Guide to Choosing a

Medicare-Approved

Drug Discount Card

This official government

booklet will help you answer

these questions:

• What are these cards?

• Who can get a card?

• How do they work?

• How do I choose the best card

for me?

Table of Contents

1

Note: The information in this booklet was correct when it was printed. Changes may

occur after printing. For the most up-to-date information, look at www.medicare.gov

on the web. Select “Publications.” Or, call 1-800-MEDICARE (1-800-633-4227). 

A Customer Service Representative can tell you if the information has been updated.

TTY users should call 1-877-486-2048.

Guide to Choosing a Medicare-Approved Drug Discount Card isn’t a legal document. 

The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-6

Section 1: Discount card basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-16

Section 2: Help with your prescription drug costs . . . . . . . . . . . . . . . . . 17-24

Section 3: Steps to choosing a discount card . . . . . . . . . . . . . . . . . . . . . 25-29

Section 4: Have a problem with your discount card? (What to do) . . . . . . . 30

Section 5: For more information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Section 6: Words to know (definitions of words in blue) . . . . . . . . . . . . . . . 32

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Medicare-Approved Drug Discount Cards
Introduction

2

Choices to Save on Prescription Drugs

The cost of paying for prescription drugs has been increasing every

year, especially for people with Medicare, like you. Medicare pays for

some prescriptions, like certain cancer drugs, but Medicare doesn’t

cover everything. Many people with Medicare have prescription drug

coverage through other insurance like an employer group health

plan, a Medicare Managed Care plan, or a Medigap policy. Even

with this coverage, you may still have trouble paying for your

prescriptions. 

Another way people with Medicare get help paying for their

prescriptions is by using drug discount cards like a card from a

pharmacy or company that makes drugs. These cards can help you

get prescriptions at lower costs. Now you have another choice to

help you save money on your prescriptions. Medicare is contracting

with private companies to offer new, voluntary discount cards. 

Medicare-Approved Drug Discount Card

If you have Medicare and don’t have outpatient prescription drug

coverage through Medicaid, you can get a Medicare-approved drug

discount card. You can enroll as early as May 2004. The discount cards

are good until December 31, 2005, when Medicare’s new prescription

drug benefit starts on January 1, 2006. For a small annual enrollment

fee, these cards can help you save on your outpatient prescription costs. 

You can recognize these cards because all discount cards approved by

Medicare will have this seal on them:

Words in blue

are defined on

page 32.
3

Introduction

Medicare-Approved Drug Discount Card (continued)

You can get a discount card from the private companies that meet

Medicare’s standards. You can only get one Medicare-approved drug

discount card at a time. Keep in mind that some private companies

may offer you discount cards that aren’t Medicare-approved. You

should review all discount cards carefully. If the Medicare-approved

seal (shown on page 2) isn’t on the discount card, that discount card

isn’t Medicare-approved. For a list of Medicare-approved drug

discount cards, you can do one of the following:

• Look at www.medicare.gov on the web. 

Select “Prescription Drug and Other Assistance Programs.”

• Call 1-800-MEDICARE (1-800-633-4227) and ask about drug 

savings. TTY users should call 1-877-486-2048.

If you enroll in a Medicare-approved drug discount card, you are the

only one who can use the card. You shouldn’t give your card to

anyone for any reason. To learn more about Medicare-approved drug

discount cards, turn to page 7.

Remember, if you already have outpatient prescription drug coverage

through Medicaid, you aren’t eligible for a Medicare-approved drug

discount card.
4

Words in blue

are defined on

page 32.

Introduction

$600 to Help Pay for Your Prescriptions

If you choose to get a Medicare-approved drug discount card, you

might also qualify for up to a $600 credit each calendar year (2004

and 2005) to help pay for prescriptions. Depending on your annual

income, you will still have to pay a 5% or 10% coinsurance for your 

prescription drugs. To get the $600 credit, you have to get a

Medicare-approved drug discount card and all of the following 

conditions must apply:

• You have Medicare Part A and/or Part B

• You don’t have other health insurance with any outpatient

prescription drug coverage* (except a Medicare + Choice plan

or a Medigap policy)

• Your annual income in 2004 is no more than $12,569 if you 

are single, or no more than $16,862 if you are married 

(this includes your income and your spouse’s income)**

* Includes outpatient prescription drug coverage from some Medicare

Managed Care plans. 

** Income includes money that you receive through retirement benefits

from Social Security, Railroad Retirement, the Federal government, or

other sources. Income also includes benefits you receive for a disability

or as a Veteran, plus any other sources of the type that you would report

for tax purposes. These income limits change each year. If you live in

Alaska or Hawaii, income limits are different.

Important note: If your state helps pay your Medicare Part A or 

Part B premiums, you may still qualify if your income is above

$12,569 if single or $16,862 if married (your coinsurance at the

pharmacy would be 10%). 

