What is Medicare Part D?
Medicare Part D was added to Medicare 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 you don’t have other drug coverage that is equal or better than the coverage offered by Medicare (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.
How much will it cost?
Blue Shield of California’s Medicare Advantage-Prescription Drug Plan premiums vary by counties.
- $0 monthly plan premium: Los Angeles, Orange, Riverside, San Bernardino, San Diego, Ventura, Kern, San Luis Obispo and Santa Barbara counties – Blue Shield 65 Plus
- $39 monthly plan premium: Sacramento County – Blue Shield Trio Medicare (HMO)
- $20 monthly plan premium: Fresno County – Blue Shield 65 Plus (HMO)
- $65 monthly plan premium: Alameda County – Blue Shield Inspire (HMO)
- $126 monthly plan premium: Alameda County – Blue Shield Medicare (PPO)
- $55 monthly plan premium: San Mateo County – Blue Shield Inspire (HMO)
The Blue Shield Medicare Rx Plus (PDP) has a monthly premium of $40.70 with a $435 deductible (Tier 1 Preferred Generic Drugs excluded). The Blue Shield Rx Enhanced (PDP) Plan has a monthly premium of $118.40 with no deductible.
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, the amount of extra help you get will determine your total monthly plan premium as a member of our Plan. See our Extra Help page for more information.
What is the "coverage gap"?
Most Medicare 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 the applicable 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 get "catastrophic coverage."
For Blue Shield plans, the coverage gap begins once your total drug costs reach $4,020 in 2020.
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 $6,350 in 2020 for your covered drugs, you only pay a small coinsurance or copayment amount for the rest of the year.
In 2020 you pay the greater of $3.60 for generic drugs (including brand-name drugs treated as generic), $8.95 for all other drugs, or 5% coinsurance.
Which drugs are covered?
All of Blue Shield's Medicare prescription drug plans include a formulary that has 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 physician 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 drug coverage directly from Medicare as I do Part A and Part B coverage?
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, and then each year during the same time period. There are certain circumstances that will allow a Medicare recipient to enroll during a Special Election Period. Call us at (800) 963-8008 [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, at least one percent of the national base beneficiary premium for every month you wait to enroll. If you enroll into 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.
What is a formulary?
Each Medicare prescription drug plan will have a list of drugs it covers. This list is called a formulary. At Blue Shield of California, the formulary is developed and maintained by the Pharmacy and Therapeutics (P&T) committee and contains medications that have been reviewed and approved by the Food and Drug Administration (FDA). The Blue Shield of California P&T Committee includes practicing physicians and clinical pharmacists specialist in various areas. The committee reviews and updates the formulary at least quarterly to assist physicians in prescribing medically appropriate and cost-effective medications.
What if my drug is not on the Blue Shield of California Formulary?
Once you're a Blue Shield member, if you learn that your selected plan does not cover your drug, you have two options:
- Ask Member Services for a list of similar drugs that are covered by the plan you selected. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan you selected.
- Request that Blue Shield of California make an exception and cover your drug. The process of requesting an exception is outlined in your Evidence of Coverage (EOC), or you may call Member Services for additional information.
Once I'm a member, can I use the same pharmacy I've been using to get my prescription drugs?
Blue Shield of California has an extensive network of pharmacies. The pharmacy that you've been using may very likely already be a part of our network. Check our Pharmacy Directory to confirm that your pharmacy is part of our network.
Do I need to use my ID card every time I visit the pharmacy?
Always bring your plan ID card with you every time you go to the pharmacy so you always take advantage of your drug coverage. You should even present the card if your plan has a deductible, where you might be paying 100 percent for the drug. This will allow you to receive Blue Shield's contracted rate at the pharmacy and ensures that your payment will be captured as part of your out-of-pocket expenses.
Can I get my prescription through the mail?
When you enroll in a Blue Shield of California Medicare plan, your coverage provides a mail service benefit that offers cost savings and the convenience of home delivery. You can use the Blue Shield mail service pharmacy to fill prescriptions for any drug that is indicated as a mail-service drug on the formulary list.
To receive medications through Blue Shield's mail service pharmacy, you must first register online. For instructions on registering and ordering visit our Pharmacy Directory site.
Which drugs are excluded from Part D prescription drug plans?
A drug cannot be covered under a Medicare Part D prescription drug plan if payment for that drug is available under Parts A or B of Medicare. Some examples are drugs administered in a hospital or a physician's office.
Medicare also excludes the following categories of drug:
- Drugs not approved by the FDA.
- Non-prescription drugs (also called over-the-counter drugs)
- Drugs when used to promote fertility
- Drugs when used for the relief of cough or cold symptoms
- Drugs when used for cosmetic purposes or to promote hair growth
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
- Drugs when 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 about TrOOP, please refer to the Center for Medicare and Medicaid (CMS) document Understanding True Out-of-Pocket Costs (TrOOP).
This information complete description of benefits. Contact Member Services at (800) 776-4466 [TTY 711] for more information.
What are my rights and responsibilities if I want to leave a Blue Shield Medicare Advantage HMO, PPO or Prescription Drug Plan?
The chapter Ending your membership in the plan in the plan’s Evidence of Coverage includes important topics like when you can end your membership, how to end your membership, and why Blue Shield might need to end your membership in the plan.
Ending your membership in a Blue Shield plan may be voluntary (your own choice) or involuntary (not your own choice):
1. You might leave our plan because you have decided that you want to leave.
- There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. The most common is the Annual Enrollment Period from October 15 to December 7.
During the MA Open Enrollment Period (MA OEP), MA plan enrollees may enroll in another MA plan or disenroll from their MA plan and return to Original Medicare. Individuals may make only one election during the MA OEP.
- Individuals enrolled in MA plans as of January 1 (MA OEP timeframe January 1 – March 31)- New Medicare beneficiaries who are enrolled in an MA plan during their ICEP (MA OEP timeframe the month of entitlement to Part A and Part B – the last day of the 3rd month of entitlement)
- The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. If you are enrolling in another plan with prescription drug coverage, simply enrolling in that other plan will end your membership in our plan.
2. There are also limited situations where you do not choose to leave, but we are required to end your membership. For example, you may move out of our service area or you do not stay continuously enrolled in Medicare Part A and Part B.
If you are leaving our plan, you must continue to get your medical care and/or prescription drugs through our plan until your membership ends.
We cannot ask you to leave our plan for any reason related to your health, and if we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.
How do I submit requests for reimbursement for prescriptions I paid out of pocket for?
As an eligible Medicare Part D member, anytime 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.
If you need help completing the DMR form, please contact your pharmacist or call Member Services at the number on the back of your Blue Shield ID card.
DMR form for Medicare members (PDF, 404KB)
Mail the completed DMR form to:
P.O. Box 419019
Kansas City, MO 64141