Frequently Asked Questions

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Learn more about our prescription drug plans. We know you have questions about Medicare and prescription drug plans. Here we've answered some of the questions we receive most often. Simply click on the question below to see its answer.

Understanding Medicare Part D Plans

Costs

Coverage

Filling Prescriptions

Preferred Pharmacies

Enrollment

Coverage Start Date

Member ID Cards





Understanding Medicare Part D Plans

What is Medicare Part prescription drug coverage?

Medicare Part D prescription drug coverage is insurance that:

  • helps pay for prescription drugs at participating pharmacies *
  • provides coverage to help offset the cost of prescription drugs
  • helps to pay for unexpected prescription drug costs
As a federal program, Medicare Part D was enacted as a part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006.

Medicare Part D is available as stand-alone coverage (also called Prescription Drug Plan or PDP), or as a prescription drug benefit added to a Medicare Part C plan (MA-PD). You have both options available to you at Aetna.

Medicare Part D prescription drug coverage is only available through private insurance companies approved by Medicare.

* Covers drugs defined by Medicare as being Part D drugs. Part B drugs will continue to be covered under the medical plan, even when you have an integrated MAPD plan.

Do I need a Medicare prescription drug plan?

Even if you don’t take many prescriptions now, you should consider joining a Medicare prescription drug plan for the three following reasons:

  • Prescription costs rise every year.
  • You can avoid paying a late enrollment penalty if you enroll in a plan when you turn 65 or are first eligible for Medicare. If you don’t enroll, or you go without creditable coverage for 63 days or more, you may have to pay a late enrollment penalty.
  • The older you get, the greater the chances of you needing medications.
You may have prescription drug coverage through a union or your employer's retiree plan. If you have coverage through an employer or union plan, contact the benefits administrator from your current plan before making any changes to your coverage.

What does a Medicare prescription drug plan cover?

Medicare prescription drug plans cover Part D eligible generic and brand-name drugs CMS defines what drug classes are covered by the plans. Most plans have a formulary, or list of drugs covered by the plan. Our preferred drug lists have been approved by the Centers for Medicare and Medicaid Services (CMS). CMS is the federal agency that oversees the Medicare program.

Do you have a quality improvement program?

Yes. We design our programs to improve the quality of the care you receive. The health care information we give you is supported by clinical data and industry-accepted, evidence-based guidelines. And we offer credible clinical information and tools to help you and your doctors make informed decisions about your care.

Costs

Can your Medicare prescription drug plans save me money?

Yes. We are one of the largest Medicare prescription drug plans in the nation. We negotiate savings on your behalf to help you in the form of lower premiums and cost sharing. In addition, our plans offer a robust preferred cost-share pharmacy network of more than 30,000 pharmacies, which are designed to save you more by passing along even greater savings from pharmacies who are interested in filling your prescriptions. If you have a favorite pharmacy that is not one of our preferred cost-share pharmacies, we have more than 60,000 pharmacies in our network nationwide.

How much will I pay for your Medicare prescription drug plan?

The amount you pay depends on several factors including your plan, which tier your drug is in, the pharmacy you use, if you get Extra Help, and the phase of coverage you’re in. Use our online search tool to estimate costs for your drugs, If you have limited income, you may be able to get Extra Help paying for your plan. *See questions 6 and 7 for more information.

How do I pay for my Medicare prescription drug plan?

You can pay us directly or have your plan premium taken out of your monthly Social Security check (just like your Part B premium). Have a retiree benefit plan? Your employer may pay your premium. Check with your benefits administrator.

Which of your Medicare prescription drug plans lets me pay the least out of my pocket for my prescriptions?

Use our cost estimate tools to find out what you'll pay for our Medicare prescription drug plans. We'll ask you questions about your eligibility, coverage needs, and medications to help you compare the plans available in your area.

Can I get Extra Help paying for prescription drugs? How do I find out more and apply?

If your income is at or below a set amount with limited assets, you may qualify for Extra Help If you receive “extra help” it can:

  • reduce your premiums and eliminate your deductibles
  • reduce your prescription cost-sharing
  • cover your drug costs during the coverage gap or "donut hole".
We offer our Saver plan in all states and DC. Your premium could be $0 if you are eligible for 100% low-income subsidy (except in Florida).

