Your Guide to Medicare 

Prescription Drug Coverage

C E N T E R S f o r M E D I C A R E & M E D I C A I D S E R V I C E S 

This official government 

booklet tells you: 

■ How your coverage works 

■ How to get Extra Help if you have 

limited income and resources 

■ How Medicare drug coverage 

works with other drug coverage 

you may have 
“Your Guide to Medicare Prescription Drug Coverage” isn’t a legal 

document. Official Medicare Program legal guidance is contained in the 

relevant statutes, regulations, and rulings. 

The information in this booklet describes the Medicare program at 

the time this booklet was printed. Changes may occur after printing. 

Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get 

the most current information. TTY users can call 1-877-486-2048.

Paid for by the Department of Health & Human Services
3

Table of Contents

Section 1: The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Medicare prescription drug coverage adds to your Medicare 

health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Pick the drug coverage that meets your needs . . . . . . . . . . . . . . . . . . . . . 9

Get help with your choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Section 2: How Medicare Drug Coverage Works . . . . . . 11

How is Part D coverage different from Part B coverage for 

certain drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

What plans are available in my area? . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

How much will my drug coverage cost? . . . . . . . . . . . . . . . . . . . . . . . . . 13

How can I pay my plan premium? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

When can I join, switch, or drop a drug plan? . . . . . . . . . . . . . . . . . . . 18

How do I switch plans? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

How do I join a plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

What’s the Part D late enrollment penalty? . . . . . . . . . . . . . . . . . . . . . . 20

How much is the late enrollment penalty? . . . . . . . . . . . . . . . . . . . . . . . 20

How do I avoid paying a penalty? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Is my prescription drug coverage through the Marketplace 

considered creditable health insurance? . . . . . . . . . . . . . . . . . . . . . 22

What information do I need to join a Medicare drug plan? . . . . . . . . 22

Will I get a separate card for my Medicare drug plan? . . . . . . . . . . . . . 23

What if I need to fill a prescription before I get my 

membership card? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Where can I fill my prescriptions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Can I use an automatic refill mail-order service to get my drugs? . . . 25

What are the special rules for people with End-Stage Renal Disease 

(ESRD)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

What drugs are covered by Medicare drug plans? . . . . . . . . . . . . . . . . 26
4

What if I’m taking a drug that isn’t on my plan’s drug list 

when my drug plan coverage begins? . . . . . . . . . . . . . . . . . . . . . . . . 30

What if I join a plan, and then my doctor changes 

my prescription? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

If I take medications for different medical conditions, am I eligible 

for Medication Therapy Management? . . . . . . . . . . . . . . . . . . . . . . 32

Section 3: How to Get Extra Help . . . . . . . . . . . . . . . . . . . . 33

Ways to qualify for Extra Help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

How do I apply for Extra Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

How long will I get Extra Help if I qualify? . . . . . . . . . . . . . . . . . . . . . . 41

If I qualify for Extra Help, what can I do to make sure I pay 

the right amount? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

What if my application for Extra Help is denied? . . . . . . . . . . . . . . . . . 44

What if I don’t qualify for Extra Help? . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Other ways to save if you don’t get Extra Help . . . . . . . . . . . . . . . . . . . 46

Section 4: Your Coverage Choices . . . . . . . . . . . . . . . . . . . . 49

Get help with drug coverage decisions . . . . . . . . . . . . . . . . . . . . . . . . . . 49

What else do I need to think about before I decide to get 

Medicare drug coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

I have only Part A and/or Part B and no drug coverage . . . . . . . . . . . . 51

I have Medicare and a Medicare Supplement Insurance 

(Medigap) policy without drug coverage . . . . . . . . . . . . . . . . . . . . . 51

I have Medicare and a Medicare Supplement Insurance 

(Medigap) policy with drug coverage . . . . . . . . . . . . . . . . . . . . . . . . 52

I have Medicare and get drug coverage from a current or 

former employer or union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

I have Medicare and a Federal Employee Health Benefits 

(FEHB) plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Table of Contents (continued)
5

I have Medicare and TRICARE or benefits from the Department of 

Veterans Affairs (VA) that include drug coverage . . . . . . . . . . . . . 57

I have a Medicare health plan without drug coverage . . . . . . . . . . . . . 58

I have a Medicare health plan with drug coverage . . . . . . . . . . . . . . . . 59

I have Medicare and Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

I have Medicare and get Supplemental Security Income (SSI) 

benefits or belong to a Medicare Savings Program . . . . . . . . . . . . 61

I have Medicare and live in a nursing home or other institution . . . . 62

I have Medicare and benefits through Programs of All-inclusive 

Care for the Elderly (PACE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

I have Medicare and get help from my State Pharmacy Assistance 

Program (SPAP) paying drug costs . . . . . . . . . . . . . . . . . . . . . . . . . 64

I get help from an AIDS Drug Assistance Program (ADAP) . . . . . . . 65

I have Medicare and get drug coverage from the Indian Health 

Service, Tribe or Tribal Health Organization, or Urban 

Indian Health Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Section 5: 3 Steps to Choosing a Medicare Drug Plan . . 67

Step 1: Gather information about your current drug coverage 

and needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Step 2: Compare Medicare drug plans based on cost, coverage, 

and customer service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Step 3: Decide which plan is best for you, and join . . . . . . . . . . . . . . . . 70

Section 6: Tips for Using Your New Medicare 

Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

If you have both Medicare and Medicaid or qualify for Extra Help . . . . 71

What if the pharmacist can’t confirm my drug plan or 

Extra Help status? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6

Table of Contents (continued)

Section 7: Rights & Appeals . . . . . . . . . . . . . . . . . . . . . . . . . 73

How do I protect myself from fraud and identity theft? . . . . . . . . . . . . 73

What if I need help applying for Extra Help, joining a Medicare 

drug plan, or requesting a coverage determination or appeal? . . . 74

What if my enrollment in a Medicare drug plan is denied? . . . . . . . . 76

What if my plan won’t cover a drug I need? . . . . . . . . . . . . . . . . . . . . . . 76

How do I appeal if I have Medicare drug coverage? . . . . . . . . . . . . . . . 78

What’s the appeals process for Medicare drug coverage? . . . . . . . . . . 78

How do I file a complaint (grievance)? . . . . . . . . . . . . . . . . . . . . . . . . . . 78

What if I don’t agree with Medicare’s late enrollment penalty? . . . . . 80

Section 8: For More Information . . . . . . . . . . . . . . . . . . . . . 81

Section 9: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7

Section

1 The Basics 

Medicare prescription drug coverage adds to 

your Medicare health coverage 

Medicare prescription drug coverage (Part D) helps you pay for both 

brand-name and generic drugs. Medicare drug plans are offered 

by insurance companies and other private companies approved by 

Medicare. 

You can get coverage 2 ways: 

1. Medicare Prescription Drug Plans (sometimes called “PDPs”) add 

prescription drug coverage to Original Medicare, some Medicare 

Private Fee-for-Service (PFFS) Plans, some Medicare Cost Plans, 

and Medicare Medical Savings Account (MSA) Plans. 

2. Some Medicare Advantage Plans (like HMOs or PPOs) or 

other Medicare health plans offer prescription drug coverage. 

You generally get all of your Medicare Part A (Hospital 

Insurance), Medicare Part B (Medical Insurance), and Part D 

through these plans. Medicare Advantage Plans that offer 

prescription drug coverage are sometimes called “MA-PDs.” 

In this booklet, the term “Medicare drug plans” means all plans 

that offer Medicare prescription drug coverage.

Words in 

red are 

defined 

on pages 

83–86. 
8

1 The Basics 

Medicare prescription drug coverage adds to 

your Medicare health coverage (continued) 

Joining a drug plan 

To join a Medicare Prescription Drug Plan, you must have 

Medicare Part A (Hospital Insurance) or Medicare Part B (Medical 

Insurance). To join a Medicare Advantage Plan (like an HMO 

or PPO) or other Medicare health plan with prescription drug 

coverage, you must have Part A and Part B. You must also live in 

the service area of the Medicare health plan or drug plan you want 

to join. 

All Medicare drug plans must give at least a standard level 

of coverage set by Medicare. However, plans offer different 

combinations of coverage and cost sharing. Medicare drug plans 

may differ in the prescription drugs they cover, how much you have 

to pay, and which pharmacies you can use. 

If you decide to join a Medicare drug plan, compare plans in your 

area and choose one that meets your needs. If you don’t join a 

Medicare drug plan when you’re first eligible for Medicare, and 

you don’t have drug coverage that’s expected to pay, on average, 

at least as much as standard Medicare prescription drug coverage 

(called creditable prescription drug coverage), you may have to pay 

a lifetime late enrollment penalty if you join later. The penalty is 

in addition to your premium each month for as long as you have a 

Medicare drug plan. 

Words in 

red are 

defined 

on pages 

83–86. 
9

1 The Basics 

Pick the drug coverage that meets your needs 

Everyone with Medicare has to make a decision about prescription 

drug coverage. If you don’t use a lot of prescription drugs now, you still 

may want to think about joining a Medicare drug plan to help lower 

your drug costs now and help protect against higher costs in the future. 

If you’re new to Medicare and already have other drug coverage, you 

have new options to think about. If you aren’t new to Medicare, you may 

want to look at your options to find 

drug coverage that meets your needs. 

You can join or switch Medicare 

drug plans between October 15–

December 7 each year, with your 

coverage beginning January 1 of the 

following year. 

Consider all your drug coverage 

choices before you make a decision. 

Look at the drug coverage you may 

already have, like coverage from 

an employer or union, TRICARE, 

the Department of Veterans Affairs 

(VA), the Indian Health Service, or 

a Medicare Supplement Insurance 

(Medigap) policy. Compare your 

current coverage to Medicare drug coverage. The drug coverage you 

already have may change because of Medicare drug coverage, so 

consider all your coverage options. 

If you have (or are eligible for) other types of drug coverage, read all 

the materials you get from your insurer or plan provider. Talk to your 

benefits administrator, insurer, or plan provider before you make any 

changes to your current coverage. 

Note: Drug coverage is insurance. Doctor samples, discount cards, free 

clinics, or drug discount websites aren’t drug coverage. 

For details about how Medicare drug coverage may affect other 

coverage, see Section 4. 
10

1 The Basics 

Get help with your choices 

■ Visit the Medicare Plan Finder at Medicare.gov/find-a-plan to find 

plans in your area that cover your drugs and pharmacies that can 

fill your prescriptions. 

■ Call your State Health Insurance Assistance Program (SHIP)

for free personalized health insurance counseling. To get the 

most up-to-date SHIP phone numbers, visit shiptacenter.org or 

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

1-877-486-2048. 

■ Call 1-800-MEDICARE. 

Words in 

red are 

defined 

on pages 

83–86. 
11

Section

2

Section 2: How Medicare Drug Coverage Works 

How Medicare Drug Coverage 

Works 

Compare these things to find a plan that meets your needs: 

Coverage 

Medicare drug plans cover generic and brand-name drugs. All plans 

must cover the same categories of drugs, but generally plans can 

choose which specific drugs are covered in each drug category. 

Cost 

Plans have different monthly premiums. How much you pay for each 

drug depends on which plan you choose. If you have limited income 

and resources, you may qualify for Extra Help from Medicare with 

paying your drug plan costs. For more information on Extra Help, see 

Section 3. 

Convenience 

Check with the plan to make sure the pharmacies in the plan are 

convenient to you. Many plans also allow you to get your drugs by 

mail. If you spend part of the year in another state, see if the plan will 

cover you there. 

Quality

Use the Medicare Plan Finder at Medicare.gov/find-a-plan to get plan 

ratings in different categories, like customer service. You can also call 

1-800-MEDICARE (1-800-633-4227) for plan rating information. 

TTY users can call 1-877-486-2048. 
12

2 How Medicare Drug Coverage Works 

How is Part D coverage different from Part B 

coverage for certain drugs? 

Medicare Part B (Medical Insurance) includes limited drug coverage. 

It doesn’t cover most drugs you get at the pharmacy. You’ll need to join 

a prescription drug plan to get Medicare coverage for drugs for most 

chronic conditions, like high blood pressure. 

Part B covers certain drugs, like injections you get in a doctor’s office, 

certain oral cancer drugs, and drugs used with some types of durable 

medical equipment—like a nebulizer or external infusion pump. 

Under very limited circumstances, Part B covers certain drugs you get 

in a hospital outpatient setting. You pay 20% of the Medicare-approved 

amount for these covered drugs. Part B also covers the flu and 

pneumococcal shots. Generally, Medicare drug plans cover other 

vaccines, like the shingles vaccine, needed to prevent illness. 

Note: Medicare Part A (Hospital Insurance) or Part B generally 

doesn’t cover self-administered drugs you get in an outpatient setting 

like in an emergency room, observation unit, surgery center, or pain 

clinic. Your Medicare drug plan may cover these drugs under certain 

circumstances. You’ll likely need to pay out-of-pocket for the entire 

cost of these drugs and send in a claim to your drug plan for a refund. 

Call your plan for more information. Also, visit Medicare.gov for more 

information on how Medicare covers self-administered drugs you get 

in a hospital outpatient setting. 

What plans are available in my area? 

Get information about specific drug plans in your area by visiting 

Medicare.gov/find-a-plan or by calling 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048. For more 

information on how to compare plans and join one that meets your 

needs, see Section 5. 
13

2 How Medicare Drug Coverage Works 

How much will my drug coverage cost? 

Medicare drug plans have different coverage and costs, but all must offer 

at least a standard level of coverage set by Medicare. How much you 

actually pay for Medicare drug coverage depends on which drugs you 

use, which Medicare drug plan you join, whether you go to a pharmacy 

in your plan’s network, and whether you get Extra Help paying for your 

drug costs. Contact the plan(s) you’re interested in to get specific cost 

information. 

Your drug coverage costs are affected by: 

■ Monthly premium

■ Yearly deductible

■ Copayments or coinsurance

■ Coverage gap (also called the “donut hole”) 

■ Catastrophic coverage 

Monthly premium

Most drug plans charge a monthly fee that differs from plan to plan. 

You pay this fee in addition to the Part B premium. If you belong to a 

Medicare Advantage Plan (like an HMO or PPO) or a Medicare Cost 

Plan that includes Medicare drug coverage, the monthly premium may 

include an amount for drug coverage. 

Some people with Medicare may pay a higher monthly premium based 

on their income. If you reported a modified adjusted gross income 

of more than $85,000 (individuals and married individuals filing 

separately) or $170,000 (married individuals filing jointly) on your 2015 

IRS tax return (the most recent tax return information provided to 

Social Security by the IRS), you’ll have to pay an extra amount for your 

Medicare drug coverage, called the income-related monthly adjustment 

amount (IRMAA). You’ll pay this extra amount in addition to your 

monthly Part D plan premium. 

Social Security will send you a letter if you have to pay for this extra 

amount. Check the chart on the next page for the amount you’ll have to 

pay each month. 