If you’re enrolled in a state pharmacy assistance program (not

Medicaid), you can get a Medicare-approved drug discount card and

the $600 credit. You still need to meet the conditions listed above.
$600 to Help Pay for Your Prescriptions (continued)

You can’t get the $600 credit if you already have outpatient 

prescription drug coverage from any of the following:

• Medicaid

• TRICARE for Life (military health insurance)

• Employer group health plan or other health insurance coverage

including some Medicare Managed Care plans (other than a 

Medicare + Choice plan or Medigap policy)

• FEHBP (health insurance for Federal employees or retirees)

Even if you don’t qualify for the $600 credit, you may be able to save

money on your prescriptions through a Medicare-approved drug 

discount card. If you think you qualify for the $600 credit, or you

want to learn more about it, turn to page 17.

If you live in Puerto Rico, the U.S. Virgin Islands, Guam, American

Samoa, or the Northern Mariana Islands, different rules apply. Call 

1-800-MEDICARE (1-800-633-4227) for more information. 

TTY users should call 1-877-486-2048.

5

Words in blue

are defined on

page 32.

Introduction
Making the Best Choice for You

The Medicare-approved drug discount card isn’t insurance, and it isn’t a

substitute for any other health insurance you already have that covers

prescription drugs. You shouldn’t drop your current prescription drug

coverage for a discount card.

Medicare can help you compare the discount card programs and all of

your options to make the choice that is best for you. To get help from

Medicare 

• look at www.medicare.gov on the web.

Select “Prescription Drug and Other Assistance Programs,” or

• call 1-800-MEDICARE (1-800-633-4227) and ask about 

“drug savings.” TTY users should call 1-877-486-2048.

Other discount cards may help you save money on your 

prescriptions. For more information about cards that don’t have the

Medicare-approved seal, contact the company offering the card. Also,

check your current health insurance coverage.

The rest of this booklet gives you information about Medicareapproved drug discount cards. Keep reading for information about the

following topics:

• How these discount cards work

• Who may qualify for the $600 credit to help pay for 

prescriptions

• What to do if you have a problem with the card or a 

complaint

• Where to get more information

6

Introduction

CAUTION
Section 1: Discount card basics

7

Words in blue

are defined on

page 32.

You can enroll in a Medicare-approved drug discount card as early as

May 2004. These cards may help lower your outpatient prescription

drug costs by offering a discount off the price of your prescriptions

and some drugs you can get without a prescription if

• you don’t have health insurance that covers outpatient 

prescriptions,

• you have health insurance that limits how much it will pay for

your outpatient prescriptions,

• you don’t get any type of discount off the price of your 

outpatient prescriptions, or

• you currently get a discount that is less than the Medicareapproved drug discount card offers. 

Note: The discounts from the discount card don’t apply to drugs

that Medicare currently covers (like some cancer drugs).

How the Program Works

In this program, private companies (like a large group of pharmacies

or an insurance company) offer a discount card to people with

Medicare. To be a part of this program, companies must apply to

Medicare and meet certain Medicare standards like 

• providing quality customer service,

• being a stable, reputable business,

• setting up a process for handling complaints, and

• having experience offering prescription drug discounts.
Section 1: Discount card basics

8

Words in blue

are defined on

page 32.

How the Program Works (continued)

If a company offers a Medicare-approved drug discount card, the

company must make it available to every person with Medicare in

the state (unless the company is a Medicare Managed Care plan, 

see page 14). The companies will decide 

• which prescription drugs will be discounted, and 

• the amount of the price discount for those drugs. 

This means you need to compare each card carefully to choose the

one that offers your prescriptions at the best discounted price.

You can compare drug discount cards and drug prices at

www.medicare.gov on the web. Select “Prescription Drug and Other

Assistance Programs.” You can also call 1-800-MEDICARE 

(1-800-633-4227) to get this information. TTY users should call 

1-877-486-2048. 

Many of the companies that offer a discount card will have a list of

drugs they will discount called a discount drug list. When you

choose a discount card, you may get a lower price only on the

prescription drugs on this list. 

A company can change its discount drug list and the discounted

prices anytime. The company will give you information about, and

changes to, its discount drug list if you ask for them. It will also put

these changes on its website (if it has one). Each company will have

a toll-free telephone number for you to call with questions.

Caution: If you take a prescription that Medicare covers, you must

go to a pharmacy that accepts Medicare. If you go to a pharmacy

that doesn’t accept Medicare, Medicare won’t pay for the

prescription.
Section 1: Discount card basics

9

Who can get a Medicare-approved drug discount card?

You can get a Medicare-approved drug discount card if 

• you have Medicare Part A and/or Part B, and

• you don’t have outpatient prescription drug benefits through Medicaid 

(your state may call this Medical Assistance).

If you’re enrolled in a state pharmacy assistance program (not Medicaid), 

you can still get a card. Visit www.medicare.gov on the web to see if your

state has a pharmacy assistance program.

Note: If you already have prescription drug coverage through your current

health insurance, or you already get discounts on your prescriptions, review

your coverage closely to see if this discount card will save you more money

on your prescriptions.

When can I get a Medicare-approved drug discount card?

You can enroll in a Medicare-approved drug discount card as early as 

May 2004. The discount cards are good until December 31, 2005. When

you choose a discount card, you can’t switch to another card for the rest of

the calendar year, unless

• you move to a state in which your discount card isn’t offered,

• you join or leave a Medicare Managed Care plan,

• you enter or leave a long-term care facility (like a nursing home), or

• the private company stops offering your discount card.

