Frequently Asked Questions

Medicare Part D

Medicare Part D prescription drug coverage is insurance that helps to pay for prescription drugs at participating pharmacies. As a federal program, Medicare Part D was enacted as a part of the Medicare Modernization Act of 2003. It officially went into effect on January 1, 2006.

Medicare Part D is available as stand-alone coverage (also called Prescription Drug Plan or PDP) to supplement your Medicare Supplement or Original Medicare plan, or as a prescription drug benefit added to a Medicare Part C plan (MA-PD). Whichever you choose, you can only be enrolled in one Medicare prescription plan at a time.

Medicare Part D prescription drug coverage is only available through private insurance companies that are approved by Medicare. Blue MedicareRx is a provider of stand-alone prescription drug coverage. Learn more

The Medicare Extra Help program is designed to help people who may not be able to afford prescription drug coverage by assisting with the costs of a Part D plan. This may include premiums, deductibles and/or coinsurance.*

To see if you qualify for Extra Help, call:

* You must continue to pay your Medicare Part B premium.

If you need additional Extra Help, please view BenefitsCheckup.org, a site developed and maintained by the National Council on Aging (NCOA). BenefitsCheckup.org provides those with limited resources a web-based service that screens for benefits programs and lets you know how and where to apply for them. Millions of people have already received additional assistance by using BenefitsCheckup.org.

Enrollment

You are eligible to enroll in a Medicare Prescription Drug Plan if you are entitled to Medicare Part A and/or enrolled in Part B. In addition, you must be age 65 or older, or under age 65 with qualifying disabilities, or have been diagnosed with End-Stage Renal Disease (permanent kidney failure requiring a kidney transplant or dialysis, also written as ESRD). Learn more

When you first become eligible for Medicare, you have a 7-month initial enrollment period (IEP). If you don’t sign up in your IEP, you may have to pay a late enrollment penalty every month for as long as you have a Part D plan.

Each year, Part D open enrollment begins on October 15 and ends on December 7. It gives you the option to change your drug coverage for the start of the New Year or enroll for the first time.

You can also enroll at other times if your situation has changed and qualifies you for a Special Enrollment Period.

To learn more about when you can enroll in Medicare Part D, review the election periods.

You may incur a late enrollment penalty if there is a continuous period of 63 days or more at any time after the end of your Initial Election Period (IEP) during which you were eligible to enroll in a Medicare Part D plan, but were not enrolled and not covered under any creditable prescription drug coverage.

A late enrollment penalty is an additional amount added to your monthly Medicare Part D premium. The specific amount of this fee depends on the length of your lapse in coverage. You will be required to pay the penalty to be eligible for, and to keep, Medicare prescription drug coverage.

Note: “creditable coverage” is coverage as good as Medicare Part D coverage.

You may join, switch or drop your current Medicare Prescription Drug plan during Medicare's Annual Election Period (AEP). You have the option of adding Part D coverage, or switching Part D plans between January and March if you are enrolled in a Part C plan (MA). You may also make changes to your Medicare prescription drug coverage during a Special Election Period (SEP), when certain non-routine events happen in your life.

Paying My Monthly Premium

For automatic deduction from your Social Security or Railroad Retirement Board benefits, or automatic monthly charge to your credit card, call Customer Care at the number on your Member ID card.

For automatic withdrawal from your bank account, complete and sign the ACH coupon attached to your monthly invoice and return it with a check for your payment.

It may take two or more months for your automatic payments to begin, so please continue to pay your invoices by mail until you no longer receive them.

The Income-Related Monthly Adjustment Amount or “IRMAA” applies to Medicare beneficiaries with higher incomes. The IRMAA adjusts as income levels increase. For example, if your 2017 reported yearly income as a single taxpayer was greater than 85,000 , (greater than $ 170,000 filing jointly), you will be responsible for paying an additional $12.40 per month. This is in addition to your monthly premium.

Important points about the Part D IRMAA to keep in mind:

  • If you owe an IRMAA, Social Security will send you a letter notifying you of the extra amount you will owe monthly.
  • The Part D IRMAA is billed directly by the Centers for Medicare and Medicaid Services, which means any IRMAA payment should not be sent to your prescription drug plan.
  • If you do not pay your IRMAA, you risk disenrollment from your Medicare Part D plan.

More information about the Part D IRMAA can be found on Medicare’s website.

It may take one or more months for automatic payments to begin. Please continue to pay your premium invoice as long as you receive it. Once you stop receiving invoices by mail, your automatic premium payments will begin.

Yes. You may call Customer Care to cancel or change automatic payments at any time. The choice is always yours.

