Frequently asked questions

Q: What is Blue Medicare Rx coverage?

A: Blue Medicare Rx coverage, which is sometimes referred to as Medicare Part D, is designed to help you by covering prescription drugs at local pharmacies and through mail order.

Everyone with Medicare is eligible for this coverage, but the coverage is not mandatory. It is a voluntary program that you may choose to purchase each year.

Blue Medicare Rx coverage is insurance. Private companies, like Blue Cross and Blue Shield of North Carolina, provide the coverage.

Q: How does the coverage work?

A: Medicare has designed a standard plan. Insurance companies may also offer additional enhanced plans, but they must offer a benefit package that is at least equal in value to Medicare’s standard plan.

5% coinsurance - Once your total annual out-of-pocket drug costs exceed $4,050, you pay very little for prescription drugs. You generally pay just 5% (or $2.25 generic/$5.60 brand, whichever is greater), and BCBSNC pays 95%.

100% coinsurance - Once your total annual drug costs exceed $2,510, you can avoid the "coverage gap" when you purchase generic drugs.

25% coinsurance - Initially you pay $10 for generic, $30 for brand and 25% coinsurance for certain specialty drugs.

$275 deductible - You will be responsible for 100% of the first $275 in total prescription drug costs in each calendar year before your prescription drug benefit begins.

Source: Medicare & You 2006, Pub No. 10050, September 2005, page 53.

Q: What if I have a limited income?

A: If you have Medicare and have limited income and resources, you may qualify for special financial assistance to help you pay for your Blue Medicare Rx plan costs. The amount of assistance you qualify for will depend on your income and resources:

• If your annual income is below $15,315 for a single person (or $20,535 if you are married and living with your spouse), you may qualify for financial assistance. Slightly higher income levels may apply if you provide half support to other family members living with you.
• If your resources (including your savings and stocks, but not counting your home or car) are under $11,710 (for a single person) or under $23,410 (for a married couple) you may qualify for financial assistance.

Beneficiaries interested in qualifying for extra help with Blue Medicare Rx Plan costs should call:

• Medicare at 1-800-MEDICARE (1-800-633-4227)
  TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week.
• Your state Medicaid office
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday.
  TTY/TDD users should call 1-800-325-0778.

If you qualify for extra help with your Blue Medicare Rx Plan, your premium and drug costs will be lower. When you join BCBSNC, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay.

Q: What drugs are covered under Blue Medicare Rx coverage?

A: Each plan provider will establish its own formulary, or list of prescription drugs, that it will cover. Although formularies must meet certain requirements set by Medicare, they still differ by plan.

Blue Medicare Rx coverage will include:

• Prescription drugs
• Vaccines
• Insulin
• Certain medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs and gauze).

Generally speaking, Blue Medicare Rx coverage covers drugs that meet the following criteria:

• They must be available only by prescription
• They must be approved by the Food and Drug Administration
• They must be used and sold in the United States
• They must be used for a medically necessary prescription

Certain drugs, or classes of drugs, will not be covered because they are excluded by law, such as over the counter medicines like aspirin.

To learn which drugs are covered by BCBSNC’s Blue Medicare Rx Plans, search our drug list.

Q: Will mail-order drugs be available through Blue Medicare Rx coverage?

A: You will have the convenient option of using a mail-order pharmacy. You can purchase up to a 90-day supply through mail order, and your medications will be delivered directly to your home. Depending on your plan, there may be savings available to you if you use the mail option.

Q: Can I change plans when I want to?

A: Congress designed Blue Medicare Rx coverage on an annual enrollment cycle. This means that each year, you will have the option to re-enroll in your existing Blue Medicare Rx coverage plan or change plans between November 15 and December 31.

You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan’s service area, you’ll have an opportunity to choose another plan that serves your new area.

Q: How do I join a plan?

A:

1. You must fill out an application for the Blue Medicare Rx Plan that you select. BCBSNC will enroll you in your Blue Medicare Rx Plan and inform Medicare that you have enrolled.
2. Once you become eligible for Medicare, you can join a Blue Medicare Rx Plan any time between November 15 and December 31 of that year. If you are eligible, but enroll after the enrollment period, you may have to pay a late fee when you do enroll.

Q: Are there penalties for late enrollment?

A: You can join a Blue Medicare Rx Plan any time between November 15 and December 31. If you enroll any time after December 31, you may have to pay a penalty. This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their employer or another plan, or for people who have not yet turned 65 when the enrollment period begins. To find out if your coverage is "equal or better," check with your employer or former employer.

Q: What is the penalty for late enrollment?

A: The late penalty equals one percent of the premium amount for each month that enrollment is delayed. For example, if you delay enrollment in Blue Medicare Rx coverage for two years, you will pay an additional 24 percent on top of the premium each month.

Q: Why is there a penalty for late enrollment?

A: The penalty was designed to encourage beneficiaries to sign up at the youngest possible age. It helps hold down the overall costs of the drug program and is similar to the late penalty imposed for late enrollment in Medicare Part B.

Q: Must I continue to pay my Medicare Part B premium?

A: Yes. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.