How do I choose a Medicare-approved drug discount card?

When comparing your Medicare-approved drug discount card choices,

you may want to review the discount drug list, drug prices, and choice of

pharmacies. This may help you choose the Medicare-approved drug

Words in discount card that’s best for you. blue

are defined on

page 32.
Section 1: Discount card basics

10

Words in blue

are defined on

page 32.

How do I enroll in a Medicare-approved drug discount

card?

You can enroll in a Medicare-approved drug discount card as early as

May 2004. If a company offers a Medicare-approved drug discount

card, the company must make it available to every person with

Medicare in the state (unless the company is a Medicare Managed

Care plan, see page 14). 

When you choose a discount card, you will need to provide

information like that on the sample enrollment form on pages 15-16.

For a copy of an enrollment form, call the company that offers the

drug discount card you want. Ask for the Medicare-approved drug

discount card enrollment form. Depending on the company, you can

apply by mailing or faxing the completed form to the company or by

providing your information over the telephone or on the web. To get a

card, you must apply by December 31, 2005.

You may be able to choose from several Medicare-approved drug

discount cards. To find out which discount cards are available in your

area, for help choosing a discount card, or for help filling out the

enrollment form

• look at www.medicare.gov on the web.

Select “Prescription Drug and Other Assistance Programs,”

• call 1-800-MEDICARE (1-800-633-4227), 

• call your State Health Insurance Assistance Program (SHIP). 

To find the telephone number for your SHIP, call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048. Or, visit www.medicare.gov on the web. Select 

“Helpful Contacts,” or

• call the company offering the drug discount card you want.

Once your enrollment form has been approved, the company will send

you a Medicare-approved drug discount card. The company will also

send specific materials you will need like a member handbook,

discount drug list, pharmacy provider directory, and complaint

procedures. 
Section 1: Discount card basics

11

Can I enroll in more than one Medicare-approved drug

discount card?

No. You can enroll in only one Medicare-approved drug discount

card at a time. If you have non-Medicare-approved discount cards,

you may use these and your Medicare-approved drug discount card.

You should compare the different costs of your prescriptions among

all of the drug discount cards that are available, to make sure you are

making the best choice. 

If you move to another state where your current discount card isn’t

offered, you can enroll in another discount card.

Note: If you live part-time in more than one state during the

year, you can still enroll in only one Medicare-approved drug

discount card. If you want to use the discount card in more than one

state, make sure you choose a discount card that is offered in all of

the states where you live.

Are there any costs to join a Medicare-approved drug

discount card?

Private companies that offer these cards are allowed to charge you an

annual enrollment fee of no more than $30. You will have to pay a

new enrollment fee every calendar year. You may have to pay it more

often if

• you voluntarily decide to switch to a different discount card

because you move to another state where your discount card isn’t 

offered,

• you switch to a different discount card after you join or leave a 

Medicare Managed Care plan, 

• you choose a new discount card because the company stopped 

offering your discount card, or

• you switch to a different discount card after you enter or leave a 

long-term care facility (like a nursing home).

If you don’t pay the annual enrollment fee, the company can cancel your

discount card. No matter when you join a Medicare-approved drug

discount card, you still have to pay the entire annual enrollment fee.
Section 1: Discount card basics

12

Are there any costs to join a Medicare-approved drug discount

card? (continued)

Except for the annual enrollment fee and the costs for your prescriptions,

private companies offering Medicare-approved drug discount cards can’t

charge any extra fees. There is no monthly fee for any of these discount cards.

What happens if my enrollment form for a Medicare-approved

drug discount card is denied? 

If you apply for a Medicare-approved drug discount card and your

enrollment form is denied, the company will send you a letter explaining

how to get Medicare to review your enrollment form again. You should

follow the instructions in that letter. If Medicare decides that you do

qualify for the card, they will send you a letter explaining what to do.

What drug discounts are available?

The discount amount is a lower retail price on your prescriptions. The

private companies will decide which prescriptions will be offered at a

discount and your cost for those prescriptions. If there is a generic drug

available, the pharmacy should tell you the difference in price between

generic and brand name covered discount drugs. Only drugs included on

the private company’s discount drug list will be discounted. Different

drugs on this list may be discounted at different rates, and the discounted

prices may change over the course of the year.

Where can I get my prescriptions if I have a Medicareapproved drug discount card?

The company will send you a pharmacy provider directory after you are

enrolled in the discount card. To get the discount on your prescriptions,

you must go to one of the pharmacies listed in this directory. If you don’t

go to a pharmacy listed in this directory, you may not get the discount on

your prescriptions. You can also find the pharmacy closest to you that

accepts your Medicare-approved drug discount card by looking at

www.medicare.gov on the web. Select “Prescription Drug and Other

Assistance Programs.”

Words in blue

are defined on

page 32.
13

Words in blue

are defined on

page 32.

Section 1: Discount card basics

What happens if I choose a discount card and then my

doctor changes my prescription?

If your doctor changes your prescription or prescribes a new drug,

give your doctor a copy of the discount drug list for your discount

card. This list should be in the materials you get from the company

offering your discount card. This list and the prices for drugs can

change. You can call the company, or look on the company’s website

to find out if the discount drug list has changed. 