Words in 

red are 

defined 

on pages 

83–86. 
14

2 How Medicare Drug Coverage Works 

If your yearly income in 2015 was 

File individual 

tax return

File joint 

tax return

File married & 

separate tax 

return

You pay 

each month 

(in 2017)

$85,000 or less $170,000 or less $85,000 or less Your plan 

premium

above $85,000 

up to $107,000

above $170,000 

up to $214,000

N/A $13.30 + your 

plan premium

above $107,000 

up to $160,000

above $214,000 

up to $320,000

N/A $34.20 + your 

plan premium

above $160,000 

up to $214,000

above $320,000 

up to $428,000

above $85,000 

up to $129,000

$55.20 + your 

plan premium

above $214,000 above $428,000 above $129,000 $76.20 + your 

plan premium

Your adjustment amount will get taken out of your monthly Social 

Security, Railroad Retirement, or Office of Personnel Management 

check, no matter how you usually pay your plan premium. If that 

amount is more than what’s in your check, you’ll get a bill from 

Medicare each month. 

If you don’t pay your entire Part D premium (and the extra amount), 

you may be disenrolled from your Part D plan. You must pay both the 

extra amount and your plan’s premium each month to keep Medicare 

drug coverage. 

If you have to pay a higher amount for your Part D premium and you 

disagree, visit socialsecurity.gov, or call 1-800-772-1213. TTY users can 

call 1-800-325-0778. 

Yearly deductible

The deductible is what you pay for your drugs before your plan begins 

to pay. No Medicare drug plan may have a deductible more than $400 

in 2017. Some plans don’t charge a deductible. 
15

2 How Medicare Drug Coverage Works 

Copayments or coinsurance

You pay copayments or coinsurance for your drugs after you pay 

the deductible. You pay your share, and your plan pays its share for 

covered drugs. 

Usually, the amount you pay for a covered drug is for a one-month 

supply of a drug. However, you can request less than a one-month 

supply for most types of drugs. You might do this if you’re trying a new 

medication that’s known to have significant side effects or you want to 

get the refills for all your drugs on the same refill schedule. If you do this, 

the amount you pay is reduced based on the quantity you actually get. 

Talk with your prescriber (a health care provider who’s legally allowed to 

write prescriptions) to get a drug for less than a one-month supply. 

Coverage gap (also called the “donut hole”) 

The Affordable Care Act has made Medicare drug coverage more 

reasonably priced for people with Medicare with the gradual closing 

of the coverage gap. You reach the coverage gap after you and your 

plan have spent a certain amount of money for covered drugs. When 

you’re in the coverage gap, you may pay more costs for your drugs 

out-of-pocket, up to a limit. Not everyone will reach the coverage 

gap. Your yearly deductible, coinsurance or copayments, and what 

you pay in the coverage gap all count toward this out-of-pocket limit. 

The limit doesn’t include the drug plan’s premium or what you pay for 

drugs that aren’t on your plan’s formulary (drug list). The limit also 

doesn’t include drugs you get through an exception. 

You won’t need to pay all out-of-pocket costs when you’re in the 

coverage gap. In 2017, your plan will cover at least 10% of the cost 

of covered brand-name drugs, and the drug manufacturer will give 

a 50% discount, for a combined savings of at least 60% on these 

brand-name drugs. The amount you pay and the 50% discount you get 

from the manufacturer both count as out-of-pocket spending that will 

help you get out of the coverage gap. Also, in 2017, Medicare will cover 

49% of the price for generic drugs when you’re in the coverage gap. 

The coverage gap will continue to shrink each year until 2020, when 

you’ll only pay 25% for both covered generic and brand-name drugs 

when in the gap. 

Words in 

red are 

defined 

on pages 

83–86. 
16

2 How Medicare Drug Coverage Works 

For each month that you fill a prescription, your drug plan mails you an 

“Explanation of Benefits” (EOB) notice, which tells you how much you’ve 

spent on covered drugs and if you’ve reached the coverage gap. In 2017, your 

EOB notice will also show the 10% your plan pays and the 50% discount 

from the drug manufacturer on covered brand-name drugs you buy in the 

coverage gap. 

Catastrophic coverage 

The amount you pay for drugs and the 50% discount in the coverage gap 

both count toward your out-of-pocket limit. Once you reach your plan’s 

out-of-pocket limit, you come out of the coverage gap and you automatically 

get “catastrophic coverage.” Under catastrophic coverage, you only pay a 

small coinsurance amount or a copayment for the rest of the year. 

The example below shows the costs for covered drugs in 2017 for a plan that 

has a coverage gap: 

Ms. Smith joined the ABC Prescription Drug Plan. Her coverage began on 

January 1, 2017. She doesn’t get Extra Help and uses her Medicare drug plan 

membership card when she buys drugs. 

Monthly premium—Ms. Smith pays a monthly premium throughout the year. 

1. Yearly 

deductible 

2. Copayment 

or coinsurance 

3. Coverage gap 4. Catastrophic 

coverage 

Ms. Smith 

pays the 

first $400 

of her 

drug costs 

before her 

plan starts 

to pay its 

share.

→

Ms. Smith pays 

a copayment, 

and her plan 

pays its share 

for each covered 

drug until their 

combined

amount (plus 

the deductible) 

reaches $3,700. 

→

Once Ms. Smith and her plan have 

spent $3,700 for covered drugs, she’s 

in the coverage gap. In 2017, she 

gets a 50% discount from the drug 

manufacturer on covered brand-name 

prescription drugs that counts as 

out-of-pocket spending, and helps her 

get out of the coverage gap. For 2017, 

she gets an additional 10% coverage 

from her plan on covered brand-name 

drugs and 49% coverage on covered 

generic drugs while in the coverage gap. 

→

Once Ms. Smith 

has spent $4,950 

out-of-pocket 

for the year, her 

coverage gap 

ends. Now, she 

only pays a small 

copayment or 

coinsurance for 

each drug until 

the end of the 

year. 
17

2 How Medicare Drug Coverage Works 

Visit the Medicare Plan Finder at Medicare.gov/find-a-plan to view 

estimated yearly costs for each plan and your costs per drug for 

each month. 

How can I pay my plan premium? 

You can pay your premium by: 

■ Signing up to have your plan deduct it from your checking or savings 

account. 

■ Charging it to a credit or debit card. 

■ Having your plan bill you each month directly. Some plans bill in 

advance for next month’s coverage. Send your payment to the plan—

not to Medicare. Contact your plan for their payment address. 

■ Having funds withheld from your Social Security payment. 

Contact your plan—not Social Security—to ask for this payment 

option. It may take up to 3 months to start, and it’s likely the first 3 

months of premiums will be collected at one time. 

■ If you get Extra Help to pay part of your drug plan premium, 

Social Security may withhold your share of the monthly 

premiums.

■ Note: If you’re in an employer health plan and your plan pays 

part of your drug plan premium, Social Security can’t withhold 

your share of the monthly premiums.

Example of Social Security withholding: Ms. Brown’s 

monthly drug plan premium is $25, and her coverage 

begins in January. Her first premium payment of $75 is 

collected in March. It includes her premium for January, 

February, and March. Starting in April, only one month 

of premium payments ($25) will be withheld from her 

Social Security payment each month. 

If you qualify for Extra Help, it will cover some or all of your drug plan 

premiums. For more information, see Section 3. 

Words in 

red are 

defined 

on pages 

83–86. 
18

2 How Medicare Drug Coverage Works 

When can I join, switch, or drop a drug plan? 

■ During your 7-month Initial Enrollment Period, when you first become 

eligible for Medicare. You can join a Medicare drug plan during the 

7-month period that begins 3 months before you turn 65, includes the 

month you turn 65, and ends 3 months after the month you turn 65. If 

you join during 1 of the 3 months before you turn 65, your coverage will 

begin the first day of the month you turn 65. If you join during the month 

you turn 65 or 1 of the 3 months after you turn 65, your coverage will 

begin the first day of the month after you ask to join a plan. 

■ During the 7-month period around your 25th month of disability.

If you get Medicare due to a disability, you can join a Medicare drug 

plan during the 7-month period that begins 3 months before your 25th 

month of getting disability, includes your 25th month of getting disability, 

and ends 3 months after your 25th month of getting disability. If you 

join during 1 of the 3 months before your 25th month of disability, your 

coverage will begin the first day of the 25th month of disability. If you join 

during your 25th month of getting disability or 1 of the 3 months after 

your 25th month of getting disability, your coverage will begin the first 

day of the month after you ask to join a plan. You’ll have another chance 

to join when you turn 65 (see above). 

■ During Open Enrollment, between October 15–December 7 each year. 

Your coverage begins January 1 the following year, as long as the plan gets 

your request during Open Enrollment. 

■ At any time if you qualify for Extra Help. This includes people who 

have Medicare and Medicaid, belong to a Medicare Savings Program, 

get Supplemental Security Income (SSI) benefits, and those who apply 

and qualify. Your coverage will begin the first day of the month after you 

qualify for Extra Help and ask to join a plan. 

Note: In certain limited circumstances, you may be able to join, drop, 

or switch to another Medicare drug plan at other times. For example, you 

may be able to switch at other times if: 

■ You permanently move out of your drug plan’s service area. 

■ You lose creditable prescription drug coverage. 

■ You enter, live in, or leave a nursing home. 
19

2 How Medicare Drug Coverage Works 

■ You want to switch to a plan with a 5-star overall quality rating. 

Quality ratings are available on Medicare.gov.

■ Your plan tells you that it’s leaving the Medicare program or Medicare 

has ended its contract. 

If you currently have Medicare drug coverage, you may want to review 

your coverage each fall. If you’re happy with your coverage, cost, and 

customer service, and your Medicare drug plan is still offered in your area, 

you don’t have to do anything to continue your coverage for another year. 

However, if you decide another plan will better meet your needs, you can 

switch to a different plan. 

How do I switch plans? 

All you need to do is join a new plan. You don’t need to tell your current 

drug plan you’re leaving or send them anything because joining a different 

Medicare drug plan, at the times listed on the previous page, disenrolls you 

from your current drug plan. Your new Medicare drug plan should send 

you a letter telling you when your coverage with your new plan begins. 

How do I join a plan? 

Contact the company that offers the plan. You may be able to enroll on 

the plan’s website, or by mailing or faxing a completed enrollment form to 

the plan. 

You can also enroll directly by visiting 

Medicare.gov/find-a-plan/questions/enroll-now.aspx, or by calling 

1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 

Visit Medicare.gov/find-a-plan, or call 1-800-MEDICARE to get a list of 

Medicare plans in your area. 

To join a Medicare drug plan, you’ll need to give your Medicare number 

and the date your Medicare Part A (Hospital Insurance) and/or Medicare 

Part B (Medical Insurance) coverage started, which you’ll find on your 

Medicare card. 

Note: Medicare drug plans aren’t allowed to call you to enroll you in a 

plan. Call 1-800-MEDICARE to report a plan that does this.

Words in 

red are 

defined 

on pages 

83–86. 
20

2 How Medicare Drug Coverage Works 

What’s the Part D late enrollment penalty? 

The late enrollment penalty is an amount that’s added to your Part D 

premium if, at any time after your Part D Initial Enrollment Period is 

over, there’s a period of 63 or more days in a row when you don’t have 

Part D or other creditable prescription drug coverage. 

Note: If you get Extra Help, you don’t pay a late enrollment penalty. 

How much is the late enrollment penalty? 

Currently, the late enrollment penalty is calculated by multiplying 

the 1% penalty rate times the “national base beneficiary premium” 

($35.63 in 2017) times the number of full, uncovered months you 

were eligible to join a Medicare drug plan but didn’t and went 

without other creditable prescription drug coverage. 

The final amount is rounded to the nearest $.10 and added to your 

monthly premium. The “national base beneficiary premium” may 

go up each year, so the penalty amount may also go up each year. 

In addition to your premium each month, you may have to pay this 

penalty for as long as you have a Medicare drug plan. 

Words in 

red are 

defined 

on pages 

83–86. 
21

2 How Medicare Drug Coverage Works 

Example: 

Mrs. Martinez is currently eligible for Medicare, and her Initial 

Enrollment Period ended on May 31, 2014. She doesn’t have 

prescription drug coverage from any other source. She didn’t join 

by May 31, 2014, and instead joined during the Open Enrollment 

Period that ended December 7, 2016. Her drug coverage was effective 

January 1, 2017. 

Since Mrs. Martinez was without creditable prescription drug 

coverage from June 2014–December 2016, her penalty in 2017 was 

31% (1% for each of the 31 months) of $35.63 (the national base 

beneficiary premium for 2017) or $11.05. Since the monthly penalty 

is always rounded to the nearest $0.10, she paid $11.10 each month in 

addition to her plan’s monthly premium in 2017. 

Here’s the math: 

.31 (31% penalty) × $35.63 (2017 base beneficiary premium) = $11.05 

$11.05 (rounded to the nearest $0.10) = $11.10 

$11.10 = Mrs. Martinez’s monthly late enrollment penalty for 2017 

When you join a Medicare drug plan, the plan will tell you if you owe a 

penalty and what your premium will be. 

How do I avoid paying a penalty? 

■ Join a Medicare drug plan when you’re first eligible (see page 18), or 

have other creditable prescription drug coverage at that time. 

■ Don’t go 63 days or more in a row without a Medicare drug plan or 

other creditable prescription drug coverage. Creditable prescription 

drug coverage could include drug coverage from a former employer 

or union, TRICARE, the Department of Veteran Affairs (VA), or the 

Indian Health Service. Your plan must tell you each year if your drug 

coverage is creditable. It may send you this information in a letter, or let 

you know in a newsletter or other piece of mail. Keep this information, 

because you may need it if you join a Medicare drug plan later. 
22

2 How Medicare Drug Coverage Works 

■ Tell your Medicare drug plan when you join if you have other 

creditable prescription drug coverage. When you join a Medicare 

drug plan, the plan may send you a letter asking if you have 

creditable prescription drug coverage if the plan believes you went 

63 or more days in a row without other creditable prescription drug 

coverage. Complete the form and return it by the deadline in the 

letter. If you don’t tell your plan about your creditable prescription 

drug coverage, you may have to pay the late enrollment penalty. 

Is my prescription drug coverage through the 

Marketplace considered creditable health 

insurance? 

The Health Insurance Marketplace helps uninsured people find 

health coverage, and the Small Business Health Options Program 

(SHOP) Marketplace helps businesses provide health coverage to their 

employees. 

Prescription drug coverage in a Marketplace or SHOP Marketplace 

plan isn’t required to be creditable prescription drug coverage. 

However, all private insurance companies offering prescription drug 

coverage, including Marketplace and SHOP plans, are required to 

determine if their prescription drug coverage is creditable each year 

and let you know in writing. 

For more information on the Marketplace or SHOP Marketplace, visit 

HealthCare.gov. 

What information do I need to join a Medicare 

drug plan? 

■ Name, birth date, and permanent home address 

■ Information found on your Medicare card (like your Medicare 

number) 

■ How you want to pay your plan premiums

■ Other insurance information and any creditable coverage notices 

Words in 

red are 

defined 

on pages 

83–86. 
23

2 How Medicare Drug Coverage Works 

You may be asked for this information when you join a Medicare drug 

plan, but it’s optional and not required to process your enrollment: 

■ Email address 

■ Name and information for an emergency contact 

■ Name, address, and phone number of nursing home or institution

where you live (if applicable) 

Once you join a plan, it will send you specific materials you’ll need, like 

a membership card, member handbook, formulary (drug list), pharmacy 

provider directory, and complaint and appeal procedures. 