Your first invoice may take up to 45 days to arrive, and you may be billed for two months’ coverage at that time. Your payment is not due until you receive your first invoice. You are always welcome to call Blue MedicareRx Customer Care at the number on the back of your Member ID card to make a payment over the phone.

Premium payments are due on the first of each month. If you select convenient automatic premium payments through your bank account or credit card, your payment will be processed between the 8th and 10th of each month.

To avoid confusion, we ask that you send separate checks for each member account and include the associated Payment ID number on your check. Your Payment ID number is located on the payment coupon attached to your invoice. This helps to ensure each member account is updated accurately.

Payment plans are available for premium payments. Call the number on your Member ID card to discuss your premium payment options with a representative. You can also request Extra Help, which is a program that helps people with limited income and resources pay for their Medicare prescription drug costs. To see if you qualify for Extra Help, visit your local Social Security office or call 1-800-772-1213 (TTY 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.

Drug Coverage

To find out if your drug is covered, start by reviewing the comprehensive formulary for your Blue MedicareRx plan. The comprehensive formulary is our complete list of prescription drugs we cover. You can also use the Drug Pricing Tool to find coverage and costs.

We suggest that you first speak with your doctor to see if a different drug that is covered by your plan is appropriate for your treatment and usage needs. If you and your doctor feel that the drug you are currently taking is the best option for your treatment, you may submit a coverage determination request, asking your Blue MedicareRx plan to cover your drug based on your current usage.

A coverage determination is a request for your plan to cover a drug that is not on our formulary, or for which your current prescription does not meet the formulary requirements or limitations. Learn more about coverage determination process.

We may discontinue or reduce coverage of a drug during the coverage year if a new, less expensive generic drug becomes available, if we add a new requirement/limitation on the drug, if we receive new adverse information about the safety or effectiveness of a drug, or if a drug is removed from the market. We suggest that you speak with your doctor to find out if a different drug is appropriate for your treatment and covered by your Blue MedicareRx plan based on your current usage. If you and your doctor feel that the drug you are currently taking is the best option for your treatment, and the drug remains on the market, you may submit a coverage determination request, asking your plan to continue to cover your current drug.

You will need to discuss trying a different drug with your prescribing physician, as only they can determine if any of the other lower cost options on our formulary will be appropriate for your treatment, and they will need to write a new prescription for the drug.

The cost for any alternative drugs can be found in your comprehensive formulary document, or on our drug pricing tool where you can determine what tier level the other options fall under and compare their pricing to the one you are currently taking.

Members can also access the Prescription Savings Guide on our pharmacy benefit manager’s website, Caremark.com, to find out if there are different drugs for your treatment that may cost you less.

Our Customer Care team is also always available to assist you with questions.

No. Only you and your doctor can make decisions about your treatment. Blue MedicareRx and/or Caremark sometimes suggest different brand-name or generic drugs that may cost you less and still provide effective treatment for your condition so that you can discuss your options with your doctor.

The Medicare Coverage Gap

Medicare created the four coverage stages - including the Coverage Gap - that are part of all Part D plans, not just Blue MedicareRx plans. Some plans offer additional coverage in the Gap, such as Blue MedicareRx Premier (PDP).

You may be able to delay your entry into the Gap, or avoid it completely, by choosing less expensive drugs when possible. Check with your doctor to find out whether a different drug is covered by your plan that will cost you less and is appropriate for your treatment.

Pharmacy Network

A network pharmacy is one that contracts with a Medicare Part D prescription drug plan such as Blue MedicareRx to provide covered prescription drugs for plan members. Network pharmacies in both the Blue MedicareRx Value Plus and Premier Networks allow members to get their medications at a reduced cost.

Generally, your prescription medications are covered only if they are filled at a pharmacy that is in the plan’s network. If you use an out-of-network pharmacy, you will likely pay more for your prescription medications than if you purchased them at a network pharmacy.

Prescriptions filled at an out-of-network pharmacy are usually not covered, unless there are extenuating circumstances, such as a medical emergency, the need for a 24-hour pharmacy, or an immediate need for an out-of-stock medication. While the pharmacy will fill your prescription, they will not submit a claim to Blue MedicareRx for you, and you will likely pay more than you would have paid at a network pharmacy.

Use our pharmacy locator to find a pharmacy near you.

A preferred cost-sharing pharmacy in the Blue MedicareRx Network is a pharmacy that has agreed to offer preferred cost-sharing (our lowest copays and coinsurance) for covered prescription drugs purchased by Blue MedicareRx members during the Initial Coverage stage. Not all pharmacies choose to participate. With more than 36,000 preferred network pharmacy locations nationwide, there’s likely to be one nearby. Note that CVS Caremark Mail Service Pharmacy offers preferred cost-sharing to Blue MedicareRx members for 90-day supplies of covered prescription drugs purchased during the Initial Coverage stage.