If your doctor needs to prescribe a drug that isn’t on the discount drug

list for your card and you don’t have any other health insurance that

covers outpatient prescription drugs, you will have to pay full price for

the prescription.

You can also look at www.medicare.gov on the web to find other

programs that may help you pay for your prescriptions. Select

“Prescription Drug and Other Assistance Programs.” Or, call 

1-800-MEDICARE (1-800-633-4227) for this information. 

TTY users should call 1-877-486-2048.

What should I do if a company that offers a Medicareapproved drug discount card contacts me directly?

If a company contacts you about joining its Medicare-approved drug

discount card, you should compare the card it offers to your other

discount card choices before you make a decision. To compare your

choices, you can 

• look at www.medicare.gov on the web. 

Select “Prescription Drug and Other Assistance Programs,” or 

• call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048.
Section 1: Discount card basics

14

Words in blue

are defined on

page 32.

Can I get a Medicare-approved drug discount card if I am in

a Medicare Managed Care plan?

Yes. Your Medicare Managed Care plan may offer a Medicare-approved

drug discount card only to its plan members. If it does, you can choose to

join only this discount card. If you choose not to join the discount card

offered by your Medicare Managed Care plan, you can’t choose another

Medicare-approved drug discount card.

If your Medicare Managed Care plan doesn’t offer a Medicare-approved

drug discount card, or offers a discount card that is open to non-members,

you can choose any discount card offered in your state. Call your Medicare

Managed Care plan for more information.

Can I leave a Medicare-approved drug discount card? 

Yes. You can leave a discount card anytime by notifying the company to

tell them why you are leaving. 

If you must leave for any of the following reasons, you can choose a

new discount card anytime:

• You move to a state in which your discount card isn’t offered

• You join or leave a Medicare Managed Care plan

• You enter or leave a long-term care facility (like a nursing home)

• The private company stops offering your discount card 

If you choose to leave the program in 2004 for any reason other than

those listed above, you can apply for a new discount card beginning on 

November 15, 2004. You will be able to use your new discount card

beginning in 2005. If you choose to leave the program in 2005 for any

reason other than those listed above, you can’t apply for a new discount

card.

What if the company stops offering my discount card?

If the company stops offering your discount card, the company will

notify you, in writing, within a reasonable amount of time. If you

choose to join another discount card, you will have to pay the annual

enrollment fee again.
SAMPLE

15

Section 1: Discount card basics

[Company Name]

[Medicare Seal] 

Enrollment Form for the Medicare-Approved Drug Discount Card

Step 1: Please answer the following statements:

Name: First Middle Initial Last Birth Date Sex

Residence Address: Street City State Zip

Social Security Number Medicare ID Number Telephone Number

I have Medicare Part A or Medicare Part B.

Yes No

I do not have outpatient prescription drug benefits under my State Medicaid Program.

Yes No

Step 2: Please complete this information about yourself:

If you answered YES to BOTH of the statements above, continue to STEP 2.

If you answered NO to either of the statements above, you may not be eligible for this

program. Please see the information on page 1, or call [company 800 #] for assistance.

Please continue to the next page
SAMPLE

16

Section 1: Discount card basics

Release of Information: By applying for enrollment for a Medicare-approved

discount card, I allow the Centers for Medicare & Medicaid Services (CMS) to give

information to the company of the drug discount card. The information will say

whether I have Medicare Hospital Insurance Benefits (Part A) and/or Supplementary

Medical Insurance Benefits (Part B). I also allow the State Medicaid Program or any

other agency with relevant information about me to give CMS or CMS’s agents the

information needed to determine if I am eligible for the drug discount card.

Review of Eligibility: I understand that my application will be considered 

without regard to race, color, sex, age, handicap, religion, national origin, or political

belief. I understand that by signing this application I am agreeing to a full 

investigation or review of my eligibility by states, federal agencies, or their 

contractors and, if requested, I agree to provide the documents necessary to confirm

the accuracy and completeness of the information provided in this application. If

documents aren’t available, I agree to give the name of the person or organization

that can provide and release this necessary information.

By signing below, you certify that you have read and understand the information on this

enrollment form. If you can’t sign, a representative may sign for you. Federal law provides

for fine or imprisonment, or both for any person who withholds or gives false 

information to obtain assistance to which (s)he is not entitled. I understand the 

questions on this application and I certify, under penalty of perjury, that the information

given by me on this form is correct and complete to the best of my knowledge.

Your Signature: Date:

Step 3: Read all the information:

Please return your enrollment form in the envelope provided.
17

Words in blue

are defined on

page 32.

Section 2: Help with your prescription drug costs

If your annual income is below a certain level, Medicare may pay your

annual enrollment fee for the Medicare-approved drug discount card

and provide up to a $600 credit each calendar year (2004 and 2005)

toward your prescription drugs. You can use the $600 credit toward

most prescriptions, even those not on the discount drug list. If you get

the $600 credit to help you pay for your prescriptions, you will still have

to pay a percentage of the cost for each prescription. 

Who can get the $600 credit from Medicare to help pay

for prescriptions?

