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the medicare drug plan
6 Key Facts

1. Anyone on Medicare can get coverage regardless of income or health.

2. You are not obligated to enroll, but there may be consequences if you don't sign up when you are first eligible to do so.

3. To get Medicare drug coverage, you must select one approved private drug plan among many offering different choices. There is no single government plan.

4. Is your income limited? If you qualify for a part of the program known as "Extra Help." you'll pay very little for your medications.

5. Are your drug costs very high? You'll pay no more than 5 percent of the cost of each prescription after you've spent a certain amount of money out-of-pocket in any one year.

6. Do you have better drug coverage already? You probably won't need Medicare's Part D coverage. But it's wise to check.

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Medicare Prescription Drug Coverage Guide

Part 2: 'Extra Help' Paying for Prescriptions

On limited income, you may qualify for more assistance

What plan choices will I have?

You will have many plans to choose from. But to guarantee a zero premium, you must choose a plan with a premium that is below the regional average cost. If you choose a more expensive plan, you must pay the difference between the regional average and that plan’s premium. (To find out which plans are available to you at a zero premium, call Medicare at 1-800-633-4227 or compare plans on Medicare's website.)

What if Medicare doesn’t cover all the drugs I now get through Medicaid, or I can’t afford the costs?

Medicaid programs in some states continue to supply drugs that a Medicare drug plan doesn’t cover. Some state pharmacy assistance programs pay all or some out-of-pocket costs. Some charities, patient support groups and other assistance programs may be able to help. Go here for information on many of these.

Can I get a 90-day supply of my drugs?

Yes—usually by choosing the plan’s mail order option. (Most, but not all, plans offer mail order.) You may also be able to get 90-day supplies at a local pharmacy in your plan’s network. To find out, ask the pharmacist or call the plan. People who receive Extra Help pay only one copay for each 90-day supply.

Will Extra Help affect other benefits I get?

Food stamps and housing assistance may decrease, but your savings on drugs will still leave you better off. Heating assistance and SSI are not affected.

Once eligible for Extra Help, can I lose it?

It’s possible if your circumstances change. Certain marital events may affect eligibility. If your spouse dies, you separate or get divorced, you get back together after being separated or you marry someone else, you must report these changes to Social Security immediately so that your eligibility can be reviewed. (These events won’t necessarily result in your losing Extra Help—in some situations, they may mean that you qualify for more Extra Help than you had before.)

If your financial circumstances change, you’ll probably continue to receive Extra Help until the end of the year. But you could lose eligibility for next year if your income or assets have risen above the limits or if you no longer qualify for one of the programs that make you automatically eligible for Extra Help — receiving Medicaid or SSI or having your Medicare premiums paid by your state.

If you applied for Extra Help and receive a letter from Social Security asking if your circumstances have changed, you must fill out the form and return it within 30 days — otherwise your Extra Help benefits will end on Dec. 31.

What if I’m denied or lose Extra Help?

If you’re denied Extra Help, you can appeal the decision, either by asking for a telephone hearing (when you, or someone helping you, can present the facts of your case personally) or a case review (when your case is reconsidered without any input from you, except for any new documentary information you may have submitted). To request either type of appeal, call Social Security at 1-800-772-1213. You can use this same appeals process if you applied for Extra Help and received it but are now told you are no longer eligible.

If you qualified for Extra Help automatically (by receiving Medicaid or SSI or having your Medicare premiums paid by your state) and have now been told (unfairly in your opinion) you no longer qualify for Extra Help, contact Medicare at 1-800-633-4227 immediately.

In general, you should contact Medicare (at 1-800-633-4227) to resolve problems if you receive Extra Help automatically, or Social Security (at 1-800-772-1213) if you applied for it.

What if I live in the U.S. territories?

The Extra Help benefit works differently there. For information and help in Puerto Rico, call the Medicare Platino program at 1-866-596-4747 toll free. In the U.S. Virgin Islands, call the Department of Human Services at 340-774-5265 (St. Thomas or St. John) or 340-773-2323 (St. Croix). For or other U.S. territories, call Medicare at 1-800-633-4227.

Where can I learn more or get help?

  • Social Security Administration: For Extra Help application forms and information, call the Social Security Administration’s help line at 1-800-772-1213 or go to the Social Security website. The site, normally in English, can also be read in Arabic, Armenian, Chinese, Farsi, French, Greek, Haitian-Creole, Italian, Korean, Polish, Portuguese, Spanish, Russian, Tagalog and Vietnamese. To choose your language, click on the “Other Languages” button at the top right of the home page. You can also ask for free interpreter services in any language when you call Social Security’s help line at 1-800-772-1213 (press 2 for Spanish or 1 for any other language) or when you arrange to visit a local office.
  • Your local state health insurance counseling program (SHIP): There’s a SHIP in every state, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. SHIPs offer free, expert counseling by trained staff or volunteers who can help you apply for Extra Help or other assistance programs. You can also ask to talk with a counselor who speaks your own language. To find contact information for your local SHIP, click here.
  • National Alliance for Hispanic Health: This organization provides information and personal counseling on health issues, including Medicare and the Part D prescription drug program, in Spanish and English for Hispanics around the country. Call its toll-free phone help line (Su Familia) at 1-866-783-2645 or go to the NAHH website.

  • National Asian Pacific Center on Aging: This organization provides a national multilingual help line so that Asian and Pacific Islander seniors can call NAPCA counselors and get help with Medicare Part D prescription drug coverage in their own language. Call the following numbers toll free according to the language you want to use: Chinese, 1-800-582-4218; Korean, 1-800-582-4259; Vietnamese, 1-800-582-4336; English, 1-800-336-2722. Or, see the NAPCA website

Patricia Barry writes the AARP Ask Ms. Medicare column and is the author of Medicare for Dummies (Wiley/AARP, October 2013).

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