SmartD Rx (PDP) is not currently accepting enrollments due to CMS sanction action.
CMS has suspended all marketing and enrollment activities for SmartD Rx as of April 23, 2013.
Medicare Part D FAQ
Medicare offers prescription drug coverage to everyone with Medicare that:
- Helps cover the cost of prescription drugs
- May help lower your prescription drug costs and help protect against higher costs
- Is run by Medicare-approved private insurance companies
Even if you don't take a lot of prescriptions now, it's very important for you to consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you're first eligible, and you don't have other creditable prescription drug coverage, or you don't get Extra Help, you will likely pay a late enrollment penalty.
To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and specific drugs covered.
When you're first eligible for Medicare, you can join during the 7 month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
If you get Medicare due to a disability, you can join during the 7 month period that begins 3 months before your 25th month of disability and ends 3 months after your 25th month of disability. You will have another chance to join during the 7 month period that begins 3 months before the month you turn 65 and ends 3 months after the month you turn 65.
Between October 15 - December 7, anyone can join, switch, or drop a Medicare drug plan. The change will take effect on January 1 as long as the plan gets your request by December 7.
If you qualify for Extra Help, you can join, switch, or drop a Medicare drug plan anytime.
You generally must stay enrolled for the calendar year. However, in certain situations like the following, you may be able to join, switch, or drop Medicare drug plans at other times:
- If you move out of your plan's service area
- If you lose other creditable prescription drug coverage
- If you live in an institution (like a nursing home)
Call your State Health Insurance Assistance Program (SHIP) for more information. You can also call
Note: If you have limited income and resources, you may qualify for Extra Help to pay for Medicare prescription drug coverage. You may also be able to get help from your state.
Once you choose a Medicare drug plan, you may be able to join by doing the following:
- Enrolling on the plan's website or on www.medicare.gov.
- Completing a paper application.
- Calling the plan.
- Calling 1-800-MEDICARE (1-800-633-4227). TTY users should call
When you join a Medicare drug plan, you will have to provide your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
Note: Medicare drug plans aren't allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this. Don't give your personal information to anyone who calls you to enroll in a plan.
You can switch to a new Medicare drug plan simply by joining another drug plan during one of the times described under "When can I join, switch, or drop a Medicare Drug Plan?"
You don't need to cancel your old Medicare drug plan or send them anything. Your old Medicare drug plan coverage will end when your new drug plan begins. You should get a letter from your new Medicare drug plan telling you when your coverage begins.
If you want to drop your Medicare drug plan and you don't want to join a new plan, you can do so, but only during certain times of the year. You can disenroll by calling 1-800-MEDICARE. You can also send a letter to the plan to tell them you want to disenroll. If you drop your plan and want to join another Medicare drug plan later, you have to wait for an enrollment period. You may have to pay a late enrollment penalty.
Your actual drug plan costs will vary depending on the following:
- Your prescriptions and whether they are on your plan's formulary (drug list)
- The plan you choose
- Whether you go to a pharmacy in your plan's network
- Whether you get Extra Help paying your Part D costs
Most drug plans charge a monthly fee that varies by plan. You pay this in addition to the Part B premium.
Note: Contact your drug plan (not Social Security) if you want your premium deducted from your monthly Social Security payment. If you want to stop premium deductions and get billed directly, contact your drug plan.
What you pay for Part D coverage could be higher based on your income. This includes Part D coverage you get from a Medicare Prescription Drug Plan.
If your income is above a certain limit, you will pay an extra amount in addition to your plan premium. Usually, the extra amount will be deducted from your Social Security check. If you have to pay an extra amount and you disagree (for example, you have a life event that lowers your income), call Social Security at
The amount you must pay before your drug plan begins to pay its share of your covered drugs. Some drug plans don't have a deductible.
Amounts you pay for your covered prescriptions after the deductible (if the plan has one). You pay your share and your drug plan pays its share for covered drugs.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there is a temporary limit on what the drug plan will cover for drugs. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.
Once you enter the coverage gap, you get a 50% discount on covered brand name drugs and pay 86% of the plan's cost for covered generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap.
The following items all count toward you getting out of the coverage gap:
- Your yearly deductible, coinsurance and copayments
- The discount you get on brand-name drugs in the coverage gap
- What you pay in the coverage gap
The drug plan premium and what you pay for drugs that aren't covered don't count toward getting you out of the coverage gap.
Some plans offer additional coverage during the gap, like for generic drugs, but they may charge a higher monthly premium. Check with the plan first to see if your drugs would be covered during the gap.
