Medicare Help for Consumers

We have a special Medicare Part D Appeals Unit to help older and disabled Maine residents with Medicare Part D. This help is free.  

If you live in Maine and have Medicare, but you cannot get your medicine, are paying too much for it, or are just confused, call the Medicare Part D Unit, toll-free:

1-877-774-7772  
 

We are here Monday through Friday, 9 a.m. to 12 p.m. and 1 p.m. to 4 p.m.

We will help you by phone. You also may be able to find some answers to some of your questions below.

Medicare Part D is really complicated.  We provide this service and the answers to the questions below to help you better understand how to make Part D work for you.  

Getting Started - the Basics

What is Medicare prescription drug coverage?

Medicare prescription drug coverage is a voluntary benefit under the Medicare program. The Medicare prescription drug coverage program is called "Medicare Part D." 

There are many stand-alone Medicare Part D Plans to choose from in Maine. These plans are provided by private insurance companies.  There are prescription-only Medicare Part D plans.  Those are called stand-alone Medicare Part D Plans.  Medicare drug coverage also is offered through some Medicare Advantage Plans (which also provide Medicare Part A and B coverage).

You can enroll in a new Medicare Part D plan during Open Enrollment from October 15 to December 7 every year.  Coverage then starts the next January.  If you have “extra help” with your Medicare Part D costs, you have Special Enrollment Periods (SEPs).  Learn more about extra help with Medicare Part D costs here.  This means you can change your Part D Plan more often. Contact your local Area Agency on Aging for information on Special Enrollment Periods and to help you enroll. 

Who is eligible for Part D Coverage?

Anyone entitled to Medicare Part A or enrolled in Medicare Part B is eligible for Medicare Part D benefits.

You are eligible for Medicare Part D if you have a Medicare card.

If I have Medicaid (MaineCare) and am now eligible for Medicare, do I need Medicare Part D coverage?

When you become eligible for Medicare, you need to enroll in a Medicare Part D Plan for drug coverage. The state and federal government will help with some of your costs.

If you also have prescription drug coverage from another source, click here for more information.

What if I already have prescription drug coverage from another source?

You may not need Medicare Part D coverage if you have prescription drug coverage from a different source.  Sources could be a private insurance company, an employer/retiree plan, VA, or a union plan.

Your insurance company would have sent you information saying your prescription drug coverage qualifies as "creditable coverage."  Contact your insurance plan Administrator or Human Resources department if you are not sure.  

"Creditable Coverage" means that your other source of prescription drug coverage is at least as good as Medicare Part D coverage.  That means you DO NOT need Medicare Part D coverage.  In some cases, you could lose your retiree coverage entirely if you enroll in a Medicare Part D Plan.  In some cases, like with a VA plan, you can keep both. 

Where do I go for help with Part D?

General Information:

For help choosing a Medicare Part D plan:

Apply for extra help paying your Medicare Part D costs:

What Medicare Part D plans are available in Maine?

To learn about the Part D plans in your area:

About Enrolling

How do I enroll for Medicare Part D coverage?

First, make a list of your drugs and dosages, as well as your preferred pharmacy. After you have completed this step, you are ready to enroll.

There are several ways to enroll:

You can find a Medicare Part D Plan and enroll on-line using the Medicare Plan Finder.

OR

If you have MaineCare or Low Cost Drugs for the Elderly and Disabled (DEL), call:  
MaineCare Pharmacy Help Desk at 1-866-796-2463, or TTY: (800) 423-4331 (for the hearing impaired)

OR

Call your local Area Agency on Aging and tell them you need help getting a Medicare Part D Plan.  

Is there a deadline to enroll for Medicare Part D coverage?

Yes.  When you first get Medicare, you can join a Medicare drug plan during your Initial Enrollment Period.

After the Initial Enrollment Period:

Unless you have a Special Enrollment Period, you can only change plans once a year, during the Annual Open Enrollment Period.  That period runs October 15 through December 7, and your new plan starts in January.

Special Enrollment Periods:

There are a few different kinds of Special Enrollment Periods.  For example, if you have MaineCare or the Medicare Savings Program and Medicare, you have Special Enrollment Periods to change plans more often. If you move to a new area of the country, or move into or out of a nursing home, you also have a Special Enrollment Period. If you lose other prescription drug coverage and it was creditable coverage, you also have a Special Enrollment Period to enroll in a Medicare drug plan.

For more information on these and other Special Enrollment Periods, contact your local Area Agency on Aging.    

Costs and Coverage

How much does Medicare Part D coverage cost?

There are three categories of out-of-pocket expenses associated with Medicare Part D drug plans: the monthly premium, the annual deductible (some plans do not have a deductible), and the co-payments.

The monthly premium is the amount you pay each month for coverage.  Each Part D plan has a different monthly premium. You can find the cost of monthly premiums on the Medicare website. If you have “extra help” with Medicare Part D costs, you can get into a Medicare Part D Plan that does not charge you a premium.  Learn more about extra help here.  

The annual deductible is the amount you pay for your medications before your coverage begins. Some Medicare Part D Plans have no deductible. This deductible is in addition to your monthly premium.  During the deductible you pay 100% of your drug costs. If you have “extra help” with Medicare Part D, you should not have a deductible.

A co-payment (or co-insurance) is the amount you pay for your prescriptions after you have met the annual deductible amount. This will vary depending on your total drug costs and the Medicare Part D Plan you choose.  

If you have “extra help” with Medicare Part D, you should pay relatively low co-pays for all your covered medications regardless of which plan you are in.

Most Medicare Part D Plans have a Coverage Gap (often called the "Donut Hole").  Under the Affordable Care Act, the Coverage Gap is gradually going away. Once you are out of the coverage gap, you will pay a small co-insurance/co-payment for your drugs.  If you have “extra help” with Medicare Part D costs, you do not have a Coverage Gap.