Find the closest preferred cost-sharing pharmacy near you using our pharmacy locator.

A standard cost-sharing pharmacy in the Blue MedicareRx Network is a contracted pharmacy where you may use your Blue MedicareRx plan benefit. Unlike a preferred cost-sharing pharmacy, a standard cost-sharing pharmacy may not offer the lowest copay or coinsurance for covered drugs purchased during the Initial Coverage stage. You will still pay less for your covered drugs than you would at an out-of-network pharmacy.

Blue MedicareRx plan members can get Preferred Cost-Sharing Pharmacy savings and convenient home delivery with CVS Caremark Mail Service Pharmacy. Mail Service Pharmacy is a convenience offered to Blue MedicareRx members at no additional cost, and may save you more money.

The typical number of business days after the mail order pharmacy receives an order to receive your shipment is up to 10 days. Enrollees have the option to sign up for automated mail order delivery. If your mail order drugs do not arrive within the estimated time frame, please contact us toll-free at 1-888-620-1747, 24 hours a day, 7 days a week. TTY users call 711.

The length of time to get your first prescription filled will depend on how long it takes to receive your prescriptions from your doctor. Once the mail order pharmacy receives your prescription, it may take up to 10 business days for you to receive your medications.

All of the information you need can be found on the label on your current medication container. You will be asked to provide the name of the medication(s) you would like to order, the dosage and the name of your prescribing doctor. The mail service pharmacy will handle the rest.

A pharmacy employee will contact your prescribing doctor(s) to request a new prescription for 90-day supplies of your medication(s). You will receive notice from the mail service pharmacy if your doctor’s office does not respond within a few days.

We suggest that you contact your doctor to request the new prescription directly. The mail service pharmacy cannot send your medications without a prescription.

Some medications are not eligible for delivery by mail. The Start Mail Service feature Caremark.com on will not allow you to order prescriptions that are not eligible for mail service. Also, our Customer Care representatives can review your medications with you to determine which are eligible for delivery by mail.

The easiest way for you to pay for your prescriptions is to provide us with a credit card number that the pharmacy can use each time an order ships. If you prefer to pay using a check, you will need to fill out and mail the Mail Service Order Form from our documents library and include your check along with the form.

The mail service pharmacy is required to get your approval before mailing any medication you didn’t order yourself, including prescriptions submitted by your doctor. If your authorization is required, you will receive a call, text message or email, depending on the communication preference we have on file for you, when your prescription is due for refill. You can also provide your consent to ship your medications using the CVS Caremark mobile app.

Simply call the number on the back of your Blue MedicareRx ID card or call the number on your mail service packing slip to opt out of mail service. Check with alternative providers for your medications, such as your local retail pharmacy, to ensure that there will not be a gap in your treatment.

Caremark.com

While your plan coverage and benefit details, as well as helpful tips about Medicare, are all located on our Blue MedicareRx website, your detailed claims information is stored on our pharmacy benefit manager’s website, Caremark.com. They offer online tools to help you safely manage your prescriptions. You can access copays and coinsurance information, review true out-of-pocket (TrOOP) costs, request Mail Service Pharmacy prescriptions and order refills, review and manage medication costs and more. Registration is easy – all you need is your Member ID card to get started.

When you select Check Drug Cost and Coverage from the menu, the price listed for your medication is based on the pharmacy you use most often, your current Blue MedicareRx coverage and your current Medicare Part D coverage stage. Learn more about the Medicare Part D coverage stages.

Online/Electronic Explanation Of Benefits (EOB)

The online statements are exactly the same as the paper statements you receive in the mail. Rather than taking up space in your files with paper statements, you can access up to 36 months of your statements safely online in your Caremark.com password-protected account, ready for you to access or print at your convenience.

Email transmissions put you at risk for unauthorized parties to gain access to your personal information. We keep all of your personal information secure by requiring you to log in to your account at Caremark.com with a user name and password.

You can choose to print your statement on your personal printer at any time. If you do not have access to a printer, call Customer Care at the number on your Member ID card and we will arrange to have a copy sent to you by mail.

No. Your statements remain safely stored on Caremark.com, even if you are experiencing computer issues.

Personal & Contact Information

To change your address or any information in your member account, please call us at the number on your Member ID card. Customer Care representatives are available 24 hours a day, 7 days a week.

You and your designee need to complete, sign, and date the Appointment of Representative form (or an equivalent form of documentation) showing that the representative is authorized to act on your behalf.

Mail your completed form to:

  • Blue MedicareRx
  • PO Box 30014
  • Pittsburgh, PA 15222-0330
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