In addition to the 50% discount on covered brand-name prescription drugs, there will be increasing savings for you in the coverage gap each year until the gap closes in 2020. For more information, visit www.medicare.gov/publications to view the fact sheet, "Closing the Coverage Gap-Medicare Prescription Drugs Are Becoming More Affordable." You can also call
Once you get out of the coverage gap, you automatically get "catastrophic coverage." Catastrophic coverage assures that you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.
Note: If you get Extra Help, you won't have some of these costs.
To get specific Medicare drug plan costs, call the plans you're interested in. You can also visit the Medicare Plan Finder at www.medicare.gov/find-a-plan, or call
The late enrollment penalty is an amount that's added to your Part D premium. You may owe a late enrollment penalty if, at any time after your initial enrollment period is over, there is a period of 63 or more days in a row when you don't have Part D or other creditable prescription drug coverage.
Note: If you get Extra Help, you don't pay a late enrollment penalty.
Here are a few ways to avoid paying a late enrollment penalty:
- Join a Medicare drug plan when you're first eligible. You won't have to pay a penalty, even if you've never had prescription drug coverage before.
- Don't go 63 days or more in a row without a Medicare drug plan or other creditable coverage. Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or health insurance coverage. Your plan must tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later.
- Tell your plan about any drug coverage you had if they ask about it. When you join a Medicare drug plan, and the plan believes you went at least 63 days in a row without other creditable prescription drug coverage, the plan will send you a letter. The letter will include a form asking about any drug coverage you had. Complete the form and return it to your drug plan. If you don't tell the plan about your creditable prescription drug coverage, you may have to pay a penalty.
The cost of the late enrollment penalty depends on how long you didn't have creditable prescription drug coverage. Currently, the late enrollment penalty is calculated by multiplying 1% of the "national base beneficiary premium" ($31.08 in 2012) times the number of full, uncovered months that you were eligible but didn't join a Medicare drug plan and went without other creditable prescription drug coverage.
The final amount is rounded to the nearest $.10 and added to your monthly premium. Since the "national base beneficiary premium" may increase each year, the penalty amount may also increase every year. You may have to pay this penalty for as long as you have a Medicare drug plan.
After you join a Medicare drug plan, the plan will tell you if you owe a penalty, and what your premium will be.
If you don't agree with your late enrollment penalty, you can ask Medicare for a review or reconsideration. You will need to fill out a reconsideration request form (that your Medicare drug plan will send you), and you will have the chance to provide proof that supports your case, such as information about previous creditable prescription drug coverage.
If you need help, call your Medicare plan. You can also contact your State Health Insurance Assistance Program (SHIP).
You should get a welcome package with your membership card within five weeks after the plan gets your completed application. If you need to go to the pharmacy before your membership card arrives, you can use any of the following as proof of membership:
- A letter from the plan that includes your membership information. You should get this letter within 2 weeks after the plan gets your completed application.
- An enrollment confirmation number that you got from the plan, the plan name, and phone number.
- A temporary card that you may be able to print from MyMedicare.gov. Visit www.MyMedicare.gov for more information.
If you don't have any of the items listed above, your pharmacist may be able to get your drug plan information if you provide your Medicare number or the last four digits of your Social Security number. If your pharmacist can't get your drug plan information, you may have to pay out-of-pocket for your prescriptions. If you do, save the receipts and contact your plan to get your money back.
Every month that you fill a prescription, your drug plan mails you an Explanation of Benefits (EOB) notice. This notice gives you a summary of your prescription drug claims and your costs. Review your notice and check it for mistakes. Contact your plan if you have questions or find mistakes. If you suspect fraud, call the Medicare Drug Integrity Contractor (MEDIC) at
Each plan has its own list of covered drugs, called a formulary (see the searchable Formulary on this website for a list of drugs covered by SmartD Rx).
For plans you are considering, contact the plan for its current formulary, or visit the plan's website. Visit the Medicare Plan Finder at www.medicare.gov/find-a-plan to get phone numbers for the plans in your area. You can also call
Your Medicare drug plan may cover these drugs under certain circumstances. You will likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Or, if you get a bill for self-administered drugs you got in a doctor's office, call your Medicare drug plan (Part D) for more information.
Visit www.medicare.gov/publications to view the fact sheet, "How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings." You can also call
Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
In some cases, if your drug is on a higher tier and your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
Note: Medicare drug plans must cover all commercially available vaccines (like the shingles vaccine) when medically necessary to prevent illness, except for vaccines covered under Part B. If you're in a Medicare drug plan and you have complex health needs, you may be eligible to participate in a Medication Therapy Management (MTM) program (see "Clinical Programs" on this website for more on the SmartD Rx MTM program).