Will I get a separate card for my Medicare drug 

plan? 

When you join a Medicare Prescription Drug Plan that works with 

Original Medicare, the plan will mail you a separate card to use when 

you fill your prescriptions. You’ll still use your Medicare card for hospital 

and doctor services. If you join a Medicare Advantage Plan (like an HMO 

or PPO) or other Medicare health plan with drug coverage, you’ll also 

get a new card to use when filling your prescriptions and for hospital and 

doctor visits. 

What if I need to fill a prescription before I get my 

membership card? 

Within 2 weeks after your plan gets your completed application, you’ll 

get a letter letting you know it got your information. Within 5 weeks, you 

should get a welcome package with your membership card. If you need 

to go to the pharmacy before your membership card arrives, you can use 

any of these as proof of membership: 

■ The acknowledgement, confirmation, or welcome letter you got from 

the plan 

■ An enrollment confirmation number you got from the plan, and the 

plan name and phone number 

■ A temporary card you may be able to print from MyMedicare.gov
24

2 How Medicare Drug Coverage Works 

Also bring your Medicare and/or Medicaid card and a photo ID, like 

your driver’s license. If you qualify for Extra Help, see page 43 for 

more information about what you can use as proof of Extra Help. 

If you don’t have any of the items on the previous page, and your 

pharmacist can’t get your drug plan information any other way, you 

may have to pay out-of-pocket for the entire cost of your drugs. Save 

the receipts and contact your plan if you do pay for your drugs 

out-of-pocket—you may be able to get back some of the cost or have 

the amount credited toward your out-of-pocket costs. 

Once you choose a plan, enroll early in the month. This gives the 

Medicare drug plan time to mail you important information, like 

your membership card, before your coverage becomes effective. 

This way, even if you go to the pharmacy on your first day of coverage, 

you can fill your prescriptions without delay. 

Where can I fill my prescriptions?

Each company that offers a Medicare drug plan has a list of 

pharmacies you can use. If you want to continue filling prescriptions 

at the same pharmacy you use now, check to see if the pharmacy is 

on the plan’s list. You can visit Medicare.gov, or call the plan, your 

pharmacy, or 1-800-MEDICARE (1-800-633-4227) to see if your 

pharmacy works with the plan you want to join. TTY users can call 

1-877-486-2048. 

Once you join a Medicare drug plan, the company will send you a 

pharmacy provider directory. Generally, you must go to one of these 

pharmacies for your plan to cover your drugs. Medicare requires plans 

to have network pharmacies for you to choose from. Plans can’t make 

you use a mail-order pharmacy, but you may have this option and 

want to use it. You may find using a mail-order pharmacy to be a cost 

effective and convenient way to fill prescriptions for drugs you take 

every day. 
25

2 How Medicare Drug Coverage Works 

Can I use an automatic refill mail-order service to 

get my drugs? 

Some people with Medicare get their drugs by using an “automatic refill” 

service that automatically delivers prescription drugs when you’re about to 

run out. 

Plans have to get your approval to deliver a prescription drug (new or 

refill) unless you ask for the refill or request the new prescription. Some 

plans may ask you for your approval every year so that they can send you 

your drugs without asking you before each delivery. Other plans may ask 

you before every delivery. 

This policy doesn’t affect refill reminder programs where you go in person 

to pick up the drug, and it doesn’t apply to long-term care pharmacies that 

give out and deliver prescription drugs. 

Note: Be sure to give your pharmacy the best way to reach you, so you 

don’t miss the refill confirmation call or other communication. 

Contact your plan if you get any unwanted prescription drugs through 

an automated delivery program. You may be eligible for a refund for the 

amount you were charged. Call 1-800-MEDICARE (1-800-633-4227) if 

you experience any problems using automatic delivery and billing. TTY 

users can call 1-877-486-2048. 

What are the special rules for people with End-Stage 

Renal Disease (ESRD)? 

If you have End-Stage Renal Disease (ESRD) and you’re in Original 

Medicare, you can join a Medicare Prescription Drug Plan. You generally 

can’t join a Medicare Advantage Plan (like an HMO or PPO) except: 

■ If you’re already in a Medicare Advantage Plan when you develop ESRD. 

You can stay in it or join another plan offered by the same company 

under certain circumstances. 

■ If you’re a member of a health plan (like through a former employer 

or union) offered by the same company that offers one or more Medicare 

Advantage Plans. You may be able to join one of their Medicare 

Advantage Plans when you develop ESRD. 
26

2 How Medicare Drug Coverage Works 

■ If you’ve had a successful kidney transplant. You may be able to join 

a Medicare Advantage Plan. 

If you have End-Stage Renal Disease (ESRD) and are in a Medicare 

Advantage Plan (like an HMO or PPO), and the plan leaves Medicare 

or no longer provides coverage in your area, you have a one-time right 

to join another Medicare Advantage Plan, but you don’t have to use this 

right immediately. If you go directly to Original Medicare after your 

plan leaves or stops providing coverage, you may use this right later as 

long as the plan accepts new members. 

Also, you may be able to join a Medicare Special Needs Plan (SNP), 

a type of Medicare Advantage Plan for people with certain chronic 

diseases and conditions or who have specialized needs, if one is 

available in your area. 

If you have ESRD and join a Medicare Prescription Drug Plan, 

Medicare Part B (Medical Insurance) will pay for some of the drugs 

you need, like injectable drugs and their oral forms, and biologicals 

including erythropoiesis-stimulating agents used for dialysis. Part D 

will continue to cover most ESRD-related drugs that are available only 

in oral form. 

Visit Medicare.gov for more information if you have ESRD. You can 

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

1-877-486-2048. 

What drugs are covered by Medicare drug plans? 

Each plan may cover different drugs, so there’s no single formulary

(drug list) that fits all plans. All Medicare drug plans must make sure 

the people in their plan can get medically necessary drugs to treat their 

conditions. Drug lists, prior authorization, step therapy, and quantity 

limits are some of the coverage rules plans use to make sure certain 

drugs are used correctly and only when medically necessary. These 

coverage rules are described on the following pages. 

Words in 

red are 

defined 

on pages 

83–86. 
27

2 How Medicare Drug Coverage Works 

Drug lists 

Most Medicare drug plans have their own formulary (drug list). Plans 

cover both generic and brand-name drugs. Although Medicare drug 

plans aren’t required to cover certain drugs (like drugs used for weight 

loss, weight gain, or erectile dysfunction, or over-the-counter drugs), 

some plans may cover them as an added benefit. 

All Medicare drug plans generally must cover at least 2 drugs per 

drug category, but the plans can choose which specific drugs they 

cover. Plans are required to cover almost all drugs within these 

protected classes: antipsychotics, antidepressants, anticonvulsants, 

immunosuppressants, cancer drugs, and HIV/AIDS drugs. 

A Medicare drug plan can make some changes to its drug list during 

the year if it follows guidelines set by Medicare. Your plan may change 

its drug list during the year because drug therapies change, new drugs 

are released, or new medical information becomes available. 

If the change involves a drug you’re currently taking, your plan must 

do one of these: 

■ Give you notice in writing at least 60 days before the date the change 

becomes effective. 

■ At the time you request a refill, provide written notice of the change 

and a 60-day supply of the drug under the same plan rules as before 

the change. 

Note: A plan isn’t required to tell you in advance if it removes a drug 

from its drug list because the Food and Drug Administration (FDA) is 

taking the drug off the market for safety reasons, but it’ll let you know 

afterward. 

You may need to change the drug you use or pay more for it. In some 

cases, you can keep taking the drug until the end of the year. You can 

also ask for an exception. See page 77. 
28

2 How Medicare Drug Coverage Works 

If you use a drug not on your plan’s drug list, you’ll have to pay full 

price, instead of a copayment or coinsurance, unless you qualify for a 

formulary exception. All Medicare drug plans have negotiated to get 

lower prices for the drugs on their drug lists, so using those drugs will 

generally save you money. Also, using generics instead of brand-name 

drugs may save you money. 

Generic drugs 

The FDA says generic drugs are copies of brand-name drugs and are the 

same as those brand-name drugs in dosage form, safety, strength, route 

of administration, quality, performance characteristics, and intended 

use. Generic drugs use the same active ingredients as brand-name drugs. 

Generic drug makers must prove to the FDA that their product works 

the same way as the brand-name prescription drug. In some cases, there 

may not be a generic drug the same as the brand-name drug you take, 

but there may be a generic drug that will work as well for you. Talk to 

your doctor or other prescriber. 

Tiers 

To lower costs, many plans place drugs into different “tiers” on their 

formularies (drug lists). Each tier costs a different amount. A drug in a 

lower tier will cost you less than a drug in a higher tier. Each plan can 

divide its tiers in different ways. 

Example of a drug plan’s tiers: 

■ Tier 1–Generic drugs. Tier 1 drugs cost the least. 

■ Tier 2–Preferred brand-name drugs. Tier 2 drugs cost more than 

Tier 1 drugs. 

■ Tier 3–Non-preferred brand-name drugs. Tier 3 drugs cost the 

most. 

Your plan’s drug list might not include a drug you take. However, in 

most cases, you can get a similar drug that’s just as effective. 

Words in 

red are 

defined 

on pages 

83–86. 
29

2 How Medicare Drug Coverage Works 

Prior authorization 

You may need drugs that require prior authorization. This means 

before the plan will cover a particular drug, you must show the plan 

you meet certain criteria for you to have that particular drug. Plans 

also do this to be sure these drugs are used correctly. Contact your 

plan about its prior authorization requirements, and talk with your 

prescriber. 

However, if your prescriber believes that it’s medically necessary for 

you to be on that particular drug even though you don’t meet the prior 

authorization criteria, you or your prescriber can contact the plan to 

request an exception. Your prescriber must give a statement supporting 

the request. If the request is approved, the plan will cover the particular 

drug, even if you didn’t get prior authorization for the drug. 

Step therapy

Step therapy is a type of coverage rule. In most cases, you must first try 

a certain less-expensive drug on the plan’s formulary (drug list) that’s 

been proven effective for most people with your condition before you 

can move up a “step” to a more expensive drug. For instance, some 

plans may require you first try a generic drug (if available), then a 

less expensive brand-name drug on their drug list before it’ll cover a 

similar, more expensive, brand-name drug. 

However, if your prescriber believes that because of your medical 

condition it’s medically necessary for you to be on a more expensive 

step therapy drug without trying the less expensive drug first, you or 

your prescriber can contact the plan to request an exception. Your 

prescriber can also request an exception if he or she believes you’ll have 

adverse health effects if you take the less expensive drug, or if your 

prescriber believes the less expensive drug would be less effective. Your 

prescriber must give a statement supporting the request. If the request 

is approved, the plan will cover the more expensive drug, even if you 

didn’t try the less expensive drug first. 
30

2 How Medicare Drug Coverage Works 

Example: 

Step 1–Dr. Smith wants to prescribe an ACE inhibitor to treat 

Mr. Mason’s heart failure. There’s more than one type of ACE inhibitor. 

Some of the drugs Dr. Smith considers prescribing are brand-name 

drugs covered by Mr. Mason’s Medicare drug plan. The plan rules 

require Mr. Mason to use a generic drug first. For most people, the 

generic drug works as well as the brand-name drugs. 

Step 2–If Mr. Mason takes the generic drug but has side effects or 

limited improvement, Dr. Smith can provide that information to the 

plan to request approval to cover a brand-name drug that Dr. Smith 

wants to prescribe. If approved, Mr. Mason’s Medicare drug plan will 

then cover the requested brand-name drug. 

Quantity limits

For safety and cost reasons, plans may limit the amount of drugs they 

cover over a certain period of time. For example, most people prescribed 

heartburn medication take 1 tablet per day for 4 weeks. Therefore, a plan 

may cover only an initial 30-day supply of heartburn medication. 

If your prescriber believes that, because of your medical condition, a 

quantity limit isn’t medically appropriate (for example, your doctor believes 

you need a higher dosage of 2 tablets per day), you or your prescriber can 

contact the plan to ask for an exception (see page 77). 

What if I’m taking a drug that isn’t on my plan’s drug 

list when my drug plan coverage begins? 

Generally, your drug plan will give you a one-time, temporary supply of your 

current drug during your first 90 days in a plan. Plans must give you this 

temporary supply so that you and your prescriber have time to find another 

drug on the plan’s formulary (drug list) that will work as well as what you’re 

taking now, or you or your prescriber can contact the plan to ask for an 

exception. There may be different rules for people who move into or already 

live in an institution (like a nursing home or long-term care hospital). 
31

2 How Medicare Drug Coverage Works 

However, if you already tried similar drugs on your plan’s drug list and 

they didn’t work, or if your prescriber decides you need a certain drug 

because of your medical condition, you or your prescriber can contact 

your plan to ask for an exception as soon as your coverage begins. 

Also, you or your prescriber can ask for an exception if your prescriber 

thinks you need to have a coverage rule, like a quantity limit waived. 

If the plan agrees to your request, it’ll cover the drug. If your plan 

doesn’t agree to the exception, you can appeal the plan’s decision. 

For more information on appeals, see pages 74–80. 

What if I join a plan, and then my doctor changes 

my prescription? 

Your doctor or other prescriber may need to change your prescription 

or prescribe a new drug. If your doctor prescribes electronically, he 

or she can check which drugs your drug plan covers through his or 

her electronic prescribing system. If your doctor doesn’t prescribe 

electronically, give him or her a copy of your Medicare drug plan’s 

current formularies (drug lists). 

If your doctor needs to prescribe a drug not on your Medicare drug 

plan’s drug list and you don’t have any other health coverage that 

covers outpatient prescription drugs, you or your doctor can ask 

the plan for an exception. For more information on exceptions, see 

page 77. 

If your plan still won’t cover a specific drug you need, you can file an 

appeal. If you want to get the drug before you file an appeal, you may 

have to pay out-of-pocket for the entire cost of the drug. Keep the 

receipt and give a copy of it to the person deciding your appeal. If you 

win the appeal, the plan will pay you back. For more information 

about what to do if a plan won’t cover a drug you need, see page 76–77. 

Plans can change their drug list and costs for drugs. Call your plan or 

look on your plan’s website to find the most up-to-date Medicare drug 

list and costs. 

Words in 

red are 

defined 

on pages 

83–86. 
32

2 How Medicare Drug Coverage Works 

If I take medications for different medical conditions, 

am I eligible for Medication Therapy Management? 

If you’re in a Medicare drug plan and take medications for different medical 

conditions, you may be eligible to get services, at no cost to you, through a 

Medication Therapy Management (MTM) program. This program helps you 

and your doctor make sure that your medications are working to improve 

your health. A pharmacist or other health professional will give you a 

comprehensive medication review of all your drugs and talk with you about: 

■ How to get the most benefit from the drugs you take. 

■ Any concerns you have, like medication costs and drug reactions. 

■ How best to take your medications. 

■ Any questions or problems you have about your prescription drug and 

over-the-counter medication. 