You may be able to get the $600 credit to help pay for your prescriptions if 

• you have Medicare Part A and/or Part B, 

• you don’t have other health insurance with any outpatient 

prescription drug coverage (except a Medicare + Choice plan or a 

Medigap policy), and

• your annual income in 2004 is no more than $12,569 if you are 

single, or no more than $16,862 if you are married (this includes 

your income and your spouse’s income).* 

* Income includes money that you receive through retirement benefits

from Social Security, Railroad Retirement, the Federal government, or

other sources. Income also includes benefits you receive for a disability or

as a Veteran, plus any other sources of the type that you would report for

tax purposes. These income limits change each year. If you live in Alaska

or Hawaii, income limits are different.

You can’t get the $600 credit from Medicare for prescription drugs if you

have outpatient prescription drug coverage from any of the following:

• Medicaid

• TRICARE for Life (military health insurance)

• Employer group health plan or other health insurance coverage 

including some Medicare Managed Care plans (other than a 

Medicare + Choice plan or Medigap policy)

• FEHBP (health insurance for Federal employees or retirees)

You also can’t get the $600 credit if you are in a Medicare Managed Care

plan that is a “cost” plan that offers a drug discount card to its members.

If you have questions about whether this applies to you, call your plan.
Section 2: Help with your prescription drug costs

18

Words in blue

are defined on

page 32.

How do I get the $600 credit from Medicare to help pay

for prescriptions?

To find out if you can get the $600 credit from Medicare, complete

and return an enrollment form like the sample enrollment form on

pages 22-24. To get a copy of this form, call the company offering

the discount card you want, and ask for an enrollment form for the

$600 credit. You can apply by mailing or faxing the completed form

to the company. 

If you don’t already have a Medicare-approved drug discount card

when you apply for the $600 credit, you must apply for the $600

credit to help pay for your prescriptions and the discount card you

want at the same time.

After you provide this information, the company will send your

completed form to Medicare. Medicare will see if you meet the

requirements for the $600 credit. If you qualify for the $600 credit

from Medicare, you won’t have to pay the annual enrollment fee for

the discount card you choose.

If you are already enrolled in a Medicare-approved drug discount card

and you become eligible for the $600 credit, you can apply through the

company that offers your card at anytime. If you qualify, Medicare will

pay the annual enrollment fee, and the company will refund any

enrollment fee you already paid for that year.

When can I apply for the $600 credit from Medicare to

help pay for prescriptions?

In 2004, you can apply anytime for the $600 credit through a

Medicare-approved drug discount card. If you are eligible, you will get

the full $600 credit no matter when you apply in 2004. You don’t have

to reapply for the $600 credit to help pay for your prescriptions in

2005. As long as you have a Medicare-approved drug discount card,

you will get another $600 credit on your discount card at the

beginning of 2005.
19

Section 2: Help with your prescription drug costs

When can I apply for the $600 credit from Medicare to help

pay for prescriptions? (continued)

In 2005, if you are applying for the first time, the amount of your

credit will depend on when you apply for a Medicare-approved drug

discount card. The chart below shows how much you will get

depending on when you apply in 2005: 

What happens to the rest of the $600 credit if I have

money left on December 31, 2004?

You may be able to carry over any of the $600 credit you have left at

the end of 2004. The three situations below and on page 20 describe

when you can carry over any of the credit you have left.

1. If you keep the same discount card for all of 2004 and some of your

$600 credit is left at the end of the year, you can use that money in

2005. 

2. If you leave a Medicare-approved drug discount card and join a new

Medicare-approved drug discount card in 2004 for any of the

following reasons and you have some of your $600 credit left, you

may be able to use that money when you join the new Medicareapproved drug discount card:

• You move to a state in which your discount card isn’t offered

• You join or leave a Medicare Managed Care plan

• You enter or leave a long-term care facility (like a nursing home)

• The private company stops offering your discount card

If you apply between You will get

January 1 - March 31, 2005

April 1 - June 30, 2005

July 1 - September 30, 2005

October 1 - December 31, 2005

$600 credit

$450 credit

$300 credit 

$150 credit

Words in blue

are defined on

page 32.
20

Words in blue

are defined on

page 32.

Section 2: Help with your prescription drug costs

What happens to the rest of the $600 credit if I have money

left on December 31, 2004? (continued)

3. If you change Medicare-approved drug discount cards, you can use

any of the $600 credit you have left at the end of 2004 under your

new card in 2005 if

• you changed cards for one of the reasons listed on page 19, or

• you elected to change cards between November 15, 2004 and 

December 31, 2004.

If you switch discount cards for any reason not listed above, you will

lose any of the $600 credit left from 2004.

What happens if I don’t get the $600 credit from Medicare

to help pay for prescriptions? 

If you apply for the $600 credit from Medicare and your enrollment

form is denied, the company will send you a letter explaining how to

get Medicare to review your enrollment form again. You should follow

the instructions in that letter. If you ask for a review and Medicare

decides that you do qualify for the $600 credit to help pay for your

prescriptions and you have already paid your annual enrollment fee,

you will get a refund. 
21

Section 2: Help with your prescription drug costs

How do I use the $600 credit from Medicare to help pay

for prescriptions?