These programs help you and your doctor make sure that your medications are working. MTM programs include a free discussion and review of all of your medications by a pharmacist or other health professional to help you use them safely. You will get a summary of this discussion to help you get the most benefit from your medications. You can have this summary available when you talk with your doctors or other health care providers. If you take many medications for more than one chronic health condition, contact your drug plan to see if you're eligible.
Plans may have coverage rules regarding prior authorization (to show that a drug is medically necessary for the plan to cover it), limits on how much medication you can get at a time, or requirements to try one or more similar, lower cost drugs before the plan will cover the prescribed drug.
If you or your prescriber believe that one of these coverage rules should be waived, you can ask for an exception.
With a few exceptions, most prescriptions aren't covered by Original Medicare. You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D). Original Medicare is one of your health coverage choices as part of the Medicare Program and is managed by the federal government. You will be in Original Medicare unless you choose a Medicare health plan.
Employer or Union Health Coverage - This is health coverage from your, your spouse's, or other family member's current or former employer or union. If you have prescription drug coverage based on your current or previous employment, your employer or union will notify you each year to let you know if your prescription drug coverage is creditable.
Keep the information you get. Call your benefits administrator for more information before making any changes to your coverage. Note: If you join a Medicare drug plan, you, your spouse, or your dependants may lose your employer or union health coverage.
COBRA - Federal law that may allow you to temporarily keep employer or union health coverage after the employment ends or after you lose coverage as a dependent of the covered employee. There may be reasons why you should take Part B instead of, or in addition to, COBRA. However, if you take COBRA and it includes creditable prescription drug coverage, you will have a special enrollment period to join a Medicare drug plan without paying a penalty when the COBRA coverage ends. Talk with your State Health Insurance Assistance Program (SHIP) to see if COBRA is a good choice for you.
Medicare Supplement Insurance (Medigap) Policy with Prescription Drug Coverage - It may be to your advantage to join a Medicare drug plan because most Medigap drug coverage isn't creditable and you may pay more if you join a drug plan later. Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information.
Other Government Insurance - If you have one of these types of insurance, in most cases, it will be to your advantage to keep your current coverage.
Federal Employee Health Benefits (FEHB) Program
- This program provides health coverage for current and retired federal employees and covered family members. FEHB plans usually include prescription drug coverage, so you don't need to join a Medicare drug plan. However, if you decide to join a Medicare drug plan, you can keep your FEHB plan, and your plan will let you know who pays first. For more information, contact the Office of Personnel Management at
- If you have health coverage for veterans and people who have served in the U.S. military, you may be able to get prescription drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you can't use both types of coverage for the same prescription at the same time. For more information, call the VA at
TRICARE (Military Health Benefits) - This health care plan is for active-duty service members, retirees, and their families. Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you don't need to join a Medicare Prescription Drug Plan. However, if you do, your Medicare drug plan pays first, and TRICARE pays second.
If you join a Medicare Advantage Plan (like an HMO or PPO) with prescription drug coverage, your Medicare Advantage Plan and TRICARE may coordinate their benefits if your Medicare Advantage Plan network pharmacy is also a TRICARE network pharmacy. For more information, call the TRICARE Pharmacy Program at
Indian Health Services - For American Indians and Alaska Natives, this health care service provides coverage through many Indian health facilities that participate in the Medicare prescription drug program. If you get prescription drugs through an Indian health facility, you will continue to get drugs at no cost to you and your coverage won't be interrupted. Joining a Medicare drug plan may help your Indian health facility because the drug plan pays the Indian health facility for the cost of your prescriptions. Talk to your local Indian health benefits coordinator who can help you choose a plan that meets your needs and tell you how Medicare works with the Indian health care system.
If you have employer or union coverage, call your benefits administrator before you make any changes, or before you sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependants.
The answers to these questions may help you to choose or change your Medicare Part D Prescription Drug Coverage:
- Do you need to join a Medicare drug plan?
- Do you already have creditable prescription drug coverage?
- Will you pay a penalty if you join a drug plan later?
- What will your prescription drugs cost under each plan?
- Are your drugs covered under the plan's formulary?
- Are there any coverage rules that apply to your prescriptions?
Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs. You may qualify for Extra Help, also called the low-income subsidy (LIS), if your yearly income and resources are below the following limits in 2012:
- Single person - Income less than $16,755 and resources less than $13,070
- Married person living with a spouse and no other dependants - Income less than $22,695 and resources less than $26,120
These amounts may change in 2013. You may qualify even if you have a higher income (like if you still work, live in Alaska or Hawaii, or have dependants living with you). Resources include money in a checking or savings account, stocks, bonds, mutual funds, and Individual Retirement Accounts (IRAs). Resources don't include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person), or life insurance policies.
