Understanding Medicare Advantage Prescription Drug and Medicare Prescription Drug Plans
What is Medicare Part D?
Medicare Part D was added to help individuals pay for prescription drugs. Signing up for Medicare Part D is voluntary, although penalties may apply if you don't sign up when you're first eligible and if you don’t have other drug coverage that is equal to or better than the coverage offered by Medicare. (This is known as creditable coverage.)
Who is eligible?
To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B. For prescription drug coverage through a Medicare Advantage plan, you must have both Medicare Part A and Part B to enroll. You must continue to pay your Medicare Part B premium.
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What is the "coverage gap"?
Most Medicare Prescription Drug Plans have a coverage gap. This means that after you and your plan have spent a certain amount of money (this is called the "initial coverage limit" and may vary by plan) for covered drugs, you pay a different cost-sharing amount for your drugs while you are in the coverage "gap."
In addition, when you are in the coverage gap stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs.
Read your plan Summary of Benefits or Evidence of Coverage for more information on each plan's coverage through the gap. Once you reach the gap limit, you will then receive "catastrophic coverage."
In 2023, the coverage gap begins once your total drug costs reach $4,660.
What is catastrophic coverage?
Catastrophic coverage is special coverage for people who have extremely high drug costs. Once you or other qualified parties on your behalf have paid more than $7,400 in 2023 for your covered drugs, you only pay a small coinsurance or copayment amount for the rest of the year.
In 2023, your coinsurance will be one of the following, whichever is greater:
- $4.15 for generic drugs (including brand-name drugs treated as generic) and $10.35 for all other drugs
- 5% coinsurance
Which drugs are covered?
All of Blue Shield's Medicare Advantage Prescription Drug and Medicare Prescription Drug Plans include a formulary (list of covered drugs) that have been approved by the Centers for Medicare and Medicaid Services. Please review the appropriate plan formulary to make sure it includes the prescription drugs you need before choosing a plan. If you cannot find your drug on our formulary, ask your doctor or other prescriber if there is a drug on our formulary that can be prescribed to treat your condition. Find out more about covered drugs in Blue Shield of California’s Formulary for Medicare Part D.
Can I get prescription coverage from Medicare Part A and Part B?
No. Medicare prescription drug coverage is not available directly from Medicare. Although you are able to have your premium deducted from your Social Security check, you must purchase Medicare prescription drug coverage from an insurance company or a private company, such as Blue Shield of California, that has been approved by Medicare to offer Part D prescription coverage.
When can I get Medicare prescription drug coverage?
The next opportunity for Medicare recipients to enroll will be from October 15 to December 7, during open enrollment. This window is available at the same time every year. There are certain circumstances that will allow a Medicare recipient to enroll during a Special Election Period. Call us at (855) 203-3874 (TTY: 711) for more information about Special Election Periods.
If you don't enroll when you're first eligible and you don’t have other creditable coverage, you may have to pay a late-enrollment penalty, which is calculated/charged as at least 1% of the national base beneficiary premium for every month you wait to enroll. If you enroll in the program late, you may have to pay that penalty each month for as long as you stay in a Medicare Part D prescription drug plan.
For an explanation of how to determine your penalty amount for late enrollment, call 1-800-MEDICARE (1-800-633-4227) TTY/TDD 1-877-486-2048, 24 hours a day, seven days a week.
Who can I call at Blue Shield of California to answer additional questions?
Find a list of phone numbers for your particular plan at the Contact us page.
Are any drugs excluded from Medicare Advantage Prescription Drug or Medicare Prescription Drug plans?
A drug is not covered under a Medicare Advantage Prescription Drug Plan or Medicare Prescription Drug Plan if payment for that drug is available under Part A or B of Medicare. For example, a drug cannot be covered if it is administered in a hospital or a physician’s office.
Medicare also excludes drugs from the following categories:
- Drugs not approved by the FDA
- Nonprescription drugs (also called over-the-counter drugs)
- Drugs used to promote fertility
- Drugs used for the relief of cough or cold symptoms
- Drugs used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
- Drugs used for the treatment of anorexia, weight loss, or weight gain
- Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
Note: Costs associated with these drugs will not apply toward your true out-of-pocket expenses (TrOOP). For more information, please refer to the Center for Medicare and Medicaid document Understanding True Out-of-Pocket Costs (TrOOP).
This information is not a complete description of benefits. Contact the Customer Care number on your ID card.
How do I submit reimbursement requests to my Part D plan for prescriptions I paid out-of-pocket for?
As an eligible Medicare Part D member, any time you pay out-of-pocket for a prescription that is covered under your pharmacy benefit plan, you can submit a request for reimbursement.
The reimbursement form must be received within one year from the date you paid for the service. This process of reimbursing is called direct member reimbursement or DMR.
Submission of the form is not a guarantee of payment. Reimbursement requests will not be processed without a prescription receipt.
If you need help completing the DMR form, please contact your pharmacist or call the Customer Care number on your Blue Shield ID card.
DMR form for Medicare members, English (PDF, 233 KB)
DMR form for Medicare members, Español (PDF, 144 KB)
Mail the completed DMR form to:
Blue Shield of California
P.O. Box 52066
Phoenix, AZ 85072-2066