If you are approved for the $600 credit from Medicare to help pay for

your prescriptions, the amount you are approved for will be applied to

your discount card. Each time you use your discount card, you will pay

a 5% or 10% coinsurance on the discounted cost of your prescription.

The pharmacy will then deduct the amount you spend on your

prescriptions from your discount card. Whether you pay a 5% or 10%

coinsurance depends on your annual income when you applied for the

$600 credit and the Medicare-approved drug discount card. 

How do I know how much of my $600 credit I have left?

When you use your discount card, the pharmacist or the statement you

get with your prescription will tell you how much of the $600 you

have left. You can also call the company’s toll-free telephone number to

get this information.

What happens to my $600 credit if I leave the discount

card?

You can leave the discount card anytime by writing the company to tell

them why you are leaving. If you are leaving for reasons other than the

four listed on page 19, you will lose the remainder of the $600 credit

for that year. You may be able to choose another discount card any

time from November 15, 2004 through December 31, 2004. You will

be able to use your new discount card in 2005. You will also be able to

get a $600 credit in 2005 if you qualify.

What happens when my $600 credit runs out?

When you have used all of your $600 credit, you still will be able to

use your Medicare-approved drug discount card to save money on your

prescriptions. If you don’t have other prescription drug coverage, you

will have to pay the full discounted price.
22

SAMPLE

Step 3: Please answer the following questions:

[Company Name]

[Medicare Seal] 

Enrollment Form for the Medicare-Approved Drug Discount Card AND

Additional Assistance in Paying for Your Prescription Drugs 

Step 1: Please answer the following statements:

Name: First Middle Initial Last Birth Date Sex

Residence Address: Street City State Zip

Social Security Number Medicare ID Number Telephone Number 

Do you have TRICARE (military health insurance)? Yes No

Do you have Federal employee or retiree health insurance (FEHBP)? Yes No

Do you have other health coverage that includes outpatient prescription

drugs, such as employer or retiree plans? Yes No

Note: If your health coverage is through a Medicare + Choice (M+C) plan or Medigap plan, answer “no”

to this question.

If you answered YES to any of the statements above, you may not be eligible for the $600 credit.

Please see the information on page 2, or call [company 800 # ] for assistance.

If you answered NO to all of these questions, please continue to the next page.

I have Medicare Part A or Medicare Part B. Yes No

I do not have outpatient prescription drug benefits under my State Medicaid Program.

Yes No

Step 2: Please complete this information about yourself:

If you answered YES to BOTH of the statements above, continue to STEP 2.

If you answered NO to either of the statements above, you may not be eligible for this 

program. Please see the information on page 1, or call [company 800 #] for assistance.

Section 2: Help with your prescription drug costs
23

Section 2: Help with your prescription drug costs

SAMPLE [Company Name] 

Enrollment Form for the Medicare-Approved Drug Discount Card AND

Additional Assistance in Paying for Your Prescription Drugs 

I am single and my income is:

$12,569 or less (10% coinsurance at the pharmacy)

$9,310 or less (5% coinsurance at the pharmacy)

I am married and my income, including my spouse’s income, is: 

$16,862 or less (10% coinsurance at the pharmacy)

$12,490 or less (5% coinsurance at the pharmacy)

If married, please include your spouse’s Social Security Number:

Have you recently (within the last 2 years) retired or been widowed or divorced? Yes No

Step 4: Please answer the following questions about your income:

Does your state help you pay your Medicare Part A or Part B premiums? Yes No

If you answered YES, please complete the following then SKIP to STEP 5:

Please indicate your income here: $ 

Please check one: I am single -or- I am married 

If your state helps pay your Medicare Part A or Part B premiums, you may still qualify

if your income is above $12,569 if single or $16,862 if married (your coinsurance at the 

pharmacy would be 10%).

If you answered NO, please complete the remaining questions in this box.
24

SAMPLE

Section 2: Help with your prescription drug costs

Release of Information: By applying for enrollment in this company’s Medicareapproved discount card, I allow the Centers for Medicare & Medicaid Services (CMS) to give

information to the company of the Medicare-approved drug discount card. The information

will say whether I have Medicare Hospital Insurance Benefits (Part A) and/or Supplementary

Medical Insurance Benefits (Part B). I also allow the State Medicaid Program, Social Security

Administration, and Internal Revenue Service, or any other agency with relevant information

about me to give CMS or CMS’s agents the information needed to determine if I am eligible

for the Medicare-approved prescription drug card and, if applying, for a credit of up to $600

toward prescription drugs.

Review of Eligibility: I understand that my application will be considered without

regard to race, color, sex, age, handicap, religion, national origin, or political belief. I also

understand that by signing this application I am agreeing to a full investigation or review of

my eligibility by states, federal agencies, or their contractors and, if requested, I agree to 

provide the documents necessary to confirm the accuracy and completeness of the 

information provided in this application. If documents aren’t available, I agree to give the

name of the person or organization that can provide and release this necessary information.

By signing below, you certify that you have read and understand the information on this

entire enrollment form. If you can’t sign, a representative may sign for you.

Federal law provides for fine or imprisonment, or both for any person who withholds or

gives false information to obtain assistance to which (s)he is not entitled. I understand the

questions on this application and I certify, under penalty of perjury, that the information

given by me on this form is correct and complete to the best of my knowledge. 

