Medicare Part D prescription drug coverage pays for brand-name and generic prescription drugs. You pay your monthly premium coinsurance and copayments. Some plans also require that you pay a deductible before they start paying for your drugs.
Unlike drug coverage that you may be used to, Part D coverage has a coverage gap. After you and your health plan spend a certain amount for your medications, coverage is greatly reduced. The federal health care reform law passed in 2010 helps close the Part D coverage gap starting in 2011 by reducing the amount you pay for generic drugs. You pay for almost the full cost of your drugs until you reach another set amount, when your plan coverage kicks in again. Some companies offer Part D plans that add extra coverage in the gap period, usually by covering generic drugs.
To learn more, choose a link below:
Understanding Medicare Part D
Medicare Part D is prescription drug coverage run by private insurance companies approved by and under contract with Medicare. They help to lower your prescription drug costs. While they're offered through private companies, the benefits are based on a minimum set of benefits set by the government and will be similar in how they are set up with an initial coverage period and catastrophic coverage.
Medicare Part D coverage is administered year-to-year and may include up to three coverage periods.
- Initial coverage period
At the beginning of each plan year, you start in the "initial coverage period" during which the plan pays a portion of your drug costs and you pay the appropriate copayment. Your cost-sharing amount depends on how the drug is classified (such as Tier 1, Tier 2, etc.), where you obtain the medication, such as from a network retail pharmacy or by mail order, and the copayments the plan you purchase requires.
- Coverage gap
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The initial coverage period ends when the total amount spent on your drug claims reaches $2,970 (this is the 2013 amount and could change in future years). This amount includes your copayments combined with the amount paid by the plan on your behalf.
At this point, you enter the second segment called the coverage gap. This is also sometimes referred to as the "donut hole." During this period, you may have to pay almost the entire cost of your prescription drugs. Some plans include extra coverage in this gap, usually for generic drugs.
- Catastrophic coverage
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When your total out-of-pocket spending reaches $4,750 (this is the 2013 amount and could change in future years), the coverage gap closes, and you enter the catastrophic coverage segment. Under catastrophic coverage, the plan resumes paying a portion of your drug claims, and you pay a copayment.
| Initial coverage period | Coverage gap | Catastrophic coverage |
|---|---|---|
|
You pay a portion Plan pays a portion until the total spent for your drugs is $2,970 |
You pay almost all drug costs unless your plan includes extra coverage. |
You pay a lesser portion Plan pays a greater portion when your spending reaches $4,750 |
As you consider your prescription drug plan options, these are features you will want to consider:
- Whether the drugs you take are included on the plan's formulary, the list of drugs the plan covers
- The copayments and coinsurance you will pay when you need to purchase drugs
- What annual deductible, if any, is required
- The monthly premium you will pay for your coverage
- If there is extra coverage for the coverage gap
Extra help for prescription drug plan premiums
You might qualify for extra help to pay for your prescription drug benefits. If you do, you'll pay a reduced monthly premium or no premium for your prescription drug coverage. The amount of extra help you get will determine your total monthly plan premium. You may still need to pay your Medicare Part B premium.
To see if you qualify for extra prescription drug help, call:
- Medicare, 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.
- Social Security Administration, 1-800-772-1213 between 7 a.m. and 7 p.m. Monday through Friday. TTY users should call 1-800-325-0778.
- Michigan Department of Human Services, 1-517-373-2035, between 8 a.m. and 5 p.m. Monday through Friday. TTY users should call 711.
The Social Security Administration sends a letter to those who are eligible for a low-income subsidy. If you feel you are eligible and have not received a letter, call Social Security or Medicare at the numbers above or contact one of the following:
- Michigan Department of Community Health, 1-517-373-3740 between 8 a.m. and 5 p.m. Monday through Friday. TTY users should call the Michigan Relay Service at 711.
- Benefits Checkup, a Web-based service of the National Council on Aging. It can help older people — especially those with limited incomes — find help paying for prescription drugs, health care, utilities and other basic needs.
Medicare drug coverage frequently asked questions
- Am I required to join a Medicare drug plan?
No. Joining a Medicare drug plan is your choice. However, to have Medicare help pay for your drugs, you must join a plan that provides Medicare prescription drug coverage. If you don't use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining when you're first eligible for Medicare means you won't have to pay a penalty if you choose to join later. Your premium will be higher if you wait to join because of the penalty.