You’ll get a written summary of this discussion to have available when 

you talk with your health care providers. The summary has a medication 

action plan that recommends what you can do to make the best use of your 

medications, with space for you to take notes or write down any follow-up 

questions. You’ll also get a personal medication list that will include all of the 

medications you’re taking and why you take them. 

Your drug plan may enroll you in this program if you meet all of these 

conditions: 

1. You have multiple chronic health conditions. 

2. You take several different medications.

3. Your medications have a combined cost of more than $3,919 for 2017. This 

dollar amount (which can change each year) is estimated based on your 

out-of-pocket costs and the costs your plan pays for the medications each 

calendar year. Your plan can help you find out if you may reach this dollar 

limit.

Visit Medicare.gov/find-a-plan to get general information about program 

eligibility for your Medicare drug plan or for other plans that interest you. 

Contact each drug plan for specific details. 
33

Section

3 How to Get Extra Help 

Ways to qualify for Extra Help 

The chart on the following page shows different ways you may 

qualify for Extra Help, depending on your situation. It includes 

many, but not all, of the types of letters that Medicare sends, by 

color and name.

If you get one or more of these letters, keep them in case you 

need to show them to your plan as proof that you qualify for 

Extra Help. 
34

3 How to Get Extra Help 

When you Medicare will 

mail you a 

letter that’s 

this color

Official name

Automatically qualify for Extra Help because 

of any of these: 

■ You have both Medicare and Medicaid

■ You’re in a Medicare Savings Program

■ You get Supplemental Security Income (SSI) 

benefits

Purple “Deemed Status 

Notice”

Automatically qualify for Extra Help because 

you qualify for Medicare and Medicaid 

and currently get benefits through Original 

Medicare

Yellow “Auto-Enrollment 

Notice” 

Continue to automatically qualify for Extra 

Help, but you’ll have different copayment

levels next year 

Orange “Change in Extra 

Help Copayment 

Notice” 

Qualify for Extra Help because of one of these:

■ You belong to a Medicare Savings Program 

■ You get Supplemental Security Income (SSI) 

■ You applied and qualified for Extra Help

Green “Facilitated 

Enrollment 

Notice” 

Already get Extra Help, you joined a Medicare 

Prescription Drug Plan on your own, and your 

plan’s premium is changing

Tan “LIS Choosers 

Notice”

Already get Extra Help and Medicare 

reassigned you into a new Medicare 

Prescription Drug Plan for the coming year 

Blue “Reassign 

Formulary Notice”

No longer automatically qualify for Extra Help 

for the coming year

Grey “Loss of Deemed 

Status Notice”

Visit Medicare.gov/forms-help-and-resources/mail-about-medicare/mail-about-medicare.html

for more information about each type of letter. 
35

3 How to Get Extra Help 

Words in 

red are 

defined 

on pages 

83–86. 

If you automatically qualify for Extra Help, you don’t need 

to apply.

Medicare mails purple “Deemed Status Notices” to people 

who automatically qualify for Extra Help. If you get one, keep 

it as confirmation that you qualify. You don’t need to apply for 

Extra Help if you get this purple notice. 

You automatically qualify for Extra Help if you get any of 

these: 

■ Full coverage from a state Medicaid program 

■ Help from your state Medicaid program paying your 

Medicare Part B premiums through a Medicare Savings 

Program 

■ Supplemental Security Income (SSI) benefits 

If you aren’t already in a Medicare drug plan, you must join 

one to get this Extra Help. If you don’t join a Medicare drug 

plan on your own, Medicare will enroll you in a plan, unless 

you have certain retiree drug coverage from a former employer 

or union. If Medicare enrolls you in a plan, then Medicare 

will send you a yellow “Auto-Enrollment Notice” (if you get 

full Medicaid coverage) or a green “Facilitated Enrollment 

Notice” (if you belong to a Medicare Savings Program or get 

SSI) letting you know when your coverage begins. Check to see 

if the plan covers the drugs you use and if you can go to the 

pharmacies you want. 

If Medicare enrolls you in a plan that doesn’t meet your needs, 

you can switch plans at any time, and your new plan will begin 

the first day of the next month. If you don’t want Medicare 

to enroll you in a Medicare drug plan, call the plan listed in 

the notice. Tell them you don’t want to be in a Medicare drug 

plan and want to “opt out” of (decline) enrollment. Or, call 

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

1-877-486-2048. 
36

3 How to Get Extra Help 

Medicare drug plan costs if you automatically qualify for Extra Help in 2017 

If you have Medicare and... Your 

monthly 

premium*

Your yearly 

deductible

Your cost per drug 

at the pharmacy 

(until $4,950**) 

Your cost per drug 

at the pharmacy 

(after $4,950**) 

Full Medicaid coverage 

for each full month you 

live in an institution, like a 

nursing home 

$0 $0 $0 $0 

Full Medicaid coverage, 

and you get home- and 

community-based services 

$0 $0 $0 $0 

Full Medicaid coverage and 

have a yearly income 

at or below $12,060 (single) 

or $16,240 (married) 

$0 $0 Generic and certain 

preferred drugs:

No more than $1.20 

Brand-name drugs: 

No more than $3.70 

$0 

Full Medicaid coverage and 

have a yearly income above 

$12,060 (single) or

$16,240 (married) 

$0 $0 Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs: 

No more than $8.25 

$0 

Help from Medicaid paying 

your Medicare 

Part B premiums 

$0 $0 Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs: 

No more than $8.25 

$0 

Supplemental Security 

Income (SSI) 

$0 $0 Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs: 

No more than $8.25 

$0 

Notes: *There are plans you can join and pay no premium. There are other plans where you’ll have to 

pay part of the premium even when you automatically qualify for Extra Help. Tell your plan you qualify 

for Extra Help and ask how much you’ll pay for your monthly premium. 

** Your cost per drug generally decreases once the amount you pay and Medicare pays in Extra Help 

reaches $4,950 per year. 

The cost sharing, income levels, and resources listed are for 2017 and can increase each year. 

Income levels are higher if you live in Alaska or Hawaii, or you or your spouse pays at least half of the 

living expenses of dependent family members who live with you, or you work. 
37

3 How to Get Extra Help 

Words in 

red are 

defined 

on pages 

83–86. 

If you apply and qualify for Extra Help 

If you think you qualify for Extra Help, you can do one of these: 

■ Visit socialsecurity.gov/i1020 to apply online, or call Social Security 

at 1-800-772-1213. TTY users can call 1-800-325-0778. 

■ Apply at your State Medical Assistance (Medicaid) office. 

■ Visit Medicare.gov/contacts, or call 1-800-MEDICARE 

(1-800-633-4227), and say “Medicaid” to get the phone number. 

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

There’s no risk or cost to apply. Remember, even if you qualify, you 

still need to join a Medicare drug plan to get the Extra Help. For more 

information on what income and resources count when you apply, see 

pages 39–40. 

If you apply and qualify for Extra Help, in most cases Medicare will 

enroll you in a Medicare drug plan if you don’t join one on your own. 

This makes sure you get help paying for your drug costs. Medicare will 

mail you a green letter letting you know when your coverage begins. 

Check to see if the plan covers the drugs you use and if you can go to 

the pharmacies you want. If not, you can change plans. If Medicare 

enrolls you in a plan that doesn’t meet your needs, you can switch 

plans at any time, and your new plan will begin the first day of the next 

month. 

If you don’t want Medicare to enroll you in a Medicare drug plan (for 

example, because you want to keep your employer or union coverage), 

call the plan listed in the green letter. Tell them you don’t want to be 

in a Medicare drug plan and want to “opt out” of (decline) enrollment. 

Or, call 1-800-MEDICARE. 
38

3 How to Get Extra Help 

Medicare drug plan costs if you apply and qualify for Extra Help in 2017 

If you have Medicare and... Your 

monthly 

premium*

Your 

yearly 

deductible

Your cost per drug 

at the pharmacy 

(until $4,950**) 

Your cost per drug 

at the pharmacy 

(after $4,950**)

A yearly income below 

$16,281 (single) or

$21,924 (married) with 

resources of no more than 

$8,890 (single) or

$14,090 (married) 

$0 $0 Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs:

No more than $8.25 

$0 

A yearly income below 

$16,281 (single) or

$21,924 (married) 

with resources between 

$8,890 – $13,820 (single) or

$14,090 – $27,600 (married) 

$0 $82 Up to 15% of the 

cost of each drug

Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs:

No more than $8.25 

A yearly income between 

$16,281– $16,884 (single) or

$21,924 – $22,736 (married) 

with resources up to 

$13,820 (single) or

$27,600 (married) 

25% $82 Up to 15% of the 

cost of each drug

Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs:

No more than $8.25 

A yearly income between 

$16,884 – $17,487 (single) or

$22,736 – $23,548 (married) 

with resources up to 

$13,820 (single) or

$27,600 (married) 

50% $82 Up to 15% of the 

cost of each drug

Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs:

No more than $8.25 

A yearly income between 

$17,487 – $18,090 (single) or

$23,548 – $24,360 (married) 

with resources up to 

$13,820 (single) or

$27,600 (married)

75% $82 Up to 15% of the 

cost of each drug

Generic and certain 

preferred drugs:

No more than $3.30 

Brand-name drugs:

No more than $8.25 

* **See the notes below the table on page 36 for more information. 
39

3 How to Get Extra Help 

Words in 

red are 

defined 

on pages 

83–86. 

How do I apply for Extra Help? 

Whose income and resources count? 

■ Your own income and resources count. 

■ If you’re married and live with your spouse, both of your incomes and 

resources count, even if only one of you applies for Extra Help. 

■ If you’re married and don’t live with your spouse when you apply, only 

your income and resources count. 

Note: Married couples living together who both apply for Extra Help 

through Social Security can use the same application (SSA-1020), 

available at socialsecurity.gov/i1020. 

What income counts? 

“Income” means any cash, goods, or services you can use to meet your 

needs for food or shelter. Examples include (but aren’t limited to): 

Income counted 

■ Wages 

■ Earnings from self-employment 

■ Social Security benefits 

■ Railroad Retirement benefits 

■ Veterans’ benefits 

■ Pensions 

■ Annuities 

■ Alimony 

■ Rental income 

■ Worker’s compensation 

Income not counted 

■ Supplemental Nutrition Assistance 

Program (SNAP)

 ■ Housing assistance

 ■ Home energy assistance

 ■ Medical treatment and drugs 

 ■ Disaster assistance

 ■ Earned income tax credit payments

 ■ Assistance from others to pay for 

household expenses

 ■ Victim’s compensation payments

 ■ Scholarships and education grants 
40

3 How to Get Extra Help 

What resources count? 

Social Security or your state must count your resources to decide if 

you qualify for Extra Help. Resources include the value of the things 

you own. Your resources include cash and other things you normally 

can convert to cash within 20 workdays. Examples include (but aren’t 

limited to): 

Resources counted 

■ Cash at home or anywhere 

else

■ Bank accounts (checking, 

savings, and certificates of 

deposit)

■ Stocks, bonds, savings 

bonds, mutual funds, 

Individual Retirement 

Accounts (IRA), or other 

similar investments

■ Value of real estate other

than your primary residence 

(the home you live in) 

Resources not counted 

■ Your primary residence (the home 

you live in) and the land it’s on 

■ Your personal possessions 

■ Your car(s) or vehicle(s) 

■ Things you couldn’t easily convert 

to cash, like jewelry or furniture 

■ Burial expenses, burial plots, and 

interest earned on money you plan 

to use for burial expenses 

■ Life insurance policies 

■ Property needed for self-support, 

like rental property or land 

used to grow produce for home 

consumption 

You should contact Social Security at 1-800-772-1213 to find out which 

other types of income and resources count and which are excluded. 

TTY users can call 1-800-325-0778. 
41

3 How to Get Extra Help 

How long will I get Extra Help if I qualify? 

If you automatically qualify for Extra Help 

To automatically qualify for Extra Help for the coming year, you 

must continue to qualify for Medicaid, get help from your state 

Medicaid program to pay Medicare Part B premiums (in a Medicare 

Savings Program), or get Supplemental Security Income (SSI). 

If you won’t automatically qualify the next year, you’ll get a notice 

(on grey paper) in the mail by early fall. If the amount of Extra Help 

you get is changing, so that your copayment amounts change for 

next year, you’ll get a notice (on orange paper) in the mail with the 

new copayment amounts. If you don’t get a notice, you’ll get the 

same level of Extra Help next year that you have this year. 

Even if you get the notice on grey paper because you don’t 

automatically qualify, you may still be able to save on your Medicare 

drug coverage costs. You need to apply for Extra Help to find out. 

Words in 

red are 

defined 

on pages 

83–86. 
42

3 How to Get Extra Help 

If you apply and qualify for Extra Help 

If you qualify for Extra Help, you’ll get the Extra Help for the 

calendar year as long as you’re enrolled in a Medicare drug plan and

there aren’t changes to your income, resources, or family size. 

You’ll also get the Extra Help for the calendar year as long as you 

don’t have a change in your marital status, like: 

■ Marriage 

■ Divorce 

■ Annulment 

■ Separation (not temporary) 

■ Spouses resume living together after separating 

■ Death of spouse (in this situation, the change in your Extra Help 

may be delayed for one year) 

If you applied to Social Security for Extra Help and you qualified, 

notify them if your marital status changes, because it could raise, 

lower, or stop the amount of Extra Help you get. The change in 

Extra Help you get starts the month after you report the change in 

your marital status. 

You can report changes in your income, resources, or family size to 

Social Security to review at any time. Any changes affecting your 

Extra Help start January 1 of the following year. 

If you applied and qualified for Extra Help through your state, your 

state’s rules may require you to tell them about changes in your 

circumstances. 

Words in 

red are 

defined 

on pages 

83–86. 
43

3 How to Get Extra Help 

If I qualify for Extra Help, what can I do to make 

sure I pay the right amount? 

If you automatically qualify, you should get a purple, yellow, orange, 

or green notice from Medicare that you can show to your plan as 

proof you qualify for Extra Help (see chart on page 34). If you applied 

for Extra Help, you can show your plan your “Notice of Award” letter 

from Social Security as proof you qualify. If you have Supplemental 

Security Income (SSI), you can use your award letter from Social 

Security as proof you have SSI. 

You can also give your plan any of the documents below as proof. 

Each item must show you were eligible for Medicaid during a month 

after June 2016. 

Proof you have Medicaid and live 

in an institution or get home- and 

community-based services 

■ A bill from an institution (like a

nursing home) or a copy of a state 

document showing Medicaid paid 

for your stay for at least a month 

■ A print-out from your state’s 

Medicaid system showing you 

lived in the institution for at least 

month 

■ A document from your state 

that shows you have Medicaid 

and are getting home- and 

community-based services 

a 

Other proof you have Medicaid 

 ■ A copy of your Medicaid card 

(if you have one) 

 ■ A copy of a state document 

that shows you have Medicaid 

 ■ A print-out from a state 

electronic enrollment file, or 

screen print from your state’s 

Medicaid systems that shows 

you have Medicaid 

 ■ Any other document from 

your state that shows you have 

Medicaid 

Your plan must accept any of these documents as proof you qualify 

for Extra Help. As soon as you have given them any one of these 

documents, your plan must make sure you pay no more than the right 

amount to fill your prescriptions. 
44

3 How to Get Extra Help 

If you qualify for Extra Help because you have Medicaid, but you 

don’t have or can’t find any of the documents on the previous page, 

ask your plan for help. Your plan must also contact Medicare so 

Medicare can get proof that you qualify, if it’s available. You should 

expect your request to take anywhere from several days to up to 2 

weeks, depending on the circumstances. Be sure to tell your plan 

how many days of medication you have left. Your plan and Medicare 

will work to process your request before you run out of medication, 

if possible. 