To find out more or see if you're eligible, call:
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday - Friday. TTY users should call 1-800-325-0778. You may also apply online at http://www.ssa.gov.
  • Your state Medicaid office

I have Extra Help paying for my Medicare prescription drug plan. Will that make my Medicare Advantage plan premium go down?

If you have a Medicare Advantage plan with prescription drug coverage, Extra Help may affect your premium and copayments.

If you know how much Extra Help you get, go to Low Income Subsidy. Look at the premium subsidy table for your plan type to see what your new premium might be.

Medicaid helped pay for my prescription drug coverage in the past. Do I have to enroll in a Medicare prescription drug plan?

Medicaid won't help pay for your prescriptions if you're eligible for Medicare. (However, if Medicare doesn't cover your medication, Medicaid may still cover it.) If you have full Medicaid benefits, the federal government will assign you to a Medicare prescription drug plan if you don't select one or decline Medicare prescription drug coverage completely.

Coverage

What are the phases of a Medicare Prescription Drug Plan?

There are four phases, and each phase delivers different levels of coverage. The four phases include:

  • Deductible – The first phase of a Part D plan. It requires you to pay your prescription drug costs in full before reaching the initial coverage phase. In 2016, Medicare set the standard deductible at $360, although some plans may offer a reduced or $0 deductible*. The exception is when a plan offers a deductible waiver on one or more tiers. In this case, the copay for formulary drugs on the tier with a waiver will be effective immediately.

    OR

    The amount you must pay for health care before Medicare or the plan begins to pay. These amounts can change every year.
    *If your plan does not have a deductible, then you enter the initial coverage phase immediately.
     
  • Initial coverage – Begins once you reach the deductible limit and continues until you reach the coverage gap. You’re responsible for copays and/or coinsurance up to $3,310 in total drug costs in 2016. This phase includes covered prescription drug costs paid by all parties to the plan (such as Part D carrier, member, Extra Help, etc.). After reaching $3,310 in total drug costs, the member moves to the next phase in the plan known as the coverage gap.

    Moving from the initial coverage phase to the coverage gap phase is often referred to as meeting the initial coverage limit (ICL).
     
  • Coverage Gap - Commonly referred to as the "donut hole". The coverage gap occurs after your total covered prescription drug costs reach $3,310 in 2016. It continues until the total you pay out of your pocket for covered Part D prescription drugs reaches $4,850. This amount includes your annual deductible and copayments or coinsurance for covered prescription drugs, but excludes what you pay in premium. The Manufacturer Discount Program which pays for 50% of your member liability on brand drugs also counts toward your true out-of-pocket costs. After you reach $4,850 in true out-of-pocket spending, you'll enter the next phase called catastrophic coverage. Our Medicare prescription drug plans and our Medicare Advantage plans with prescription drug coverage often offer different levels of coverage during the gap.
     
  • Catastrophic Coverage – The phase of a Medicare Part D plan where you pay only a small coinsurance or copay for a covered prescription drug and your plan pays the rest of the cost for the remainder of the year. For 2016, member cost-share during the catastrophic phase will be the greater of 5% or $2.95 for generic and brands dispensed as generic and $7.40 for brand drugs. Catastrophic coverage begins once you’ve spent $4,850 in true out-of-pocket costs for covered drugs in 2016.

Do your Medicare prescription drug plans cover both brand-name and generic drugs?

Yes. Our plans cover both brand-name and generic prescription drugs, including many well-known brands.

How can I find out which prescription drugs are covered?

Review our formulary for more info. Or enter your drugs and search for our plans online to see if your drugs are covered. You’ll want to look at the "Benefits Overview" page, then choose the “Additional Cost Information” tab. If you have questions call member service for help at 1-800-282-5366 (TTY: 711). Hours of operation: 8 a.m. to 8 p.m., 7 days a week.

What is a preferred drug list or formulary?

Our preferred drug list, or formulary, is a list of medications we cover. Doctors and pharmacists, including geriatric specialists, helped choose these medications based on sound medical data, safety and cost.

Our preferred drug lists:

  • Were approved by the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees the Medicare program
  • Include only medications that the Food and Drug Administration (FDA) has approved as safe and effective
  • Include both brand-name and generic medications
For a complete list of the medications covered by our Medicare prescription drug plans, please call us at 1-877-988-3589 (TTY: 711), 8 a.m. to 8 p.m., local time, seven days, from October 1 – February 14; 8 a.m. to 8 p.m., local time, Monday – Friday, from February 15 – September 30. Or, you can use our website to find formularies for each of our plans that offer Part D coverage.