If you qualify for Extra Help and join a Medicare drug plan, you will get the following:
- Help paying your Medicare drug plan's monthly premium, yearly deductible, coinsurance, and copayments
- No coverage gap
- No late enrollment penalty
You automatically qualify for Extra Help if you have Medicare and meet one of these conditions:
- You have full Medicaid coverage
- You get help from your state Medicaid program paying your Part B premiums (in a Medicare Savings Program)
- You get Supplemental Security Income (SSI) benefits
To let you know you automatically qualify for Extra Help, Medicare will mail you a purple letter that you should keep for your records. You don't need to apply for Extra Help if you get this letter.
- If you aren't already in a Medicare drug plan, you must join one to use this Extra Help.
- If you don't join a Medicare drug plan, Medicare may enroll you in one. If Medicare enrolls you in a plan, you will get a yellow or green letter letting you know when your coverage begins.
- Different plans cover different drugs. Check to see if the plan you're enrolled in covers the drugs you use and if you can go to the pharmacies you want. Compare with other plans in your area.
- If you're getting Extra Help, you can switch to another Medicare drug plan anytime. Your new coverage will be effective the first day of the next month.
If you have Medicaid and live in certain institutions (like a nursing home) or get home and community-based services, you pay nothing for your covered prescription drugs.
If you don't want to join a Medicare drug plan (for example, because you want only your employer or union coverage), call the plan listed in your letter, or call
If you didn't automatically qualify for Extra Help, you can apply:
- Visit www.socialsecurity.gov/i1020 to apply online.
- Call Social Security at
1-800-772-1213to apply for Extra Help by phone or to get a paper application. TTY users should call 1-800-325-0778.
- Visit your State Medical Assistance (Medicaid) office. Visit www.medicare.gov/contacts or call
1-800-MEDICARE (1-800-633-4227)to get the phone number. TTY users should call 1-877-486-2048.
Note: You can apply for Extra Help at anytime. With your consent, Social Security will forward information to the Medicaid office in your state to start an application for a Medicare Savings Program.
Drug costs in 2013 for most people who qualify will be no more than $2.65 for each generic drug and $6.60 for each brand-name drug. Look on the Extra Help letters you get, or contact your plan to find out your exact costs.
To get answers to your questions about Extra Help and help choosing a plan, call your State Health Insurance Assistance Program (SHIP). You can also call
Proof you qualify for Extra Help. Medicare gets information from your state or Social Security that tells whether you qualify for Extra Help. If Medicare doesn't have the right information, you may be paying the wrong amount for your prescription drug coverage.
If you automatically qualify for Extra Help, you can show your drug plan the colored letter you got from Medicare as proof that you qualify. If you applied for Extra Help, you can show your "Notice of Award" from Social Security as proof that you qualify.
You can also give your plan any of the documents listed below (also called "Best Available Evidence") as proof that you qualify for Extra Help. Your plan must accept these documents. Each item must show that you were eligible for Medicaid during a month after June 2012.
- A bill from the institution (like a nursing home) or a copy of a state document showing Medicaid payment to the institution for at least a month
- A print-out from your state's Medicaid system showing that you lived in the institution for at least a month
- A document from your state that shows you have Medicaid and are getting home- and community-based service
- A copy of your Medicaid card (if you have one)
- A copy of a state document that shows you have Medicaid
- A print out from a state electronic enrollment file or from your state's Medicaid system that shows you have Medicaid
- Any other document from your state that shows you have Medicaid
If you aren't already enrolled in a Medicare drug plan and paid for prescriptions since you qualified for Extra Help, you may be able to get back part of what you paid. Keep your receipts and call Medicare's Limited Income Newly Eligible Transition (NET) Program at
For more information, visit www.medicare.gov/publications to view the fact sheet "If You Get Extra Help, Make Sure You're Paying the Right Amount." You can also call
If you don't qualify for Extra Help, you might qualify for the following to help to pay for some health care and prescription drug costs.
State Pharmacy Assistance Programs (SPAPs) - Many states have State Pharmacy Assistance Programs (SPAPs) that help certain people pay for prescription drugs based on financial need, age, or medical condition. Each SPAP makes its own rules on how to provide drug coverage to its members. To find out about the SPAP in your state, call your State Health Insurance Assistance Program (SHIP).
Pharmaceutical Assistance Programs (also called Patient Assistance Programs) - Many major drug manufacturers offer assistance programs for people with Medicare drug coverage who meet certain requirements.
Note: Visit www.medicare.gov/pap/index.asp to learn more about Pharmaceutical Assistance Programs.