If you paid for prescription drugs since you qualified for Extra 

Help, you may be able to get back part of what you paid. Keep 

your receipts, and call Medicare’s Limited Income Newly Eligible 

Transition (NET) Program at 1-800-783-1307 for more information. 

TTY users can call 711. 

If your plan doesn’t correct a problem to help you pay the 

right amount for your drugs, doesn’t respond to your request 

for help, or takes longer than expected to get back to you, call 

1-800-MEDICARE (1-800-633-4227) to file a complaint. TTY users 

can call 1-877-486-2048. 

What if my application for Extra Help is denied? 

You have the right to appeal the decision. If you applied for Extra 

Help through Social Security, they’ll give you a hearing by phone 

unless you choose a case review. Either way, Social Security will 

review those parts of the decision that you believe are wrong and 

will look at any new information you provide. Social Security may 

also review those parts which you believe are correct. Someone who 

wasn’t involved in the first decision will decide your case. 
45

3 How to Get Extra Help 

To request an appeal, call Social Security at 1-800-772-1213. 

TTY users can call 1-800-325-0778. You can also get a copy 

of form SSA-1021 (“Appeal of Determination for Help with 

Medicare Prescription Drug Costs”) and instructions on filling 

it out by visiting ssa.gov/forms. 

If you want to file an appeal, keep in mind: 

■ You have 60 days to ask for an appeal. 

■ The 60 days start the day after you get a letter from Social 

Security denying your application. Social Security will assume 

you got the letter 5 days after the date on it, unless you show 

them you didn’t get it within the 5-day period. 

■ You can have a lawyer, friend, or someone else help you. Call 

Social Security at 1-800-772-1213 for a list of groups that can 

help you with your appeal. To find your local Social Security 

office, visit socialsecurity.gov/locator. 

If you apply for Extra Help with your state, your decision 

letter should include appeal rights and procedures. Call your 

State Medical Assistance (Medicaid) office for information on 

your state’s appeals process. You can get the phone number for 

your state Medicaid office by visiting Medicare.gov/contacts, or 

by calling 1-800-MEDICARE (1-800-633-4227). TTY users can 

call 1-877-486-2048. 
46

3 How to Get Extra Help 

What if I don’t qualify for Extra Help? 

You can still choose and join a Medicare drug plan that meets your 

needs. You’ll have to pay the monthly premium, yearly deductible

(some plans don’t have a deductible), and a share of the cost of your 

drugs. 

Even if you don’t qualify for Extra Help now, you can apply or 

reapply later if your income and resources change. 

Your state may have programs to help you pay your prescription drug 

costs. Contact your state Medicaid office or State Health Insurance 

Assistance Program (SHIP) for more information. Visit 

shiptacenter.org or call 1-800-MEDICARE (1-800-633-4227) for the 

phone number of your SHIP. TTY users can call 1-877-486-2048. 

Other ways to save if you don’t get Extra Help 

There are other ways you may also be able to 

save. Consider switching to drugs that cost 

less. Ask your doctor if there are generic, 

over-the-counter, or less-expensive brand-name 

drugs that could work just as well as the ones 

you’re taking now. Switching to lower-cost drugs 

can save you hundreds or possibly thousands of 

dollars a year. Visit the Medicare Plan Finder at 

Medicare.gov/find-a-plan to get information on 

ways to save money in your Medicare drug plan. 
47

3 How to Get Extra Help 

You can also help lower your Medicare prescription drug costs by:

1. Exploring National- and Community-Based Programs that may 

have programs that can help you with your drug costs, like the 

National Patient Advocate Foundation or the National Organization 

for Rare Disorders. Get information on federal, state, and private 

assistance programs in your area by visiting benefitscheckup.org. The 

help you get from some of these programs may count toward your 

true out-of-pocket (TrOOP) costs. TrOOP costs are the expenses that 

count toward your Medicare drug plan out-of-pocket expenses—up 

to $4,950 in 2017. They determine when your catastrophic coverage 

will begin. 

2. Looking at State Pharmaceutical Assistance Programs (SPAPs) to 

see if you qualify. Many states and the U.S. Virgin Islands offer some 

type of coverage to help people with Medicare with paying drug plan 

premiums and/or cost sharing. Find out if your state has an SPAP at 

Medicare.gov/pharmaceutical-assistance-program/state-programs.aspx. 

See page 64 to find more information about SPAPs. SPAP 

contributions may count toward your TrOOP costs. 

3. Looking into Manufacturer’s Pharmaceutical Assistance 

Programs (sometimes called Patient Assistance Programs 

(PAPs)) offered by the manufacturers of the drugs you take. 

Many of the major drug manufacturers offer assistance programs 

for people enrolled in a Medicare drug plan. Find out whether 

the manufacturers of the drugs you take offer a PAP by visiting 

Medicare.gov/pharmaceutical-assistance-program. Assistance from 

PAPs isn’t part of Medicare Part D, so any help you get from this 

type of program won’t count toward your TrOOP costs. 
48

3 How to Get Extra Help 
49

Section

4 Your Coverage Choices 

Read about the choices you have with Medicare drug coverage. 

More than one situation may apply to you.

Get help with drug coverage decisions 

If you need help with your Medicare drug coverage decisions, call 

your State Health Insurance Assistance Program (SHIP). Visit 

shiptacenter.org, or call 1-800-MEDICARE (1-800-633-4227) to get 

the phone number of your SHIP. TTY users can call 1-877-486-2048. 

Medicare works with other government representatives, 

community- and faith-based groups, employers and unions, doctors, 

pharmacies, and other people and organizations to educate people 

on drug coverage choices. Look for information in your local 

newspaper, or listen for information on the radio, about events in 

your community. 

If you have limited income and resources, you may qualify for Extra 

Help paying the costs of Medicare drug coverage. See Section 3. 

Words in 

red are 

defined 

on pages 

83–86. 
50

4 Your Coverage Choices 

What else do I need to think about before I decide 

to get Medicare drug coverage? 

Before you make a decision, get answers to these questions: 

■ Do I have creditable prescription drug coverage now?—In other 

words, if I have drug coverage, is it expected to pay, on average, at 

least as much as standard Medicare drug coverage? Your current 

plan can tell you. 

■ Should I keep my drug coverage, if I have coverage now? 

■ How will joining a Medicare drug plan and keeping my current drug 

coverage affect my current coverage? Your current plan can tell you. 

■ How would joining a particular Medicare drug plan affect my 

out-of-pocket costs? 

■ Would my premium be higher later if I wait to join a Medicare drug 

plan because I have to pay a late enrollment penalty? Would my 

coverage start when I want it to? 

■ Does a Medicare drug plan in my area cover the drugs I take? Find 

out by visiting Medicare.gov/find-a-plan. 

■ Can I get Extra Help paying for my drug costs if 

I join a Medicare drug plan? 

■ Is there a particular pharmacy I want to use? 

Does it belong to a network of a Medicare drug 

plan in my area? 

■Do I spend part of each year in another state? 

This may be important if a plan you want to join 

requires you to use certain pharmacies. 

■What are a particular Medicare drug plan’s 

quality ratings? Compare Medicare Prescription 

Drug Plans at Medicare.gov/find-a plan. 

Words in 

red are 

defined 

on pages 

83–86. 
51

4 Your Coverage Choices 

I have only Part A and/or Part B and no drug coverage 

If you have Medicare Part A (Hospital Insurance) and/or Medicare Part B 

(Hospital Insurance) and live in a Medicare Prescription Drug Plan’s 

service area, you can join that plan. Use the Medicare Plan Finder at 

Medicare.gov/find-a-plan or call 1-800-MEDICARE (1-800-633-4227) for a 

list of plans in your area. TTY users can call 1-877-486-2048. You can also 

look in your “Medicare & You” handbook. Not sure if you have Part A 

and/or Part B? Check your red, white, and blue Medicare card. 

I have Medicare and a Medicare Supplement 

Insurance (Medigap) policy without drug coverage 

You can join a Medicare drug plan by: 

1. Keeping your current Medigap policy and enrolling in a Medicare 

Prescription Drug Plan. 

2. Joining a Medicare Advantage Plan (like an HMO or PPO) in your area 

that includes drug coverage. You would get all your health care benefits 

and drug coverage from the plan. 

If you join a Medicare Advantage Plan, you don’t need a Medigap 

policy. If you already have a Medigap policy, you can’t use it to 

pay for out-of-pocket costs under your Medicare Advantage Plan. 

You may want to drop your Medigap policy if you join a Medicare 

Advantage Plan. However, you might not be able to get the same 

Medigap policy back if you leave the Medicare Advantage Plan 

and then go back to Original Medicare, or you may end up paying 

higher premiums for the Medigap policy. 

You have a legal right to keep your Medigap policy, but rights to buy a 

Medigap policy may vary by state. For more information about your Medigap 

policy, contact your Medigap insurance company or visit Medicare.gov. 

If you’re joining a Medicare Advantage Plan for the first time, you may get 

a 12-month trial period during which you can disenroll from the Medicare 

Advantage Plan and get back your Medigap policy, or if it isn’t available, 

buy another Medigap policy. 
52

4 Your Coverage Choices 

I have Medicare and a Medicare Supplement 

Insurance (Medigap) policy with drug coverage 

Before 2006, some Medigap policies included prescription drug 

coverage. If you still have a Medigap policy with drug coverage, 

your Medigap insurer must send you a detailed notice each year 

describing your choices for drug coverage and stating whether its 

drug coverage is creditable prescription drug coverage. Some of your 

choices for drug coverage include: 

■ Joining a Medicare Prescription Drug Plan and keeping your 

current Medigap policy without the drug coverage. 

■ Joining a Medicare Advantage Plan (like an HMO or PPO) that 

includes drug coverage. You would get all your health care coverage 

including drug coverage from this plan, and you wouldn’t need a 

Medigap policy. If you join a Medicare Medical Savings Account 

(MSA) Plan (a type of Medicare Advantage Plan), you can continue 

to use your Medigap drug coverage, since MSAs can’t offer 

Medicare drug coverage. 

■ Keeping your current Medigap policy with the drug coverage 

included. 

Information you get from your Medigap insurance company 

describes these choices in detail. You can also check with your 

State Insurance Department to find out what other options you 

may have for drug coverage. Visit Medicare.gov/contacts or call 

1-800-MEDICARE (1-800-633-4227) to get the number of your State 

Insurance Department. TTY users can call 1-877-486-2048. 

Tip: Contact your Medigap insurance company before you make any 

changes to your drug coverage. 

Words in 

red are 

defined 

on pages 

83–86. 
53

4 Your Coverage Choices 

If you decide to join a Medicare Prescription Drug Plan, you can keep 

your current Medicare Supplemental Insurance (Medigap) policy 

without the drug coverage. You’ll need to tell your Medigap insurer 

when your Medicare drug coverage starts. They must remove the drug 

coverage from your Medigap policy and adjust your premium based 

on this change. Also, you may have to pay a lifetime late enrollment 

penalty to join a Medicare Prescription Drug Plan if the drug 

coverage you’ve had under your Medigap policy isn’t creditable 

prescription drug coverage. You may have to pay this higher premium 

for as long as you’re in a Medicare Prescription Drug Plan. 

For more information about Medigap policies, visit Medicare.gov

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

1-877-486-2048. You can also call your State Health Insurance 

Assistance Program (SHIP) for more information about Medigap. 

Visit shiptacenter.org or call 1-800-MEDICARE to get the phone 

number of your SHIP. 

I have Medicare and get drug coverage from a 

current or former employer or union 

Before making a decision about whether to join a Medicare drug 

plan, find out how your employer or union drug coverage works with 

Medicare, because your coverage may change if you join a Medicare 

drug plan. Your employer or union (or the plan that administers your 

drug coverage) will send you a “Creditable Coverage” disclosure each 

year, letting you know if it’s creditable prescription drug coverage and 

how it compares to Medicare drug coverage. Read carefully, and save 

all materials from your employer or union to know your options. If you 

don’t get this information, ask your employer or union for it. 

You may have to make choices about your employer/union drug 

coverage and Medicare drug coverage: 

■ During your 7-month Initial Enrollment Period, when you first 

become eligible for Medicare (see page 18 for details)

■ During Open Enrollment, between October 15–December 7 each year 

■ When your employer/union coverage changes or ends 
54

4 Your Coverage Choices 

I have Medicare and get drug coverage 

from a current or former employer or union 

(continued) 

Some important questions to answer before making a decision: 

■ Is your employer or union drug coverage creditable (on average, 

does it expect to pay at least as much as standard Medicare 

drug coverage)? If not, in most cases, you’ll have to pay a late 

enrollment penalty if you don’t join a Medicare drug plan when 

you’re first eligible. 

■ Will you or your spouse or dependents lose all of your employer or 

union health coverage if you join a Medicare drug plan? 

■ How do out-of-pocket drug costs with your employer or union 

drug coverage compare to out-of-pocket drug costs with a 

Medicare drug plan? 

■ How will your costs change if you get Extra Help with your 

Medicare drug plan costs? 

If your (or your spouse’s) employer or union tells you your 

current coverage IS creditable prescription drug coverage: 

■ You can keep this coverage as long as your employer or union still 

offers it. 

■ You won’t have to pay a late enrollment penalty if your employer 

or union stops offering drug coverage, or stops offering creditable 

prescription drug coverage, as long as you join a Medicare drug 

plan within 63 days after the coverage ends. 

Note: Keep materials your employer or union sends you that tell 

you your drug coverage is creditable. You may need to show it to 

your Medicare drug plan as proof of creditable prescription drug 

coverage if you decide to join a Medicare drug plan later. 
55

4 Your Coverage Choices 

If your (or your spouse’s) employer or union tells you your 

current coverage ISN’T creditable prescription drug coverage: 

If you want to join a Medicare drug plan, in most cases you must 

join when you’re first eligible to avoid a late enrollment penalty. 

If you don’t enroll when you’re first eligible, you may have to wait 

to join a Medicare drug plan until Open Enrollment, which is 

October 15–December 7. 

Find out about your options from your benefits administrator. 

You may be able to do one of these: 

■ Keep your current employer or union drug coverage, and join a 

Medicare drug plan to get more complete drug coverage. 

■ Keep only your current employer or union drug coverage. If you 

join a Medicare drug plan later, you may have to pay a late 

enrollment penalty if your current drug coverage isn’t creditable. 

■ Drop your current coverage and join a Medicare drug plan, or 

join a Medicare health plan that covers prescription drugs. 

Caution: If you drop your employer or union coverage, you 

may not be able to get it back. You also may not be able to drop 

your employer or union drug coverage without also dropping 

your employer or union health coverage. 