Can your preferred drug list change?

Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Please see your formulary guide or Evidence of Coverage for more information.

To get a complete list of the medications covered by our Medicare prescription drug plans, please call us at 1-877-988-3589 (TTY: 711), 8 a.m. to 8 p.m., local time, seven days, from October 1 – February 14; 8 a.m. to 8 p.m., local time, Monday – Friday, from February 15 – September 30. Or, you can use our website to find formularies for each of our plans that offer Part D coverage.

How do I ask for an exception to your preferred drug list?

You or your prescriber must contact our clinical prior authorization department in writing to request an exception. Generally, we’ll only approve your request for an exception if the alternative drug or a low-tiered drug wouldn’t be as effective in treating your condition and/or would cause you to have adverse medical effects.

Go to the Request for Prescription Drug Coverage Determination (Decision) Form for more info.

What is a generic drug?

A drug that’s not protected by a patent and may be produced by any manufacturer. A generic name is a common name that refers to a drug's chemical identity, as opposed to a brand name used by a particular company for marketing purposes. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

On our preferred drug list, we show generic drugs in lowercase italicized letters (ror example: ranitidine). We show brand-name drugs in all caps (for example: ZANTAC).

Find your formulary for the latest info on drugs covered by your plan. For a complete list of the medications covered by our Medicare prescription drug plans, please call us at 1-800-282-5366 (TTY: 711), 8 a.m. to 8 p.m., local time, seven days a week, from October 1 – February 14 and 8 a.m. to 8 p.m., local time, Monday – Friday, from February 15 – September 30.

Do your Medicare prescription drug plans cover wheelchairs and durable medical equipment?

Wheelchairs and durable medical equipment aren’t included under Medicare prescription drug coverage. But they may be covered under Medicare Part A and/or B.

I already have prescription drug coverage through my employer’s retiree plan. Should I enroll in a Medicare prescription drug plan?

If your union or former employer offers prescription drug benefits, compare the plan and costs with those of our prescription drug plans.

Also find out if your employer’s plan has any limitations. For example, if you leave your employer’s retiree plan, you may not have an opportunity to re-enroll later on.

Your employer has to let you know if its prescription drug plan is considered creditable coverage — coverage as good as that offered by Medicare. If it’s not creditable and you don’t enroll in a Medicare prescription drug plan when you first turn 65 or become eligible for Medicare, you may have to pay a late enrollment penalty if you enroll at a later date.

What is "creditable coverage"?

Creditable coverage is prescription drug coverage (for example, from an employer or union) that's expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Veteran's Affairs (VA) covers my prescription drugs. Will I lose my VA coverage if I have Medicare?

No. You can continue getting your prescriptions under your VA coverage if you have Medicare.

What drugs aren’t covered by Medicare prescription drug plans?

  • Drugs covered under Medicare Part A or Part B
  • Drugs purchased outside the U.S.
  • Drugs used for anorexia, weight loss, or weight gain
  • Drugs used to promote fertility
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used for relief of cough and cold symptoms
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Non-prescription, over-the-counter drugs
  • Covered outpatient drugs for which the manufacturer seeks to require associated tests or monitoring services purchased exclusively from the manufacturer or its designee as a condition of sale
  • Drugs used for the treatment of sexual or erectile dysfunction

Filling Prescriptions

Which pharmacies can I use to fill my prescriptions?

We offer a nationwide network of more than 60,000 pharmacies, including retail and regional chains and local neighborhood drug stores. To locate a pharmacy, please visit our Pharmacy Finder tool.

Can I get my prescription drugs through mail order?

Yes. If you take certain maintenance medications, you may enjoy the convenience of having them filled using mail order services.The easy-to-use, convenient Express Scripts mail order service lets you order your drugs and have them delivered to your home for free. Our Preferred Drug List shows ”MO” in the notes column if a drug is available by mail order.

Is mail-order a convenient and safe way to fill my prescriptions?

Yes. Advantages to our prescription mail-order service include:

  • Convenience. You can place your order 24-hours a day and have your medication delivered to you via the US Postal office. No waiting in line or multiple trips going to and from the pharmacy.
  • Simplicity. Our easy, two-step process makes it easy to order maintenance medications. Order via telephone or online.
  • Quality service. Registered pharmacists check your orders for accuracy and are available 24 hours a day, 7 days a week, if you have an emergency.