Signature: _____________________________Date: ____________________

Step 5: Read all the information and sign your form:

Your enrollment form is not complete unless it is signed. 

Please return your enrollment form to [company name].
25

Section 3: Steps to choosing a discount card

The five steps below can help you choose a Medicare-approved drug

discount card. Use the personal worksheets on the following pages as a

tool to help you decide which discount card is best for you. These

worksheets aren’t part of the enrollment process.

Get information about your current prescription drug

coverage. Make a list of the prescriptions you currently take

and how much you pay for each drug to see if a discount card

may be right for you. Fill in your answers on this personal

worksheet.

Find out which discount cards are available in your state, and

get information on each one.

Compare each discount card based on what is important to you.

Decide if you want a discount card. Choose the one that is best

for you. Fill out and send your enrollment form to the company.

Review your discount card choices each year.

1

2

3

4

5
26

Section 3: Steps to choosing a discount card

Get information about your current prescription drug coverage. Make a list

of the prescriptions you currently take and how much you pay for each drug

to see if a discount card may be right for you. Fill in your answers on this

personal worksheet.

1. Do you have any health insurance/coverage in addition to Medicare?

______Yes ______No (If you answer no, go to question 5.)

2. What kind of health insurance do you have (Example: an employer group health

plan, a Medigap policy, a Medicare + Choice plan, Veteran’s benefits, or TRICARE

for Life)?

3. Do you get outpatient prescription drug coverage under this plan? (If yes, go to

question 4. If no, go to question 5.)

______Yes ______No

4. How much do you pay out-of-pocket each month for your prescriptions?

$______

Is there a limit on this coverage? 

(Example: your insurance pays only $1,000 each year toward prescription drugs)

______Yes ______No

5. Do you already have a discount card (like a drugstore loyalty card or a discount card

offered by your Medicare Managed Care plan)?

______Yes ______No (If you answer no, go to question 7.)

6. What discount do you get from this card? ______%

7. In the spaces below, list specific information about the prescriptions you currently

take. If you need more space, continue on a blank piece of paper. 

Prescription name

Step 1

Dosage of 

prescription 

(ml, mg) 

Amount you pay

each month

Number of times a day

you take your prescription
27

Section 3: Steps to choosing a discount card

Find out which discount cards are available in your state, and get

information on each one.

To find out which discount cards are available in your state, look at

www.medicare.gov on the web. Select “Prescription Drug and Other Assistance

Programs.” Or, call 1-800-MEDICARE (1-800-633-4227). 

When you’ve found some discount cards you are interested in, call the private

companies and use the chart below to fill in information about these discount cards. 

Card Plan Name

Which of my prescriptions does

this discount card cover?

How much do my prescriptions cost?

Does my pharmacy accept this card?

What is the enrollment fee?

Can I use this discount card 

if I travel to other states?

Can I get my prescriptions 

through the mail?

Does mail order offer a different 

discount than a pharmacy?

What is the company’s complaint 

process? Do I understand it?

Note: If you are enrolled in a Medicare Managed Care plan that offers a Medicareapproved drug discount card to its plan members, you can only join this discount

card. See page 14 for more information if you are in a Medicare Managed Care plan.

Step 2
28

Section 3: Steps to choosing a discount card

Compare each discount card based on what is important to you.

You may want to ask yourself some of these questions:

• Which card offers discounts on most of the prescriptions I take?

• Which discount card gives me the best overall price on all of my prescriptions?

• Which company allows me to use the pharmacy I want?

If you want to get a Medicare-approved drug discount card, but don’t want 

to change your pharmacy, go to www.medicare.gov on the web. Select 

“Prescription Drug and Other Assistance Programs.” You can type in the 

name and address of your pharmacy, and get a list of the drug discount cards 

that allow you to use your pharmacy to get discounts on your prescriptions.

Decide if you want a discount card. Choose the one that is best for you. 

Fill out and send your enrollment form to the company.

Choose the discount card you think is best for you and call the private company

offering this discount card to get an enrollment form. Then, fill out the enrollment

form and mail it back to the company. You may have to include your Social Security

Number and the number on your Medicare card. 

You will also need to decide if you want to apply for the $600 credit from Medicare to

help pay for your prescriptions. Start by answering the questions on the enrollment

form to figure out if you qualify for the $600 credit. If you think you qualify, complete

the enrollment form and mail or fax it to the company offering the discount card you

want. 

Note: You may be able to sign up for the discount card over the telephone or on the

web. If you are applying for the $600 credit, you must mail or fax your completed

enrollment form to the private company.

Step 4

Step 3
29

Section 3: Steps to choosing a discount card

Review your discount card choices each year. 

Review your discount card choices because they may change. Remember,

you can get a Medicare-approved drug discount card anytime until

December 31, 2005 if

• you are joining for the first time in a calendar year, 

• you are choosing another Medicare-approved drug discount card

because the company stops offering your discount card,

• you move to a state in which your discount card isn’t offered,

• you join or leave a Medicare Managed Care plan,

• you enter or leave a long-term care facility (like a nursing home), or

• you lose Medicaid, employer group health plan, or TRICARE for

Life prescription drug coverage.

