Section 5: Medicare Prescription Drug Coverage
Medicare Part B covers immunosuppressive drugs after a covered transplant and most of the drugs you get for dialysis. More info. However, it doesn’t cover prescription drugs for other health conditions you may have, like high blood pressure or diabetes. Medicare offers prescription drug coverage to help you with the costs of your drugs not covered by Part B.
Medicare prescription drug coverage won’t cover drugs you can get under Part B—like immunosuppressive drug therapy under the conditions discussed here. However, if you don’t meet the conditions listed here, you may be able to get coverage of your immunosuppressive drug therapy by joining a Medicare Prescription Drug Plan.
Medicare prescription drug coverage (Part D) is offered by private companies approved by Medicare. There are 2 types of Medicare plans that provide Medicare prescription drug coverage:
■ Medicare Prescription Drug Plans that add coverage to Original Medicare or certain types of Medicare health plans.
■ Medicare prescription drug coverage provided as part of Medicare Advantage Plans (like an HMO or PPO). Most people with ESRD can only get prescription drug coverage through a Medicare Advantage Plan if they already belong to a plan, or if they switch to a different plan offered by the same company.
What it costs
Most Medicare drug plans charge a monthly premium that varies by plan. Your premium may be higher based on your income. You pay the Part D premium in addition to the Part B premium. Some plans have no premium at all. Your costs will vary depending on which drugs you use and which drug plan you choose. Also, if you have limited income and resources, you may be able to get Extra Help paying for your Part D prescription drug costs. More info. Look at your “Medicare & You” handbook to get detailed information about prescription drug coverage costs.
Extra Help for those who need it most
Medicare provides Extra Help to pay prescription drug costs for people who meet specific income and resource limits. Resources include your savings and stocks, but not your home or car. If you qualify, you’ll get help paying for your Medicare drug plan’s monthly premium, yearly deductible, and prescription copayments or coinsurance.
To qualify for Extra Help, your yearly income must be below $16,755 ($22,695 for a married couple living together), and your resources may be up to $13,070 ($26,120 for a married couple living together). These amounts may change in 2013.
If you live in Alaska or Hawaii, or pay more than half of the living expenses of dependent family members, your income limits are higher. Resources don’t include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person) or life insurance policies.
Note: Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa provide their residents help with Medicare drug costs. This help isn’t the same as the Extra Help described here. Call your local Medical Assistance (Medicaid) office to learn more.
How do I apply for Extra Help?
Some people with Medicare automatically qualify for Extra Help and will get a letter from Medicare.
If you didn’t automatically qualify, call Social Security at 1-800-772-1213, visit www. socialsecurity.gov, or apply at your State Medical Assistance (Medicaid) office. TTY users should call 1-800-325-0778. After you apply, you will get a letter in the mail letting you know if you qualify and what to do next. Even if you don’t qualify, you should still consider joining a Medicare Prescription Drug Plan.
If you apply and qualify for Extra Help, you can either join a plan on your own or let Medicare enroll you in a plan. Medicare will send you a letter letting you know what plan it will enroll you in and when your coverage begins. Check to see if the plan you’re enrolled in covers the drugs you use and if you can go to the pharmacies you want. If not, you can change plans at any time.
When you can join
If you become entitled to Medicare based on ESRD, your first chance to join a Medicare drug plan will be during the 7-month period that begins 3 months before the month you’re entitled to Medicare and ends 3 months after the first month you’re entitled to Medicare.
Your prescription drug coverage will start the same time your Medicare coverage begins or the first month after you make your request, whichever is later. More info.
If you don’t join when you’re first eligible, you can join between October 15–December 7 each year. Your coverage will begin on January 1 of the following year. If you join after your initial enrollment period is over and there was a period of 63 continuous days or more during which you didn’t have creditable prescription drug coverage (coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage), you may have to pay a late enrollment penalty. This amount increases the longer you go without creditable coverage. You will have to pay this penalty as long as you have Medicare prescription drug coverage. However, if you get Extra Help, you don’t have to pay a late enrollment penalty.
For more information about Medicare prescription drug coverage, visit www.medicare. gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can also contact your local State Health Insurance Assistance Program. More info.