- When can I join a Medicare drug plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from Oct. 15 through Dec. 7. Should you have and lose creditable prescription drug coverage through no fault of your own, you will also be eligible for a two-month Special Enrollment Period to join a Medicare drug plan. For more information about enrollment periods, visit When to apply for a Medicare plan.
- Could I have to pay a penalty to join a Medicare drug plan?
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If you don't join a Part D drug plan when you first become eligible or have creditable coverage, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19 percent higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join a Medicare prescription drug plan.
Still have questions? Call us!
Call 1-877-469-2583 from 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 through Feb. 14. TTY users call 711.
Current members
Call the Member Services number on the back of your ID card.
Prospective members
Call 1-877-469-2583 from 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 through Feb. 14. TTY users call 711.
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H9572 S5584_W_Apr13BCBSMAdvWeb CMS Approved 04292013
Medicare Plus Blue PPOSM, BCN Advantage HMO-POSSM and BCN Advantage HMO FocusSM are health plans with Medicare contracts. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.
Medicare Plus Blue PPO
Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.
With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare-allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.
Prescription Blue PDP
Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.
Medicare Plus Blue PPO and Prescription Blue PDP
Premiums vary by county. You must continue to pay your Medicare Part B premium.
Limitations, copayments and restrictions may apply.
Our network includes approximately 2,300 Michigan retail pharmacies, of which an estimated 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.
In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances; for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-241-2583, 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. TTY users call 711. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X510, Detroit, MI 48226.
If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and or copayments/coinsurance may change on Jan. 1 of each year.
Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS, BCN Advantage HMO or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCBSM does not control Medicare's website and is not responsible for its content.
For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system.
You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year. To learn more about enrollment periods, contact Member Services.
BCN Advantage HMO-POS
BCN Advantage HMO-POS is available in these counties: Allegan, Barry, Bay, Calhoun, Clare, Clinton, Crawford, Eaton, Genesee, Gladwin, Grand Traverse, Gratiot, Huron, Ingham, Ionia, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lapeer, Livingston, Macomb, Mecosta, Midland, Missaukee, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Ottawa, Roscommon, Saginaw, St. Clair, Sanilac, Shiawassee, Tuscola, Van Buren, Washtenaw and Wayne. Premiums vary by county. You must continue to pay your Medicare Part B premium.
You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. Out-of-network services authorized by BCN Advantage will be covered. Our point-of-service benefit allows you to get care from providers not in our network under certain conditions. If you're traveling outside of Michigan, you're covered under our point-of-service BlueCard benefit and can access out-of-network doctors, specialists or hospitals that participate with Blues plans. You may receive most plan-covered services at in-network out-of-pocket cost sharing. You may need to pay higher cost-sharing for routine care from non-network providers.
If you are enrolled in BCN Advantage ClassicSM or PrestigeSM plans, you must use a network pharmacy to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For additional information on network pharmacies, call Customer Service at 1-800-450-3680, 8 a.m. to 8 p.m., seven days a week. TTY users call 711. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.
BCN Advantage HMO Focus
BCN Advantage HMO Focus is available only to residents of Wayne County. You must use BCN Advantage Focus plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Medicare beneficiaries may also enroll in BCN Advantage through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCN Advantage's contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed. Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year.
BCN Advantage HMO Focus plan members must use a network pharmacy to access their prescription drug benefit, except under non-routine circumstances when they cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For more information call the Customer Service number on the back of your ID card from 8 a.m. to 8 p.m., Monday through Friday, with weekend hours October 1 through February 14. TTY users should call 711. Certain services are available 24/7 through our automated telephone response system. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.
The BCN Advantage benefit information provided on this website is not complete. Additional information should be requested before making a decision about your coverage. For full information on BCN Advantage benefits, current members should call our Customer Service department at 1-800-450-3680, from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. Prospective members should call 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb. 14.
Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year. Contact BCN Advantage for details.
If you decide to have your BCN Advantage premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium. Medicare beneficiaries may enroll in BCN Advantage through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, contact BCN Advantage at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb 14.
Legacy Medigap
Legacy Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. Legacy Medigap is a Medigap health insurance policy administered by Blue Cross Blue Shield of Michigan. Neither Blue Cross Blue Shield of Michigan nor agents authorized to sell Blue Cross Blue Shield of Michigan policies are connected with Medicare.
