About Medicare Part D prescription drug plans

Medicare Part D prescription drug coverage pays for brand-name and generic prescription drugs. You pay your monthly premium coinsurance and copays. 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 copay. Your cost-sharing amount depends on:

  • The Tier your drug is in
  • Where you obtain the medication, such as from a network retail pharmacy or by mail order
  • Your plan's copay amount
Coverage gap

The initial coverage period ends when the total amount spent on your drug claims reaches $2,850. This amount includes your copays combined with the amount paid by the plan on your behalf. Please note, this is the 2014 amount and could change in future years.

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

When your total out-of-pocket spending reaches $4,550, the coverage gap closes and you enter the catastrophic coverage segment. Please note, this is the 2014 amount and could change in future years. Under catastrophic coverage, the plan resumes paying a portion of your drug claims and you pay a copay.

Initial coverage period Coverage gap Catastrophic coverage

You pay a portion

Plan pays a portion until the total spent for your drugs is $2,850.

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 $4,550.

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 copays 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?

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 1-888-563-3307 from 8 a.m. to 9 p.m. Monday through Friday, Feb. 15 through Sept. 30, with weekend hours 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 1-888-563-3307 from 8 a.m. to 9 p.m. Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14. TTY users call 711.

Want us to call you? Just let us know!

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Important information about these plans

Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

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 http://www.bcbsm.com/medicare/find-a-doctor/.

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. You may enroll in only one Part D plan at a time.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,400 Michigan retail pharmacies, representing approximately 98 percent of all Michigan 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 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, 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 also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X521, 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 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. You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-888-563-3307. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14.

LegacySM 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.