Medicare Q&A

Frequently asked Medicare questions

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What is Original Medicare?


Original Medicare is the traditional health care program provided and managed by the U.S. government. In Original Medicare, you can go to a doctor or hospital whenever you feel that you need care. You pay for each service, and there are limits on how much a hospital or doctor can charge you. Part A (hospital insurance) and Part B (medical insurance) are included in Original Medicare.

What is not covered by Original Medicare?


Medicare does not cover Part A and Part B deductibles and coinsurance. It also does not cover services like routine hearing exams, eye exams, dental exams and cleanings and most outpatient prescription drugs.

Original Medicare can be paired with a Medicare Supplement and/or a Medicare Part D plan. These types of plans can give you additional benefits that aren’t covered by Part A or Part B.

Why is Medicare Part B optional?


Some people don’t need Medicare Part B (medical) because they are covered by an employer’s or spouse's health plan. However, if you don’t join Part B right away and you are not covered by another health care plan, you will have to pay a late enrollment penalty (LEP). Call Medicare at 1-800-633-4227 (TTY:1-877-486-2048) for more information, 24 hours a day, seven days a week.

How do I choose a Medicare plan?


Before you choose Medicare coverage, it’s important to consider what benefits you need and how much you want to spend.

Each type of plan outlined below can help cover health care expenses that are not covered by Medicare.

  • Medicare Advantage (MA) plans include Part A and Part B benefits in one plan. MA plans often include prescription drug coverage (MA-PD). MA plans cannot be combined with Medicare Supplement, Cost or Part D plans.
  • Medicare Supplement, sometimes called Medigap, plans help cover costs after Medicare Part A and Part B have paid their portion of your costs. There are several plans available and they are offered by private companies. Not all companies offer the same plans and each plan provides different levels of coverage. Medicare Supplement plans can be combined with Medicare Cost or Part D plans, but not Medicare Advantage.
  • Medicare Cost plans are only available in certain areas in the U.S. Cost plans help pay Medicare Part A and Part B deductibles and coinsurance. Companies offering Cost plans have options that provide different levels of coverage. Cost plans may offer Part D riders or can be paired with a stand-alone Part D plan.
  • Medicare Part D plans provide prescription drug coverage. Medicare Part D plans can be paired with Original Medicare, a Medicare Supplement plan and/or a Cost plan, but not with Medicare Advantage.

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What is Medicare Part D prescription drug coverage?


This is coverage that can help you pay for prescription drug costs that aren't covered by Original Medicare. Medicare Part D plans are offered by private companies that provide benefits for generic and brand-name prescription drugs.

Medicare Part D plans can be paired with Original Medicare, a Medicare Supplement plan and/or a Cost plan.

How do Medicare Part D plans work?


After you enroll, you will get a member ID card that you should use whenever you have a prescription filled. You will usually pay a monthly premium and a share of the cost of your prescriptions. Your share of the cost could be in the form of copayments or a coinsurance.

You may also have a deductible that you must meet before coverage begins. Drug plans can vary by what types of drugs are covered, how much you pay and which pharmacies you can use. All drug plans must provide a standard level of coverage that is set by Medicare.

Am I eligible for a Blue MedicareRx Part D plan?


You can enroll in a Blue MedicareRx plan, regardless of your income or health, if you meet the following basic eligibility requirements:

  • Must have Medicare Part A and/or Part B (you do not need to have both)
  • Live in the plan’s service area
  • Must be a U.S. citizen or lawfully present in the U.S.

You never have to do a health or income screening before you enroll in a Medicare Part D plan. If you are asked for either of these things before you enroll in a plan, you should report this to Medicare.

When can I join a Medicare Part D plan?


Your first chance to enroll will be during your initial enrollment period (IEP). You can also make changes to your Medicare coverage each year during the annual enrollment period (AEP), which runs from October 15 through December 7.

Knowing when you can enroll, disenroll and make changes to your coverage is important so that you can avoid enrollment penalties and lapses in coverage.

What if I don’t take any prescription drugs?


You should still think about joining a Medicare prescription drug plan. Most people need prescription drugs to stay healthy as they age. Enrolling in a Medicare Part D plan can protect you from unexpected prescription costs if you need to start taking them. Plus, joining as soon as possible means you pay your lowest monthly premium. Delaying your Part D enrollment can result in a Part D late enrollment penalty (LEP).

