What is Medicare Prescription Drug Coverage?

The Medicare Prescription Drug Benefit offers coverage for brand name and generic drugs to anyone eligible for Medicare. Coverage is provided through private insurance plans, and you can choose a plan that is right for you. You must enroll to get coverage.

Am I eligible for Medicare Prescription Drug Benefit?

To be eligible for the Medicare Prescription Drug Plan benefit, an individual must be:

  • entitled to Medicare Benefits under Part A and/ or enrolled in Part B
  • a resident in the prescription plan’s service area
  • not be enrolled in more than one Medicare Part D plan at a time

During the Annual Enrollment Period of November 15 through December 31 of each year, anyone eligible for Medicare Prescription Drug coverage may either enroll or switch their current Medicare Part D plan.

Should I enroll in a Medicare Prescription Drug Plan?

Enrolling in a Medicare Prescription Drug Plan can save you money and offer peace of mind, should your prescription drug costs rise in the future. You should enroll in a Medicare Prescription Drug Plan unless your current drug coverage is as good as, or better than the Medicare Prescription Drug Coverage available to you. This is called “creditable” coverage. It’s important that you join a plan when you are first eligible*. You should contact your current plan provider to determine if you have creditable coverage. If you are eligible for Medicare and have Medicaid, you may be automatically enrolled in a prescription drug plan. Check with your State Medicaid Department for more information.

There is penalty for each month you delay in enrolling in a plan once becoming eligible.

When can I enroll?

You have the opportunity to obtain drug coverage when you become eligible for Medicare, during your Initial Medicare Enrollment Period. You can join a Medicare drug plan:

  • During your Initial 7 month Medicare Enrollment Period (three months before and three months after your 65th birthday)
  • During the three months before and the three months after your 25th month of disability
  • 63 days after your creditable insurance coverage ends or during the open enrollment period which runs November 15th through December 31st each year.

What if I choose not to enroll?

If you are eligible, and don’t sign up when you are first eligible you may pay more. If you don’t join a Medicare drug plan when you are first eligible to join (during your Initial Enrollment Period), and there is a period of 63 continuous days or more during which you don’t have creditable prescription drug coverage, you may have to pay a late enrollment penalty when you do join. This amount changes every year but is approximately 1% of the plans premium price for each month you delay in enrolling for a plan. You will have to pay a penalty as long as you have Medicare Prescription Drug Coverage.

Is there help available if I can’t afford a Medicare Prescription Drug Plan?

Some people with limited income and resources will qualify for Extra Help. If you qualify, Social Security will help you pay for premiums and/or the cost of prescriptions. You can apply for Extra Help at any time, and there is no risk to submitting an application. To determine if you qualify, contact your local Social Security office, or visit for more details.

  1. To qualify for this subsidy in 2008, Medicare eligible seniors must have incomes of:
    1. $11,990 in total assets (Savings, Investment, Real Estate) for Single persons
    2. $23,970 in total assets (Savings, Investment, Real Estate) for couples

The ‘Extra Help’ benefit will also help seniors by reducing or eliminating their out of pocket deductibles, co-pays and expenses associated with the coverage gap.

How do I prepare to choose a Medicare Prescription Drug Plan?

Following these steps will help you prepare to make your decision:

  1. Make a list of all the prescription drugs you currently take.
  2. Visit River Rx to ask questions or request additional information from River Rx.
  3. Apply for Extra Help if you have limited income and resources. There is no risk to submitting an application, and you can apply for Extra Help at any time throughout the year.
  4. If you plan to enroll or change plans, be sure to complete the enrollment process by December 31st.

How do I find out if my medications are covered?

Please call us or visit the pharmacy to find out which medications are covered and the costs associated with each plan.

When Can I change plans?

The Medicare Prescription Drug Program has an Open Enrollment Period from November 15th – December 31st every year. You may change plans during this time. Dual eligible individuals with both Medicare and Medicaid may change plans monthly, at any time throughout the year.

Is the plan I am on the best option for me?

If you are currently enrolled in a Medicare Part D plan, you should think about a few things to decide if you are in “the right plan”. Each year, plan premiums, deductibles, prescription co payments, and annual out of pocket expense may change. Therefore, these costs, as well as the list of covered drugs, vary from plan to plan and from region to region. You also need to remember that only the cost of Part D covered drugs that are included on a plan’s formulary count towards the deductible and out of pocket limits.
You should take time to review the various plans available to you in light of your current and anticipated prescription needs and financial resources. You may want to consider if there is a different plan available, other than your current plan, which may be more suitable to your needs.

Is there anything I can do to avoid the Coverage Gap?

If your drug plan has a coverage gap and you are concerned that you might have trouble meeting your prescription needs as a result, the following are ways that might help you to avoid or delay in entering the gap and continue to save money on medications while in the gap:

  • Keep using your Medicare drug plan card, even while in the coverage gap. Using your drug plan card ensures that you’ll get the drug plan’s discounted rates and that the money you spend is counted towards your catastrophic coverage.
  • Consider switching to generics, over-the-counter (OTC), or other lower-cost drugs. Ask your doctor about generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now.
  • Explore national and community-based charitable programs that might offer assistance. Comprehensive information on Federal, state, and private assistance programs in your area is available on the Benefits CheckUp website.
  • Look into Pharmaceutical Assistance Programs that may be offered by the manufacturers of the drugs you take.
  • Look at State Pharmaceutical Assistance Programs (SPAP) to see if you qualify.
  • Apply for the Extra Help benefit by contacting the Social Security Administration at 1-800-772-1213.
Additionally, the open enrollment period may be a good opportunity to seek whether an alternate plan that provides gap coverage should be considered.

Where can I get more information?

Every October, Medicare recipients receive the Medicare & You handbook in the mail with more detailed information. This is a good place to start. You can also:

  • Visit your River Rx Pharmacy for help at any time.
  • Call 1-800-MEDICARE (1-800-633-4227)
  • Read about Medicare Prescription Drug Coverage and Your Rights