If you drop coverage for yourself, you may 

also have to drop coverage for your spouse 

and dependents. Medicare doesn’t have 

information about how your current employer 

or union drug coverage will be affected by 

your enrollment in a Medicare drug plan, 

so talk to your employer or union’s benefits 

administrator before you make any decisions 

about your drug coverage. 

Words in 

red are 

defined 

on pages 

83–86. 
56

4 Your Coverage Choices 

I have Medicare and a Federal Employee Health 

Benefits (FEHB) plan 

■ During Open Enrollment, you’ll get information about your drug 

coverage and whether it’s creditable prescription drug coverage. 

Read this information carefully. 

■ Contact your FEHB plan before making 

any changes. It’ll almost always be to your 

advantage to keep your current coverage 

without any changes. It isn’t cost effective for 

most people covered under a FEHB plan to 

join a Medicare drug plan unless they qualify 

for Extra Help. Caution: You can’t drop 

FEHB drug coverage without also dropping 

FEHB plan coverage for hospital and medical 

services, which may mean higher costs for 

these services. 

■ If you qualify for Extra Help paying Medicare drug costs, see how 

your costs with a Medicare drug plan and any Extra Help would 

compare to your FEHB plan drug coverage. 

■ If you ever lose your FEHB coverage and need to join a Medicare 

drug plan, in most cases you won’t have to pay a late enrollment 

penalty, if you join within 63 days of losing FEHB coverage. 

■ If you join a Medicare drug plan, you can keep your FEHB plan. 

In most cases, your Medicare drug plan pays first. 

For more information, visit opm.gov/healthcare-insurance/healthcare

or call the Office of Personnel Management at 1-888-767-6738. 

TTY users can call 1-800-878-5707. You can also call your plan. 
57

4 Your Coverage Choices 

I have Medicare and TRICARE or benefits from the 

Department of Veterans Affairs (VA) that include 

drug coverage 

■ As long as you still qualify, you can keep your TRICARE or VA drug 

coverage. TRICARE or your VA provider should send you information 

each year about your coverage and whether it’s creditable prescription 

drug coverage. Read this information carefully, and save these materials. 

■ Before making any changes, contact your benefits administrator for 

information about your TRICARE or VA coverage. It’s almost always 

to your advantage to keep your current coverage without any changes. 

For most people with TRICARE or VA coverage, unless you qualify for 

Extra Help, it isn’t cost effective to join a Medicare drug plan. 

■ If you qualify for Extra Help paying Medicare drug costs, compare 

costs with a Medicare drug plan and any Extra Help to costs with your 

TRICARE or VA drug coverage. 

■ If you ever lose your TRICARE or VA coverage and need to join a 

Medicare drug plan, in most cases, you won’t have to pay a late enrollment 

penalty, if you join within 63 days of losing TRICARE or VA coverage. 

■ If you join a Medicare drug plan and have VA coverage, you can’t use both 

types of coverage for the same prescription. 

■ If you have TRICARE and join a Medicare Prescription Drug Plan, your 

Medicare Prescription Drug Plan pays first, and TRICARE pays second. 

■ If you join a Medicare Advantage Plan (like an HMO or PPO) with 

drug coverage, you must get prescription drugs through the Medicare 

Advantage Plan. The Medicare Advantage Plan is the primary payer. 

TRICARE may cover some or all of the claim unpaid by the Medicare 

Advantage Plan if the plan’s pharmacy is a TRICARE network pharmacy 

that participates in the online coordination of benefits. 

For more information on VA benefits, visit va.gov/healthbenefits, call the 

VA Health Benefits Service Center at 1-877-222-VETS (1-877-222-8387), or 

visit your local VA medical facility. 

Get answers on how TRICARE works with Medicare drug coverage by 

calling the TRICARE Pharmacy Program at 1-877-363-1303. TTY users can 

call 1-877-540-6261. 

Words in 

red are 

defined 

on pages 

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58

4 Your Coverage Choices 

I have a Medicare health plan without drug 

coverage 

If you have a Medicare Advantage Plan (like an HMO or PPO) or 

another Medicare health plan that doesn’t include drug coverage, you 

may want to think about other ways to get Medicare drug coverage. 

■ See if your current Medicare Advantage Plan offers a Medicare 

prescription drug option. If so, you can switch to that option. 

■ If your current plan doesn’t offer Medicare drug coverage, you can 

switch to another Medicare health plan in your area that offers it. 

■ If your current plan doesn’t offer Medicare drug coverage, you 

can switch to Original Medicare and join a Medicare Prescription 

Drug Plan. 

■ Only some Medicare Private Fee-for-Service (PFFS) Plans offer 

Medicare drug coverage. If your Medicare PFFS Plan doesn’t offer 

Medicare drug coverage, you can join a Medicare Prescription Drug 

Plan to get this coverage. 

■ Medicare Medical Savings Account (MSA) Plans don’t offer Medicare 

drug coverage. If you have a Medicare MSA Plan, you can join a 

Medicare Prescription Drug Plan to get drug coverage. 

■ If you have a Medicare MSA Plan and a Medicare Prescription 

Drug Plan, any money you use from your MSA Plan account on 

Medicare drug plan deductibles or cost sharing counts toward 

your drug plan out-of-pocket costs. See pages 13–16. 

■ If you have a Medicare MSA Plan and don’t have a Medicare 

Prescription Drug Plan, you can use money in your MSA 

account for prescription or non-prescription drugs. These 

expenses don’t count towards the MSA Plan deductible. 

■ If your Medicare Cost Plan doesn’t offer Medicare drug coverage, 

you can join a separate Medicare Prescription Drug Plan to add 

drug coverage. 

Words in 

red are 

defined 

on pages 

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59

4 Your Coverage Choices 

If you stay in a plan that doesn’t offer drug coverage and you don’t 

join a Medicare Prescription Drug Plan or have other creditable 

prescription drug coverage, you may have to pay a late enrollment 

penalty if you want Medicare drug coverage later. See pages 20–21

to learn more about the late enrollment penalty. 

Contact your plan for more information about your choices. 

I have a Medicare health plan with drug 

coverage 

If you have drug coverage from a Medicare Advantage Plan (like an 

HMO or PPO) or other Medicare health plan, in most cases, you’ll 

need to get your Medicare drug coverage from your plan. 

■ If you’re in a Medicare Advantage Plan and you join a Medicare 

drug plan, in most cases, you’ll be disenrolled from your 

Medicare Advantage Plan and returned to Original Medicare. 

■ If you’re in a Medicare Private Fee-for-Service (PFFS) Plan that 

doesn’t offer Medicare drug coverage, you can join a separate 

Medicare drug plan to add drug coverage. 

■ With a Medicare Cost Plan, you can either get your Medicare 

drug coverage from the plan (if offered), or you can join a separate 

Medicare drug plan to add drug coverage. 

Contact your plan for more information about your choices. 
60

4 Your Coverage Choices 

I have Medicare and Medicaid 

Medicare helps pay for your prescription drugs instead of Medicaid. 

Because you have Medicaid, Medicare automatically gives you Extra Help

with your Medicare drug plan costs. See page 36 for information about 

your costs. If you live in an institution (like a nursing home), in most 

cases, you pay nothing for your covered drugs. 

If you haven’t joined a Medicare drug plan, Medicare will enroll you in a 

drug plan to make sure you have drug coverage (unless you already have 

certain retiree drug coverage). Medicare sends you a yellow notice telling 

you what drug plan you’re in and when your coverage starts. Check to see 

if the plan covers the drugs you take and includes the pharmacies you use. 

You can switch to a different Medicare drug plan at any time. 

If you filled any covered prescriptions before your Medicare drug plan 

coverage started, you may be able to get back some of the money you 

spent. Call Medicare’s Limited Income Newly Eligible Transition (NET) 

Program at 1-800-783-1307 for more information. TTY users can call 711. 

If you don’t want Medicare drug coverage and you don’t want Medicare 

to enroll you in a Medicare drug plan (for example, because you have 

other creditable prescription drug coverage), call 1-800-MEDICARE 

(1-800-633-4227) and tell them you want to “opt out” of (decline) Medicare 

drug coverage. TTY users can call 1-877-486-2048. 

Caution: If you call 1-800-MEDICARE and opt out of a Medicare drug 

plan, you could be left without any drug coverage. You can change your 

mind and join a Medicare drug plan at any time without paying a late 

enrollment penalty as long as you continue to qualify for Extra Help. 

In limited cases, some state Medicaid programs may pay for drugs 

Medicare doesn’t cover. If you continue to qualify for Medicaid, Medicaid 

will still cover the other health care costs that Medicare doesn’t cover. 

If you aren’t sure whether you still qualify for Medicaid, call your State 

Medical Assistance (Medicaid) office. To get the phone number, visit 

Medicare.gov/contacts or call 1-800-MEDICARE. 

Words in 

red are 

defined 

on pages 

83–86. 
61

4 Your Coverage Choices 

I have Medicare and get Supplemental Security 

Income (SSI) benefits or belong to a Medicare 

Savings Program 

If you have Medicare and get SSI or belong to a Medicare Savings 

Program, Medicare will send you a purple notice letting you know 

you automatically qualify for Extra Help paying your Medicare drug 

coverage costs. You get it automatically when you join a Medicare 

drug plan. See page 36 for more information about your costs. 

If you don’t join a Medicare drug plan on your own, Medicare will 

enroll you in a Medicare Prescription Drug Plan, to make sure you 

have coverage, unless you already have certain retiree drug coverage. 

Medicare sends you a yellow or a green notice letting you know when 

your coverage begins. You can switch to a different Medicare drug 

plan at any time as long as you continue to qualify for Extra Help. 

If you don’t want Medicare drug 

coverage, and you don’t want Medicare 

to enroll you in a Medicare drug plan 

(for example, because you have other 

creditable prescription drug coverage), 

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

and tell them you want to “opt out” 

of (decline) Medicare prescription 

drug coverage. TTY users can call 

1-877-486-2048. 

Caution: If you call 1-800-MEDICARE and tell them you don’t want 

to join a Medicare drug plan, you could be left without drug coverage. 

You can change your mind and join a Medicare drug plan at any time 

without paying a late enrollment penalty as long as you continue to 

qualify for Extra Help. 
62

4 Your Coverage Choices 

I have Medicare and live in a nursing home or 

other institution 

■ While you’re living in an institution, you can switch Medicare drug 

plans at any time. 

■ If you move into or out of a nursing home or other institution, you 

can switch Medicare drug plans at that time. 

■ If you’re in a skilled nursing facility getting Medicare-covered 

skilled nursing care, Medicare Part A (Hospital Insurance) will 

generally cover your drugs. 

■ If you live in a nursing home or other institution, you’ll get your 

covered drugs from a long-term care pharmacy that works with your 

Medicare drug plan. This long-term care pharmacy usually contracts 

with (or is owned and operated by) your institution. 

Unless you choose a Medicare Advantage Plan (like an HMO or 

PPO) with drug coverage or a Medicare Prescription Drug Plan on 

your own, Medicare automatically enrolls people with both Medicare 

and full Medicaid coverage living in institutions into Medicare 

Prescription Drug Plans. If you live in a nursing home and have full 

Medicaid coverage, you pay nothing for your covered drugs after 

Medicaid has paid for your stay for at least one full calendar month. 

Note: Institutions 

don’t include assisted 

living, adult living 

facilities, residential 

homes, or any kind 

of nursing home not 

certified by Medicare 

or Medicaid. 

Words in 

red are 

defined 

on pages 

83–86. 
63

4 Your Coverage Choices 

I have Medicare and benefits through Programs 

of All-inclusive Care for the Elderly (PACE) 

Programs of All-inclusive Care for the Elderly (PACE) are a joint 

Medicare and Medicaid option in some states. PACE gives you 

your Medicare drug coverage, so you don’t need to join a separate 

Medicare drug plan. 

Caution: Joining a Medicare drug plan will disenroll you from your 

PACE plan. Your PACE plan gives you not only your drug coverage, 

but all of your health care services. If you join a Medicare drug plan, 

you’ll become disenrolled from your PACE plan, and you’ll no longer 

get other health care benefits through PACE. Contact your PACE plan 

for more information. 

If you also have full Medicaid coverage, you get drugs at no cost to 

you through your PACE plan. 

If you have Medicare only, you get all of your health care benefits, 

including drug coverage, through your PACE plan. You pay a reduced 

monthly PACE premium because it doesn’t include prescription 

drugs. However, you’ll also pay a separate Medicare prescription drug 

premium to your PACE organization or plan to cover the cost of your 

drugs. 

If you don’t have Medicaid coverage, you may still qualify for Extra 

Help paying for Medicare drug coverage. See Section 3 for more 

information about Extra Help. 
64

4 Your Coverage Choices 

I have Medicare and get help from my State 

Pharmacy Assistance Program (SPAP) paying 

drug costs 

Several states have programs to help certain people pay for prescription 

drugs. Depending on your state, the State Pharmacy Assistance 

Program (SPAP) will have different ways to help you pay your drug 

costs. Some SPAPs may require you to join a Medicare drug plan, and 

then they’ll cover the costs that Medicare doesn’t cover. Find your 

SPAP’s contact information by visiting 

Medicare.gov/pharmaceutical-assistance-program/state-programs.aspx. 

SPAP contributions count toward your true out-of-pocket (TrOOP) 

costs, the expenses that count toward your Medicare drug plan 

out-of-pocket threshold (or limit), which is $4,950 in 2017. 

If you belong to an SPAP, you may have another opportunity each 

year to join a plan in addition to the October 15–December 7 Open 

Enrollment Period. You can switch one time in a calendar year to a 

different plan from the one your SPAP enrolled you in. If you lose your 

SPAP benefits, you’re allowed to choose a different Medicare drug plan 

at any time during the month you lose your benefits and through the 

following 2 months. 

Your SPAP will give you more information on how Medicare drug 

coverage affects the help you get now. 

Words in 

red are 

defined 

on pages 

83–86. 
65

4 Your Coverage Choices 

I get help from an AIDS Drug Assistance Program 

(ADAP) 

Most AIDS Drug Assistance Programs (ADAPs) only cover HIV/

AIDS-related medications. If they don’t cover other drugs, they aren’t

creditable prescription drug coverage. If you don’t have creditable 

prescription drug coverage and delay joining a Medicare drug plan, you 

may have to pay a late enrollment penalty to join later. 

All Medicare drug plans cover all antiretroviral medications. Your 

ADAP may require you to join a Medicare drug plan to get ADAP 

benefits. An ADAP can cover Medicare drug plan premiums, 

deductibles, coinsurance, and/or copayments to help with your drug 

costs. Check with your ADAP to see if it requires you to join or if it’ll 

help pay for these costs. 

ADAPs vary by state so contact your ADAP to learn how it’ll work 

with Medicare’s drug coverage. ADAP contributions count toward your 

true out-of-pocket (TrOOP) costs, the expenses that count toward your 

Medicare drug plan out-of-pocket threshold (or limit), which is $4,950 

in 2017. 
66

4 Your Coverage Choices 

I have Medicare and get drug coverage from 

the Indian Health Service, Tribe or Tribal Health 

Organization, or Urban Indian Health Program 

■ You and your community may benefit if you join a Medicare drug 

plan. Ask your health provider or benefits coordinator if joining a 

plan is right for you. If you decide to join, they can help you find a 

plan. 

