

deductible

RETAIL co-paymentsper 30-day supply

MAIL ORDER co-paymentsper 90-day supply

Yearly $ Monthly $ Yearly $ Monthly $ Level 1 Level 2 Level 3 Level 1 Level 2 Level 3

1 0 - 15,512 0 - 1,293 0 - 20,939 0 - 1,745 $755 $0 $7 $18 $40 $14 $36 $80

2 15,513 - 21,601 1,294 - 1,800 20,940 - 29,159 1,746 - 2,430 $1,510 $0 $7 $18 $40 $14 $36 $80

3 21,602 - 25,853 1,801 - 2,154 29,160 - 34,898 2,431 - 2,908 $2,100 $65 $12 $30 $50 $24 $60 $100

4 25,854 - 34,470 2,155 - 2,873 34,899 - 46,530 2,909 - 3,878 $2,515 $110 $12 $30 $50 $24 $60 $100

5 34,471 - 57,450 2,874 - 4,788 46,531 - 77,550 3,879 - 6,463 $3,355 $220 $12 $30 $50 $24 $60 $100

6 57,451 or over 4,789 or over 77,551 or over 6,464 or over $5,585 $350 $12 $30 $50 $24 $60 $100

Prescription Advantage Customer Service l 1-800-AGE-INFO (1-800-243-4636); Press 2 l TTY (toll free) for the deaf and hard of hearing 1-877-610-0241 SIDE 2

Monthly Premium:You are not required to pay a monthly premium to receive Prescription Advantage benefits.

Deductibles and Co-payments:Each quarter, you must pay the deductible amount (if any) listed. Once the deductible is paid, you pay only the co-payments for the remainder of that quarter.

Annual Out-of-Pocket Spending Limit:If your total spending for deductibles and co-payments reaches your spending limit amount, Prescription Advantage will cover your co-payments for the remainder of the Plan year for all covered drugs.

How to Determine Which Drugs are Covered:Prescription Advantage uses a Plan formulary, which is a list of prescription drugs available to members. The Plan formulary is developed, reviewed and updated by a select panel of pharmacists. For detailed information regarding your medications and whether or not they are covered, please call Prescription Advantage Customer Service.

Prescription Advantage Rate Schedule Guide for Members Not Eligible for Medicare Effective April 1, 2013

Documents

Day 3 Chapter 4 - Prescription Drug Plans (Part D) Topics ... · Day 3 Chapter 4 - Prescription Drug Plans (Part D) Topics to Highlight Standard Plan Creditable Coverage Enrollment