Step 5

Words in blue

are defined on

page 32.
30

Section 4: Have a problem with your discount card?

What can I do if I have a complaint? 

If you have a complaint about your drug discount card, you should

call the company first. Some examples of why you may file a

complaint are

• having to wait too long for your prescription,

• the pharmacy won’t accept the $600 credit from Medicare, 

• the pharmacy is charging you more than it is supposed to,* or

• the company is sending you materials not related to the

Medicare-approved drug discount card that you didn’t ask to

get.

* If you think you were charged too much for a prescription, call the

company offering your discount card to get the most up-to-date 

price. Prices for prescriptions can change weekly. You can also look 

at www.medicare.gov on the web to get pricing information. Select 

“Prescription Drug and Other Assistance Programs.” Or, call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.

If the company doesn’t take care of your complaint, call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.
31

Section 5: For more information

For more detailed information about the discount cards available in

your area, you can

• look at www.medicare.gov on the web. 

Select “Prescription Drug and Other Assistance Programs,” or

• call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048.

You can find out which discount cards offer discounts on your

prescriptions, the discount amount, and other choices you may have

to lower your prescription drug costs. You can also call any company

offering a discount card to get more information.

If you need help deciding which discount card may be the best for

you, call your State Health Insurance Assistance Program. To get this

telephone number, you can

• look at www.medicare.gov on the web. 

Select “Helpful Contacts,” or

• call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048.

Words in blue

are defined on

page 32.
32

Section 6: Words to know

Discount Drug List - A list of certain drugs and their proper dosages. 

The discount drug list includes the drugs the company will discount.

Enrollment Fee - The amount you must pay every year to get a

Medicare-approved drug discount card.

Generic Drug - A prescription drug that has the same active-ingredient

formula as a brand name drug. Generic drugs usually cost less than

brand name drugs and are rated by the Food and Drug Administration

(FDA) to be as safe and effective as brand name drugs.

Medicaid - A joint Federal and State program that helps with medical

costs for some people with low incomes and limited resources. Medicaid

programs vary from state to state, but most health care costs are covered

if you qualify for both Medicare and Medicaid.

Medicare + Choice Plan - A Medicare program that gives you more

choices among health plans. Everyone who has Medicare Parts A and B

is eligible, except those who have End-Stage Renal Disease unless

certain exceptions apply. Medicare + Choice plans may also be called

Medicare Advantage plans.

Medicare Managed Care Plan - A Medicare + Choice Plan option that

is available in some areas of the country. In most managed care plans, you

can only go to doctors, specialists, or hospitals on the plan’s list. Plans

must cover all Medicare Part A and Part B health care. Some managed care

plans cover extras, like prescription drugs. Your costs may be lower than in

the Original Medicare Plan.

Medigap Policy - A Medicare supplement insurance policy sold by

private insurance companies to fill “gaps” in Original Medicare Plan

coverage. Except in Massachusetts, Minnesota, and Wisconsin, there are

ten standardized plans labeled Plan A through Plan J. Medigap policies

only work with the Original Medicare Plan.

Original Medicare Plan - A pay-per-visit health plan that lets you go

to any doctor, hospital, or other health care supplier who accepts

Medicare and is accepting new Medicare patients. You must pay the

deductible. Medicare pays its share of the Medicare-approved amount,

and you pay your share (coinsurance). The Original Medicare Plan has

two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

State Health Insurance Assistance Program - A State program that

gets money from the Federal Government to give free local health

insurance counseling to people with Medicare.
33

1-800-MEDICARE ..............................3, 6, 8, 10, 13, 27, 30, 31

$600 credit ..................................................................4, 5, 17-24

Brand name drug ......................................................................12

Complaint ........................................................................6, 7, 30

Discount drug list............................................8, 9, 10, 12, 17, 32

Employer group health plan ..................................................5, 17

Enrollment fee ........................................................11, 18, 20, 32

FEHBP............................................................................5, 17, 22

Generic drug........................................................................12, 32

Long-term care facility ........................................9, 11, 14, 19, 29

Medicaid ......................................................2, 3, 5, 9, 17, 29, 32

Medicare Managed Care plan................2, 8, 9, 11, 14, 27, 29, 32

Medicare + Choice plan........................................ 4, 5, 17, 26, 32

Medigap policy..................................................2, 4, 5, 17, 26, 32

Non-Medicare-approved discount card ..................................3, 11

Nursing home......................................................9, 11, 14, 19, 29

Pharmacy ......................................................................7, 8, 9, 12

Pharmacy provider directory ......................................................12

Sample enrollment form....................................15, 16, 22, 23, 24

State Health Insurance Assistance Program ..........................10, 32

TRICARE for Life ..............................................5, 17, 22, 26, 29

Veteran’s benefits........................................................................26

Web ....................................................3, 6, 10, 12, 13, 27, 30, 31

Index
U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official Business

Penalty for Private Use, $300

Publication No. CMS-11062

March 2004

More information is available at

• www.medicare.gov on the web

• 1-800-MEDICARE (1-800-633-4227) 

To get this booklet in Braille or Spanish, call

1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048.

¿Necesita usted una copia en español?

Llame gratis al 1-800-MEDICARE 

(1-800-633-4227).