■ If you get prescription drugs through an Indian health pharmacy, 

you pay nothing. 

■ Joining a Medicare drug plan may be helpful to your Indian health 

provider because the drug plan pays part of the cost of your drugs. 

This helps the Indian health provider with the cost of services. 

■ If you have full coverage from Medicaid and live in a nursing home, 

you pay nothing for your Medicare drug coverage. See your Indian 

health provider or check with the benefits coordinator at your local 

Indian health pharmacy to get more information on how to join a 

plan. 

■ If you get health care 

from the Indian Health 

Service, Tribal Health 

Program, or Urban Indian 

Health Program, you have 

creditable prescription 

drug coverage. You won’t 

have to pay a penalty to 

join a Medicare drug plan 

later. Ask your Indian 

health care provider for 

a letter stating you have 

creditable prescription 

drug coverage. 

Words in 

red are 

defined 

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67

Section

5

Section 5: 3 Steps to Choosing a Medicare Drug Plan 

3 Steps to Choosing a 

Medicare Drug Plan 

Follow the steps below to choose and join a Medicare drug plan, 

whether you’re joining for the first time or reviewing your plan 

options for coverage next year. Use the personal worksheets on 

pages 68–69 to help decide which plan meets your needs: 

Step 1: Prepare—Gather information about your current drug 

coverage and needs. 

Step 2: Compare—Compare Medicare drug plans based on cost, 

coverage, and customer service. 

Step 3: Decide—Decide which plan is best for you, and join. 

Tip: Before considering which Medicare drug plan to join, 

check out how any current health coverage you have could affect 

your drug coverage choices. See Section 4.

Step 1: Gather information about your current 

drug coverage and needs 

Before choosing a Medicare drug plan, you may want to gather some 

information. You need information about any drug coverage you may 

currently have, as well as a list of the drugs and doses you currently 

take. Also, gather any notices you get from Medicare, Social Security, 

or your current Medicare drug plan about changes to your plan. 

If you have drug coverage, you need to find out whether it’s creditable 

prescription drug coverage. Your current insurer or plan provider is 

required to notify you each year whether your coverage is creditable 

prescription drug coverage. If you haven’t heard from your insurer 

or plan, call the insurer, your plan, or your benefits administrator to 

find out. Request a notice about whether your coverage is creditable 

prescription drug coverage if you didn’t get one. Also, you may want 

to consider keeping your creditable prescription drug coverage rather 

than choosing a Medicare drug plan. 
68

5 3 Steps to Choosing a Medicare Drug Plan 

Drugs I take: Today’s date: _____________________

Drug name Dosage 

(ml, mg) 

Number of times 

a day I take my 

drug 

Amount I 

pay each 

month 

Step 2: Compare Medicare drug plans based on 

cost, coverage, and customer service 

For lists of the specific drug plans available in your area, use 

the Medicare Plan Finder at Medicare.gov/find-a-plan, or 

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

1-877-486-2048. You can also look in your “Medicare & You” 

handbook. 
69

5 3 Steps to Choosing a Medicare Drug Plan 

When you find some plans you’re interested in, use Medicare.gov to get the 

information below, or call the companies that offer the plans directly. 

Plan name: 

Monthly 

premium 

$ 

Yearly 

deductible 

$ 

My drugs 

that are 

covered 

My drugs 

that aren’t

covered 

Amount 

I’d pay for 

each drug 

Could I 

use my 

pharmacy? 

Is mail 

order 

available? 

1. 1.

2. 2.

3. 3.

Plan name: 

Monthly 

premium 

$ 

Yearly 

deductible 

$ 

My drugs 

that are 

covered 

My drugs 

that aren’t

covered 

Amount 

I’d pay for 

each drug 

Could I 

use my 

pharmacy? 

Is mail 

order 

available? 

1. 1.

2. 2.

3. 3.

Plan name: 

Monthly 

premium 

$ 

Yearly 

deductible 

$ 

My drugs 

that are 

covered 

My drugs 

that aren’t

covered 

Amount 

I’d pay for 

each drug 

Could I 

use my 

pharmacy? 

Is mail 

order 

available? 

1. 1.

2. 2.

3. 3.
70

5 3 Steps to Choosing a Medicare Drug Plan 

Refer to the worksheets on pages 68–69. Compare the Medicare 

drug plans based on what’s most important to your situation and 

your drug needs. You may want to ask yourself: 

■ Which plan(s) cover the drugs I take? 

■ Which plan gives me the best overall price on all of my drugs? 

■ What’s the monthly premium, yearly deductible, and the 

coinsurance or copayment(s)? 

■ Which plan(s) allows me to use the pharmacy I want? 

■ Which plan(s) allows me to get drugs through the mail? 

■ Which plan(s) provides me with coverage in multiple states (if I 

need it)? 

■ What are the plans’ quality ratings? 

■ Will I have to pay a penalty because I waited to join? 

■ Can my coverage start when I want it to? 

■ Is it likely that I’ll need protection against unexpected drug costs 

in the future? 

■ If I already have a Medicare drug plan, am I satisfied with my 

plan’s service? 

If you need help with your Medicare drug coverage decisions, 

call your State Health Insurance Assistance Program (SHIP). 

Visit shiptacenter.org, or call 1-800-MEDICARE (1-800-633-4227) 

for the phone number of your SHIP. TTY users can call 

1-877-486-2048. 

Step 3: Decide which plan is best for you, and 

join 

After you pick a plan that meets your needs, call the company 

offering it and ask how to join. You may be able to join by phone, 

by paper application, or online. You’ll have to give the number on 

your Medicare card when you join. 

Words in 

red are 

defined 

on pages 

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71

Section

6 Tips for Using Your New 

Medicare Drug Coverage

If you’ve just joined a Medicare Prescription Drug Plan (Part D) for the first 

time, or you switched to a new Medicare drug plan, there are some things 

you can do to make sure your first visit to the pharmacy goes smoothly. 

The first time you use your new Medicare drug plan, you should come to 

the pharmacy with as much information as possible. Here’s what you need 

to bring to the pharmacy: 

■ Your red, white, and blue Medicare card 

■ Photo ID (like a state driver’s license or passport) 

■ Your plan membership card 

If you don’t have a plan membership card, you should also bring these to 

the pharmacy: 

■ An acknowledgement or confirmation letter from the plan, if you have one 

■ An enrollment confirmation number from the plan, if you have one 

(Note: Only confirmation numbers from the plan will work, not those 

from Medicare’s Online Enrollment Center at Medicare.gov.) 

■ The name of the Medicare drug plan you joined 

(Note: If you haven’t gotten a plan membership card or any plan 

enrollment materials, letting your pharmacist know the name of your plan 

can help them confirm your plan enrollment and get the information they 

need to bill your plan. The pharmacist may have to search for your plan 

information, and it may take extra time for them to fill your prescription.) 

If you have both Medicare and Medicaid or qualify 

for Extra Help 

If you have both Medicare and Medicaid or qualify for Extra Help

with drug plan costs, you should also bring proof of your enrollment 

in Medicaid or proof that you qualify for Extra Help with you to the 

pharmacy. This is to help make sure you pay the right amount for your 

drugs. See the chart on page 34 for a list of some of the letters that 

confirm you qualify for Extra Help.
72

6 Tips for Using Your New Medicare Drug Coverage

Proof of Medicaid may include: 

■ Your Medicaid card 

■ A copy of your current Medicaid award letter 

■ A copy of your yellow automatic enrollment letter from Medicare 

Proof of Extra Help may include: 

■ A copy of your Medicaid card 

■ A copy of your purple, yellow, orange, green, tan, or blue Extra Help 

letter from Medicare (see chart on page 34)

■ A copy of your Extra Help “Notice of Award” letter from Social Security 

■ A copy of your Supplemental Security Income (SSI) award letter 

■ Other proof that you qualify for Extra Help (like a “Notice of Award” 

letter from a state Medicaid program) 

You don’t need to have all of these items, but anything you can bring will 

help the pharmacist confirm your Medicare drug plan enrollment and/or 

that you qualify for Medicaid or Extra Help, to make sure you pay no more 

than the right amount to fill your prescriptions. 

What if the pharmacist can’t confirm my drug plan or 

Extra Help status? 

In some rare cases, the pharmacist may not be able to confirm your plan 

enrollment or that you qualify for Medicaid or Extra Help. If this happens, 

your doctor may be able to give you a sample of your drug to help until 

your coverage is confirmed. You can also pay out-of-pocket for the drug. 

You should save the receipts and work with your new Medicare drug plan 

to get paid back for the drugs that would normally be covered under your 

plan. 

If you paid for drugs out-of-pocket before you were enrolled in a Medicare 

drug plan but after you qualified for both Medicare and Medicaid or SSI, 

you may be able to get paid back for those costs. Call Medicare’s Limited 

Income NET Program at 1-800-783-1307 to see if you qualify. TTY users 

can call 711. 

Words in 

red are 

defined 

on pages 

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73

Section

7 Rights & Appeals 

How do I protect myself from fraud and 

identity theft? 

Help protect yourself by knowing whether Medicare Advantage Plans

(like HMOs or PPOs) and Medicare Prescription Drug Plans are 

marketing to you properly. These plans and people who work with 

Medicare aren’t allowed to: 

■ Charge you a fee to enroll in a plan. 

■ Send you unwanted emails. 

■ Come to your home uninvited to get you to join a Medicare plan. 

■ Call you, unless you’re already a plan member. If you’re a member, 

the agent who helped you join can call you. 

■ Offer you money to join their plan or give you free meals while 

trying to sell you a plan. 

■ Enroll you into a drug plan over the phone unless you call them and 

ask to enroll. 

■ Ask you for payment over the phone or online. The plan must send 

you a bill. 

■ Sell you a non-health related product, like an annuity or life 

insurance policy, while trying to sell you a Medicare health or 

drug plan. 

■ Make an appointment to tell you about their plan unless you agree 

(in writing or through a recorded phone call) to the products being 

discussed. During the appointment, they can only try to sell you the 

products you agreed to hear about. 

■ Talk to you about their plan in areas where you get health care, like 

an exam room, hospital patient room, or at a pharmacy counter. 

■ Try to sell you their plans or enroll you during an educational 

event, like a health fair or conference. 

Independent agents and brokers working for plans must be licensed 

by the state. The plan must tell the state which agents are selling 

its plans. 
74

7 Rights & Appeals 

If you’re in a Medicare drug plan and you think the plan may be breaking 

these rules, call the Medicare Drug Integrity Contractor (MEDIC) at 

1-877-7SAFERX (1-877-772-3379). 

Identity theft happens when someone uses your personal information 

without your permission to commit fraud or other crimes. Personal 

information includes things like your name, or your Social Security, 

Medicare, bank account, or credit card numbers. 

If you think someone is misusing your personal information, call 

the Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338 

to make a report. TTY users can call 1-866-653-4261. For more 

information about identity theft or to file a complaint online, visit 

consumer.gov/section/scams-and-identity-theft. 

What if I need help applying for Extra Help, joining 

a Medicare drug plan, or requesting a coverage 

determination or appeal? 

You may have a legal representative who, by state or federal law, has the 

legal right (like through a Power of Attorney or a court order) to act on 

your behalf. You can also appoint a family member, friend, advocate, 

attorney, doctor, or someone else to act as your representative. 

A representative can help 

you (or act on your behalf) 

apply to see if you qualify 

for Extra Help paying for 

Medicare drug coverage, or 

file a request for a coverage 

determination, complaint (also 

called a “grievance”), or appeal. 

Your doctor or other prescriber 

can request a coverage 

determination or first or second level appeal for you without being your 

appointed representative. A representative can’t enroll you in a Medicare 

drug plan unless they’re also your legal representative according to the 

laws of your state.

Words in 

red are 

defined 

on pages 

83–86. 
75

7 Rights & Appeals 

A representative can be any of these: 

■ The person who acts on your behalf if you’re incapacitated or 

can’t make decisions for yourself. 

■ Anyone you choose to act as your representative (like your 

spouse, your child, or a caregiver). 

■ Your “representative payee” (sometimes called a “rep payee”). 

This is a person, agency, organization, or institution that Social 

Security selects to act on your behalf. 

You can appoint your representative in one of these ways: 

1. Fill out an “Appointment of Representative” form (CMS Form 

Number 1696) at Medicare.gov/MedicareOnlineForms, or call 

1-800-MEDICARE (1-800-633-4227) and ask for a free copy. 

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

2. Submit a letter that includes: 

— Your name, address, and phone number 

— Your Medicare number (found on your red, white, and 

blue Medicare card) or plan identification card 

— A statement appointing someone as your representative 

— The name, address, and phone number of your 

representative 

— The professional status of your representative or his or her 

relationship to you 

— A statement authorizing the release of your personal and 

identifiable health information to your representative 

— A statement explaining why you’re being represented and 

to what extent 

— Your signature and the date you signed the letter 

— Your representative’s signature and the date he or she 

signed the letter 
76

7 Rights & Appeals 

Your representative must send the form or letter with your appeal 

request. See page 78 on how to request an appeal. The person 

helping you must send a copy of the form or letter each time 

you file a coverage determination or appeal, so keep a copy of 

everything you send to Medicare as part of your appeal. If you have 

questions about appointing a representative, call 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048. 

What if my enrollment in a Medicare drug plan 

is denied? 

Medicare drug plans generally have to accept all eligible applicants 

who live in their service area, regardless of the applicant’s age or 

health status. If your enrollment form is denied, the company will 

send you a letter explaining why. You may contact the plan for more 

information about your options. 

What if my plan won’t cover a drug I need? 

If your Medicare drug plan won’t cover a drug you think should be 

covered, or it will cover the drug at a higher cost than you think you 

should have to pay, you have these options: 

1. Talk to your prescriber (the professional who wrote your 

prescription).

Ask your prescriber if you meet 

prior authorization or step therapy 

requirements. Contact your plan 

for more information on these 

requirements. You can also ask 

your prescriber if there are generic, 

over-the-counter, or less expensive 

brand-name drugs that could work just 

as well as the ones you’re taking now. 

Words in 

red are 

defined 

on pages 

83–86. 
77

7 Rights & Appeals 

2. Request a coverage determination (including an “exception”).

You, your representative, your doctor, or other prescriber can request 

(orally or in writing) that your plan cover the drug you need. You can 

request a coverage determination if your pharmacist or plan tells you one 

of these: 

■ A drug you believe should be covered isn’t covered. 

■ A drug is covered at a higher cost than you think you should have to 

pay. 

■ You have to meet a plan coverage rule (like prior authorization) before 

you can get the drug you requested. 

■ It won’t cover a drug on the formulary because the plan believes you 

don’t need the drug. 

You, your representative, your doctor, or other prescriber can request a 

coverage determination called an “exception” if: 

■ You think your plan should cover a drug that’s not on its formulary 

(drug list) because the other treatment options on your plan’s formulary 

won’t work for you. 

■ Your doctor or other prescriber believes you can’t meet one of your 

plan’s coverage rules, like prior authorization, step therapy, or quantity 

or dosage limits. 