What if I'm traveling and need to fill my covered prescription?

You can fill a prescription at any of the pharmacies participating in our network as long as they are in the United States or a US territory. You can also have your prescriptions delivered to you by our mail-order service.

Do your plans cover prescriptions filled outside the US and its territories?

Medicare only allows prescription drug plans only cover prescription drugs sold, dispensed and consumed within the U.S and its territories.

Preferred Pharmacies

Why should I fill my prescriptions at a preferred pharmacy?

You may save money if you get your covered prescription filled at one of our preferred pharmacies. Check your Evidence of Coverage to find out if you have this benefit. Then find a preferred pharmacy near you by using our online pharmacy locator.

Do you have preferred pharmacy plans?

Yes. All of our prescription drug plans offer a preferred pharmacy network. These plans include pharmacies that are contracted to provide lower cost sharing compared to a standard pharmacy. Many big chains like Walmart, Walgreens, Costco and Safeway are part of the preferred network.

Are there advantages to enrolling in a plan offering preferred pharmacy benefits?

Yes. While you will save money by visiting any of our network pharmacies, you may save even more when you use a preferred pharmacy. At preferred pharmacies, you can get your questions answered by an experienced pharmacist, plus:

  • You'll pay $1 at a preferred pharmacy for Tier 1 generics including drugs used for treating high blood pressure, high cholesterol and diabetes.
  • You'll pay a low cost at a preferred pharmacy for most other formulary generic drugs.

Enrollment

Do I need to sign up for Medicare prescription drug coverage?

The Medicare prescription drug program is voluntary. If you want Medicare prescription drug coverage, you can enroll in a plan that meets your needs. Keep in mind you may have to pay more if you put off enrolling.

If you have Medicare, you can enroll in a Medicare Advantage plan with prescription drug coverage. Or you can enroll in a stand-alone Medicare prescription drug plan if you have one of the following:

  • Original Medicare (Parts A and B)
  • Medicare supplement insurance (Medigap)
  • a Medicare Private Fee-for-Service plan that doesn’t cover prescription drugs
  • some Medicare Cost Plans
  • a Medicare Medical Savings Account (MSA) Plan
In addition, if you have Medicare and are receiving prescription drug coverage through a group plan offered by a former employer/union, you can continue this coverage. You will need to contact your group's benefits administrator to find out more about this coverage to ensure it is considered creditable coverage.

We have Medicare Advantage plans in some areas and Medicare-approved prescription drug plans throughout the U.S.

You can keep the prescription drug coverage you have through your union or former employer if you have Medicare coverage. Call your group's benefits administrator to make sure it’s “creditable coverage.”

Should I enroll in a plan that provides both medical and prescription drug coverage?

We offer Part D prescription drug plan options that give you the coverage you want while helping you manage your costs. And our formularies include a broad range of brand and generic medications available through our nationwide pharmacy network.

Am I eligible to enroll in a Medicare prescription drug plan?

Anyone eligible for Medicare Part A and/or B may enroll in a Medicare prescription drug plan. You'll be accepted regardless of your current health.

How do I enroll in a Medicare Part D plan?

  • ONLINE: Use our secure enrollment tool
  • BY PHONE: Call us at 1-855-893-4696 (TTY: 711), 8 a.m. - 8 p.m., local time, 7 days a week, from October 1 - February 14, 8a.m. - 8 p.m. local time, Monday - Friday, from February 15 - September 30.
  • Medicare beneficiaries may also enroll in our Medicare plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Why would I have to pay a late enrollment penalty?

You may have to pay a late enrollment penalty if:

  • You can avoid paying a late enrollment penalty if you enroll in a plan when you turn 65 or are first eligible for Medicare. If you don’t enroll, or you go without creditable coverage for 63 days or more, you may have to pay a late enrollment penalty.
  • (“Creditable coverage” means that on average the plan will pay at least as much as Medicare’s standard prescription drug coverage.)
    • The amount of your penalty will depend on how long you wait before you enroll in drug coverage or how many months you were without drug coverage after you became eligible.
    • The penalty is included as part of your monthly plan premium. If you don’t pay your monthly plan premiums, we may disenroll you.

When can I enroll or change my prescription drug plan?