What is the Medicare Part D late enrollment penalty?


This is an amount that is added to your monthly Part D premium. Starting at the end of your initial enrollment period, the Part D late enrollment penalty (LEP) is applied if you go 63 or more days in a row without creditable Part D coverage. The amount of the penalty is based on the amount of time you go without creditable coverage and must be paid for as long as you have Part D coverage.

The best way to avoid the Part D LEP is to enroll in a Part D plan when you are first eligible. If you have coverage through your employer, make sure it is considered creditable.

What does creditable coverage mean?


This is coverage that pays as much as or more than Medicare’s standard prescription drug coverage. If you have prescription drug coverage through your employer, it may be creditable (contact your benefits administrator or human resources contact to find out). That means, if you decide to switch to a stand-alone prescription drug plan later, you would not have to pay the Part D late enrollment penalty (LEP). If your coverage is not creditable, you may have to pay the Part D LEP.

I have prescription drug coverage through my or my spouse’s employer. Can I also join a stand-alone Medicare Part D plan?


Generally, no. If you have coverage through your employer and enroll in a Medicare Part D or Medicare Advantage prescription drug plan (MA-PD), you could be disenrolled from your employer plan. You also may not be able to rejoin your employer’s plan if you change your mind later.

Before you make changes to your employer plan, you should talk to your benefits administrator or human resources contact to learn the rules of your coverage.

If you know you want to drop your employer’s coverage, consider how much coverage you will need and how much you want to spend. Check to see if your drugs are covered on the drug lists, or formularies, for any stand-alone Part D or MA-PD plans you’re considering.

What can I do if I am having trouble paying for my prescription drug costs (premiums, deductibles, copayments, etc.)?


Prescription drug costs can add up quickly and many people need financial assistance covering some of the costs. If you meet certain income requirements, you could be eligible for Medicare’s assistance program, Extra Help.

To see if you qualify for Extra Help, contact Medicare, the Social Security Administration or your state Medicaid office.

What’s the difference between pharmacies that offer preferred and standard cost sharing?


Pharmacies in our network that offer preferred cost sharing will usually offer the lowest prices for your prescriptions. These are sometimes called preferred pharmacies. We worked with these pharmacies to get lower prices on some of the prescriptions on our drug list, or formulary.

Some pharmacies in our network offer only standard cost sharing. This means, you may pay more for some prescriptions at these pharmacies.

Pharmacies that are not included in our network are out-of-network, and you would have to pay all costs for prescriptions filled at these pharmacies. Use our pharmacy locator tool to find a pharmacy near you.

What are drug tiers?


When you look at our plan's drug list, sometimes called the formulary, or use our online tools, you will notice that each covered drug is on a tier.

Drug tiers are levels that we use to categorize prescription drugs and lower costs. Each tier costs a different amount. Typically, drugs on tier 1 will be the least expensive and drugs on tier 5 will be the most expensive.

Each drug on our drug list is put into 1 of 5 tiers. Each tier has a different cost-sharing amount in the form of a copay or coinsurance.

  • Tier 1: Preferred generic – This tier is the lowest tier and generally contains the lowest cost generics
  • Tier 2: Generic – Contains generics
  • Tier 3: Preferred brand – Contains preferred brand drugs and non-preferred generic drugs
  • Tier 4: Non-preferred drugs – Contains non-preferred brand drugs and non-preferred generic drugs
  • Tier 5: Specialty – Contains very high cost brand and some generic drugs, which may require special handling and/or close monitoring

I think I paid for something Blue MedicareRx should have covered. How can I ask for a refund?


You can submit a claim. For faster processing, you should fill out a claim form and send us your receipts for the purchase you want us to repay you for. You can submit a claim without using the claim form, but it may take us longer to process your claim.

You can get the claim form and more information online. You can also read chapter 5 in your Evidence of Coverage to learn more about situations when you should ask us to pay our share of your prescription costs.

What is an Explanation of Benefits? Do I have to do anything with it when I get one?


An Explanation of Benefits (EOB) is a notice that we will send to you each month that you fill a prescription. It gives you a summary of your prescription claims and costs.

An EOB is not a bill. If everything included in your EOB looks accurate, you do not need to take any action. If you see something unusual or inaccurate, like claims for prescriptions you never received, you should contact us as soon as possible.