■ You think your plan should charge a lower amount for a drug you’re 

taking on a higher-cost drug tier because the other treatment options in 

your plan’s lower-cost drug tier(s) won’t work for you. 

If you request an exception, your doctor or other prescriber will need to 

give a supporting statement to your plan explaining why you need the 

drug you’re requesting. Check with your plan to find out if the supporting 

statement is required to be made in writing. The plan’s decision-making 

time period begins once your plan gets the supporting statement. 

You can either request a coverage determination before you pay for 

or get your drug, or you can decide to pay for the drug, save your 

receipt, and request that the plan pay you back by requesting a coverage 

determination. 
78

7 Rights & Appeals 

For details on filing a coverage determination, visit Medicare.gov/appeals. 

If you disagree with the coverage determination decision, you have the 

right to appeal. 

How do I appeal if I have Medicare drug coverage? 

If your plan denies your request, it will send you a letter explaining why 

the drug you requested isn’t covered and instructions on how to file an 

appeal. You also can find information about your appeal rights in the 

plan’s “Evidence of Coverage” 

(EOC). The EOC is a document 

your plan sends you each year that 

explains what the plan covers and 

how it works. Call your plan if you 

have questions about your EOC. 

If you decide to appeal, ask your 

doctor or other prescriber for any 

information that may help your 

case. Keep a copy of everything 

you send to your plan as part of 

your appeal. 

What’s the appeals process for Medicare drug 

coverage? 

The appeals process has 5 levels. If you disagree with the decision made 

at any level of the process, you can generally go to the next level. At each 

level, you’ll be given instructions on how to move to the next level of 

appeal. For details on the appeals process, visit Medicare.gov/appeals. 

How do I file a complaint (grievance)? 

If you have a concern or a problem with your plan that isn’t a request 

for coverage or reimbursement for a drug, you have the right to file a 

complaint (also called a “grievance”). 

Words in 

red are 

defined 

on pages 

83–86. 
79

7 Rights & Appeals 

Some examples of why you might file a complaint include: 

■ You believe your plan’s customer service hours of operation should be 

different. 

■ You have to wait too long for your drug. 

■ The company offering your plan is sending you materials that you 

didn’t ask to get and aren’t related to the drug plan. 

■ The plan didn’t make a timely decision about a coverage determination

or didn’t send your case to the Independent Review Entity (IRE) when 

it should have. 

■ You disagree with the plan’s decision not to grant your request for an 

expedited (fast) coverage determination or first-level appeal (called a 

“redetermination”). 

■ The plan didn’t provide you with the required notices. 

■ The plan’s notices don’t follow Medicare rules. 

If you want to file a complaint, you should know: 

■ You must file your complaint within 60 days from the date of the event 

that led to the complaint. 

■ You can file your complaint with the plan over the phone or in writing. 

■ You must be notified of the plan’s decision generally no later than 

30 days after the plan gets the complaint. 

■ If the complaint relates to a plan’s refusal to make an expedited (fast) 

coverage determination or redetermination and you haven’t yet 

purchased or received the drug, the plan must notify you of its decision 

within 24 hours after it gets the complaint. 

■ If you think you were charged too much for a drug, call the company 

offering your plan to get the most up-to-date price. 

If the plan doesn’t address your complaint, call 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048. 
80

7 Rights & Appeals 

More information on filing a complaint 

■ Visit Medicare.gov/appeals. 

■ Call your State Health Insurance Assistance Program (SHIP) for 

free, personalized counseling and help filing a complaint. To get 

the phone number of the SHIP in your state, visit shiptacenter.org

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

1-877-486-2048. 

What if I don’t agree with Medicare’s late 

enrollment penalty? 

If you don’t join a Medicare drug plan when you’re first eligible, 

you may have to pay a late enrollment penalty unless you had other 

creditable prescription drug coverage. In some cases, you have the 

right to ask Medicare to review your late enrollment penalty. This is 

called a “reconsideration.” 

Some reasons why you may ask for a reconsideration include: 

■ You think Medicare didn’t count all your previous creditable 

prescription drug coverage. 

■ You didn’t get a notice that clearly explained whether your previous 

drug coverage was creditable. 

Your Medicare drug plan will give you a reconsideration request form 

when it sends you the letter telling you that you have to pay a late 

enrollment penalty. Mail the completed form to the address, or fax it 

to the number listed on the form within 60 days from the date on the 

letter. You should also send any proof that supports your case, like 

information about previous creditable prescription drug coverage. 

If you need more information about requesting a 

reconsideration of your late enrollment penalty, 

call your Medicare drug plan. You can also 

visit Medicare.gov, or call 1-800-MEDICARE 

(1-800-633-4227) for help. TTY users can call 

1-877-486-2048. 

Words in 

red are 

defined 

on pages 

83–86. 
81

Section

8 For More Information 

For more information about Medicare drug coverage, visit 

Medicare.gov/find-a-plan to get personalized information. Enter and save 

your current drug information to get more detailed cost information. 

You also can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 

including weekends, to get information you need. TTY users can call 

1-877-486-2048. 

Note: If you want Medicare to give your personal health information 

to someone other than you, you need to let Medicare know in writing.

You can fill out a “Medicare Authorization to Disclose Personal Health 

Information” form (CMS Form Number 10106) at 

Medicare.gov/MedicareOnlineForms, or call 1-800-MEDICARE to get a 

copy of the form. 

■ For more information about your 

current drug coverage, contact your 

benefits administrator, insurer, or 

plan. 

■ For more information about 

applying for Extra Help with your 

Medicare drug plan costs, call Social 

Security at 1-800-772-1213, or visit 

socialsecurity.gov. TTY users can call 

1-800-325-0778. 

■ For free personalized counseling on 

your coverage choices, contact your 

State Health Insurance Assistance 

Program (SHIP). Visit shiptacenter.org

or call 1-800-MEDICARE for the 

phone number of your SHIP. 
82
83

Section

9 Definitions 

Coinsurance—An amount you may be required to pay as your share of the cost 

for services after you pay any deductibles. Coinsurance is usually a percentage 

(for example, 20%). 

Copayment—An amount you may be required to pay as your share of the cost 

for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or 

prescription drug. A copayment is usually a set amount, rather than a percentage. 

For example, you might pay $10 or $20 for a doctor’s visit or prescription drug. 

Coverage determination (Part D)—The first decision made by your Medicare 

drug plan (not the pharmacy) about your drug benefits, including: 

■ Whether a particular drug is covered 

■ Whether you have met all the requirements for getting a requested drug 

■ How much you’re required to pay for a drug 

■ Whether to make an exception to a plan rule when you request it 

The drug plan must give you a prompt decision (72 hours for standard requests, 

24 hours for expedited requests). If you disagree with the plan’s coverage 

determination, the next step is an appeal. 

Coverage gap (Medicare prescription drug coverage)—A period of time 

in which you pay higher cost sharing for prescription drugs until you spend 

enough to qualify for catastrophic coverage. The coverage gap (also called the 

“donut hole”) starts when you and your plan have paid a set dollar amount for 

prescription drugs during that year. 

Creditable prescription drug coverage—Prescription drug coverage (for 

example, from an employer or union) that’s expected to pay, on average, at least 

as much as Medicare’s standard prescription drug coverage. People who have 

this kind of coverage when they become eligible for Medicare can generally 

keep that coverage without paying a penalty, if they decide to enroll in Medicare 

prescription drug coverage later. 

Deductible—The amount you must pay for health care or prescriptions before 

Original Medicare, your prescription drug plan, or your other insurance begins 

to pay. 

Drug list—A list of prescription drugs covered by a prescription drug plan or 

another insurance plan offering prescription drug benefits. This list is also called 

a formulary. 
84

9 Definitions 

End-Stage Renal Disease (ESRD)—Permanent kidney failure that requires a 

regular course of dialysis or a kidney transplant.

Exception—A type of Medicare prescription drug coverage determination. 

A formulary exception is a drug plan’s decision to cover a drug that’s not on its 

drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision 

to charge a lower amount for a drug that is on its non-preferred drug tier. You or 

your prescriber can request an exception, and your doctor or other prescriber must 

provide a supporting statement explaining the medical reason for the exception. 

Extra Help—A Medicare program to help people with limited income and 

resources pay Medicare prescription drug program costs, like premiums, 

deductibles, and coinsurance. 

Institution—For the purposes of this publication, an institution is a facility that 

provides short-term or long-term care, such as a nursing home, skilled nursing 

facility (SNF), or rehabilitation hospital. Private residences, such as an assisted 

living facility or group home, aren’t considered institutions for this purpose. 

Medicaid—A joint federal and state program that helps with medical costs 

for some people with limited income and resources. Medicaid programs vary 

from state to state, but most health care costs are covered if you qualify for both 

Medicare and Medicaid. 

Medicare—Medicare is the federal health insurance program for people who are 

65 or older, certain younger people with disabilities, and people with End-Stage 

Renal Disease (permanent kidney failure requiring dialysis or a transplant, 

sometimes called ESRD). 

Medicare Advantage Plan (Part C)—A type of Medicare health plan offered 

by a private company that contracts with Medicare to provide you with all 

your Medicare Part A and Part B benefits. Medicare Advantage Plans include 

Health Maintenance Organizations, Preferred Provider Organizations, Private 

Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account 

Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services 

are covered through the plan and aren’t paid for under Original Medicare. Most 

Medicare Advantage Plans offer prescription drug coverage. 

Medicare Cost Plan—A type of Medicare health plan available in some areas. 

In a Medicare Cost Plan, if you get services outside of the plan’s network without a 

referral, your Medicare-covered services will be paid for under Original Medicare 

(your Cost Plan pays for emergency services or urgently-needed services). 
85

9 Definitions 

Medicare health plan—Generally, a plan offered by a private company that 

contracts with Medicare to provide Part A and Part B benefits to people with 

Medicare who enroll in the plan. Medicare health plans include all Medicare 

Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. 

Programs of All-inclusive Care for the Elderly (PACE) organizations are special 

types of Medicare health plans. PACE plans can be offered by public or private 

entities and provide Part D and other benefits in addition to Part A and Part B 

benefits. 

Medicare Medical Savings Account (MSA) Plan—MSA Plans combine 

a high deductible Medicare Advantage Plan and a bank account. The plan 

deposits money from Medicare into the account. You can use the money in this 

account to pay for your health care costs, but only Medicare-covered expenses 

count toward your deductible. The amount deposited is usually less than your 

deductible amount so you generally will have to pay out-of-pocket before your 

coverage begins. 

Medicare Part A (Hospital Insurance)—Part A covers inpatient hospital stays, 

care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)—Part B covers certain doctors’ services, 

outpatient care, medical supplies, and preventive services.

Medicare prescription drug coverage (Part D)—Optional benefits for 

prescription drugs available to all people with Medicare for an additional 

charge. This coverage is offered by insurance companies and other private 

companies approved by Medicare.

Medicare Prescription Drug Plan (Part D)—Part D adds prescription drug 

coverage to Original Medicare, some Medicare Cost Plans, some Medicare 

Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. 

These plans are offered by insurance companies and other private companies 

approved by Medicare. Medicare Advantage Plans may also offer prescription 

drug coverage that follows the same rules as Medicare Prescription Drug Plans. 

Medicare Private Fee-for-Service (PFFS) Plan—A type of Medicare 

Advantage Plan (Part C) in which you can generally go to any doctor or hospital 

you could go to if you had Original Medicare, if the doctor or hospital agrees 

to treat you. The plan determines how much it will pay doctors and hospitals, 

and how much you must pay when you get care. A Private Fee-For-Service 

Plan is very different than Original Medicare, and you must follow the plan 

rules carefully when you go for health care services. When you’re in a Private 

Fee-For-Service Plan, you may pay more or less for Medicare-covered benefits 

than in Original Medicare. 
86

9 Definitions 

Medigap policy—Medicare Supplement Insurance sold by private 

insurance companies to fill “gaps” in Original Medicare coverage. Some 

Medigap policies sold before January 1, 2006, have prescription drug 

coverage. Policies sold on or after January 1, 2006, don’t have prescription 

drug coverage. 

Original Medicare—Original Medicare is a fee-for-service health plan that 

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

After you pay a deductible, Medicare pays its share of the Medicare-approved 

amount, and you pay your share (coinsurance and deductibles). 

Penalty—An amount added to your monthly premium for Medicare Part B 

or a Medicare drug plan (Part D), if you don’t join when you’re first eligible. 

You pay this higher amount as long as you have Medicare. There are some 

exceptions. 

Premium—The periodic payment to Medicare, an insurance company, or a 

health care plan for health or prescription drug coverage. 

Programs of All-inclusive Care for the Elderly (PACE)—A special type of 

health plan that provides all the care and services covered by Medicare and 

Medicaid as well as additional medically necessary care and services based 

on your needs as determined by an interdisciplinary team. PACE serves frail 

older adults who need nursing home services but are capable of living in the 

community. PACE combines medical, social, and long-term care services and 

prescription drug coverage. 

State Health Insurance Assistance Program (SHIP)—A state program 

that gets money from the Federal government to give free local health 

insurance counseling to people with Medicare. 

State Medical Assistance (Medicaid) office—A state or local agency 

that can give information about, and assist with applications for, Medicaid 

programs that help pay medical bills for people with limited income and 

resources. 

State Pharmaceutical Assistance Program (SPAP)—A state program 

that provides help paying for drug coverage based on financial need, age, or 

medical condition. 
Notice of Availability of Auxiliary Aids & Services 

We’re committed to making our programs, benefits, services, 

facilities, information, and technology accessible in accordance with 

Sections 504 and 508 of the Rehabilitation Act of 1973. We’ve taken 

appropriate steps to make sure that people with disabilities, including 

people who are deaf, hard of hearing or blind, or who have low vision 

or other sensory limitations, have an equal opportunity to participate 

in our services, activities, programs, and other benefits. We provide 

various auxiliary aids and services to communicate with people with 

disabilities, including: 

Relay service—TTY users can call 1-877-486-2048. 

Alternate formats—This product is available in alternate formats, 

including large print, Braille, audio, CD, or as an eBook. 

To request a Medicare product in an alternate format, call 

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

1-877-486-2048. To request the Medicare & You handbook in an 

alternate format, visit Medicare.gov/medicare-and-you.

Nondiscrimination Notice

The Centers for Medicare & Medicaid Services (CMS) doesn’t 

exclude, deny benefits to, or otherwise discriminate against any 

person on the basis of race, color, national origin, disability, sex, 

or age. If you think you’ve been discriminated against or treated 

unfairly for any of these reasons, you can file a complaint with the 

Department of Health and Human Services, Office for Civil Rights 

by: 

Calling 1-800-368-1019. TTY users can call 1-800-537-7697. 

Visiting hhs.gov/ocr/civilrights/complaints. 

Writing: Office for Civil Rights 

U.S. Department of Health and Human Services 

200 Independence Avenue, SW 

Room 509F, HHH Building 

Washington, D.C. 20201 
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 

CMS Product No. 11109 

Revised June 2017 

To get this booklet in Spanish, call 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048. 

¿Necesita usted una copia de esta guía en Español? 

Llame al 1-800-MEDICARE (1-800-633-4227). Los 

usuarios de TTY pueden llamar al 1-877-486-2048.