You can enroll or make changes to your Medicare prescription drug plan via phone or online at specific times of the year. If you currently have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance), you can join a prescription drug plan:

  • During your 7 month initial enrollment period that begins 3 months before and ends 3 months after the month you become eligible for Medicare
  • Between October 15 and December 7 of each year
  • Under special circumstances, such as if you move out of your plan’s service area or if you lose your employer group coverage
  • Between January 1 – February 14, if you are in a Medicare Advantage Plan (You can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage.Your coverage will begin the first day of the month after your completed enrollment form is received.)
Note: If you already have coverage through an employer or union plan, contact your benefits administrator before making any changes to your coverage.

Can a child or guardian enroll a parent in a Medicare prescription drug plan?

Generally, only the beneficiary – the person who's eligible for Medicare – can enroll in a plan. However, a court-appointed guardian or legal representative may enroll or disenroll on behalf of the beneficiary. You must have an Appointment of Representative form on file.

What should I do with my Medicare card if I enroll in one of your plans with prescription coverage?

Keep your Medicare card and continue to use it for general identification and for physician and hospital visits if you do not enroll in one of our Medicare Advantage with Prescription Drug plans. When you enroll in one of our prescription drugs plans or a Medicare Advantage with Prescription drug plans, we'll send you a member ID card which you must use whenever you fill prescriptions, or visit a physician or hospital should you enroll in an MAPD plan.

Coverage Start Date

When will my coverage start if I enroll in one of your Medicare prescription drug plans?

You can enroll in a plan only at specific times of the year. Your effective date will depend on when you enroll. If you sign up during Medicare’s Open Enrollment period from October 15 to December 7, your coverage is effective January 1 of the next year.

If you enroll when you first become eligible for Medicare or turn 65 and you apply before the first day of the month you become eligible, your coverage starts on the first day of the month. For example, if you enroll on January 23 and you're eligible for Medicare February 1, your coverage starts February 1.

You may be able to enroll at other times of the year in special circumstances.

Member ID Cards

When will I get my member ID card?

You should expect to receive your member ID card 7-10 business days after your enrollment has been processed in our system. Call us if you have questions.

How can I get my prescriptions filled if I haven't received my member ID card?

To fill your prescription at one of our network pharmacies before you get your ID card, you can:

  • Ask your pharmacist to call us. If you're eligible for prescription drug coverage and we show your application in our system, we'll allow the covered prescription to process.
  • View or print a temporary member ID card on our secure member website. If we've processed your information and show you in our system, you can print a temporary member ID card after you register on the website.
  • Pay for your covered medications and submit a prescription drug claim form to us once your enrollment is complete. NOTE: This is a temporary process. Get a claim form here.
If CMS notifies us that you're not eligible for Medicare Part D prescription drug coverage, we won't reimburse your for your medications.


Our dual-eligible Special Needs Plans (DSNPs) are available in Florida and Pennsylvania to anyone who has both Medical Assistance from the state and Medicare. Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help that you receive. Please contact the plan for further details.

You can reach First Health Part D customer service at 1-866-865-0662 (TTY: 711) or Coventry Health Care customer service for Medicare Advantage plans at 1-877-725-8933 (TTY: 711), 8 a.m. to 8 p.m., local time, seven days, from October 1 - February 14; 8 a.m. to 8 p.m., local time, Monday - Friday, from February 15 - September 30.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

See Evidence of Coverage for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

You must continue to pay your Medicare Part B premium. The Part B premium is covered for full-dual members where DSNP plans are available.

For mail-order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 7 to 14 days. Please call us if you do not receive your mail-order drugs within this timeframe. Coventry members please call the phone number listed on your member ID card. Members may have the option to sign-up for automated mail-order delivery.

Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Cost sharing for members who get “Extra Help” is the same at preferred and network pharmacies. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change.

This information is available for free in other languages. Please call First Health Part D at 1-866-865-0662 (TTY: 711) OR Coventry Health Care at 1-877-988-3589 (TTY: 711), 8 a.m. to 8 p.m., local time, seven days, from October 1 – February 14; 8 a.m. to 8 p.m., local time, Monday – Friday, from February 15 – September 30.

Y0022_PDP_2013_4006_1454
CMS Approved Date: Approved 06/17/2013
Page Last Updated: 01/12/2016

© Copyright 2008-2016 Coventry Health Care

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.