Will Medicare Part D pay for all of my prescriptions?

Not necessarily.

You might take a medication that your Medicare Part D Plan does not cover (but others plans do) unless you prove it is medically necessary.  You may need to work with your doctor to prove you need that medication or to find a suitable alternative medication.  Other plans might cover the prescription and you may need to change to a Medicare Part D Plan that covers the medication.

You might take a medication that is not covered by Medicare Part D at all or is not covered for your diagnosis.  That means no Medicare Part D Plan will cover it, even if you prove it is medically necessary.

Go to the Medicare website Formulary Finder to find out which Medicare Part D plan will best meet your needs. You can also call your local Area Agency on Aging at 1-877-353-3771 or TTY: 1-800-750-5353.

Some medications not covered by Medicare Part D at all include:  

  • Drugs used for anorexia, weight loss or weight gain. However, Medicare Part D does cover prescription drugs used for AIDS wasting and cachexia.  
     
  • Over-the-counter drugs.  
     
  • Drugs to relieve cough/cold symptoms.  However, cough and cold medicines may be covered if used for purposes other than symptomatic relief, for example a cough medication used to treat a medical condition that causes a cough.  
     
  • Fertility drugs.  
     
  • Most prescription vitamins, including vitamin D2 and D3, and minerals. Medicare Part D does cover prenatal vitamins, fluoride, and vitamin D analogs, such as calcitriol, doxercalciferol and paricalcitol.  
     
  • Prescription drugs used for cosmetic purposes or hair growth, but Medicare Part D does cover prescription drugs to treat psoriasis, acne, rosacea and vitiligo.  
     
  • Drugs that must be monitored by testing services that only the manufacturer provides, such as certain anti-psychotics.  
     
  • Drugs used to treat erectile dysfunction. These drugs may be covered by Medicare Part D if used to treat other conditions, such as pulmonary hypertension.

MaineCare, the Medicare Savings Program, and Drugs for the Elderly (DEL) may pay for some of the medications listed above.   If you are part of those programs, make sure your pharmacist knows.  

Some medications are covered by Medicare Part B, and not covered by Medicare Part D or only covered by Medicare Part D in some situations.  In those cases, your pharmacist should bill Medicare Part B.

You may be able to enroll in a plan and request an exception (called a Coverage Determination) if you cannot find a plan that covers all your drugs.  The exception could help you get full coverage.  Learn more about Exceptions/Coverage Determination here.

What if I can't afford Medicare Part D coverage?

If you have limited income, you may qualify for "extra help" with Medicare Part D plan costs.  MaineCare or the Medicare Savings Program can help you pay your monthly premium, annual deductible, and/or co-payments.  

You must apply for help covering costs UNLESS you are already enrolled in:

  • Medicare and Medicaid (MaineCare), OR
  • Medicare and the Medicare Savings Program (the QMB, SLMB, or QI levels), OR
  • Medicare and SSI (Supplemental Security Income)

Your local Area Agency on Aging or Maine's Department of Health and Human Services can give you more information about MaineCare or the Medicare Savings Program (also known as the Buy In program).  Your local Area Agency on Aging can help you apply.  Get more details on who is eligible for help through the Medicare Savings Program.  

Getting Prescriptions

My Medicare Part D plan denied coverage of my drug.  How do I find out why I was denied coverage?

Ask the pharmacist for an explanation.  They may be able to explain the reason why you were denied coverage. Depending on the reason for the denial, you may be able to request an Exception (Coverage Determination) to obtain your drug. 

A "Coverage Determination" is your Medicare Part D plan's official decision about your prescription drug benefits.  If your Coverage Determination is denied, you have the right to Appeal the denial.  

What is I need help asking for a Coverage Determination?  

You can ask your prescribing doctor or someone you trust to request a Coverage Determination for you.

If anyone other than you or the prescribing doctor is going to request the Coverage Determination, your Medicare Part D plan needs something in writing that allows the person to act for you.  You can use this form  from the Centers for Medicaid and Medicare Services (CMS) to do that.  

What happens next?

Your Medicare Part D plan must contact you within 72 hours to explain the reason why it would not cover your drug.

What if I can't wait 72 hours?

You can request an Expedited Coverage Determination.  That requires your Medicare Part D plan to contact you within 24 hours to explain why your plan doesn't cover your drug.  

How can I get an Expedited Coverage Determination?

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Medicare Part D plan and request an Expedited Coverage Determination.  Then your Medicare Part D plan will decide if you qualify for an Expedited Coverage Determination depending on the seriousness of your health condition.

NOTE: Your Medicare Part D plan MUST grant a request for an Expedited Coverage Determination if your doctor personally calls your Medicare Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

What if the Coverage Determination is denied?

You have the right to appeal the denial.  Follow the links below to find out what to do next.

You can also call us at 1-877-774-7772 if you have questions or need help.  

What if my Medicare Part D plan determined that my drug was not medically necessary?

First, contact your doctor.

Explain to your doctor that your Medicare Part D plan determined that your drug was not medically necessary.

If your doctor believes that your Medicare Part D plan's decision is incorrect, you can request an Appeal.

NOTE: You have the RIGHT to request an Appeal.

For questions or advice,  
contact the Medicare Part D Unit  
at Legal Services for Maine Elders at  
1-877-774-7772

Your Medicare Part D plan's written Coverage Determination will explain how to request an Appeal.

We have more information about the Appeal process.

What if my drug is not on my Medicare Part D plan's formulary?

First, contact your doctor.

Explain to your doctor that your Medicare Part D plan refused to cover your drug because it was not on its formulary. Find out whether your doctor will prescribe a substitute drug that is on your Medicare Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Medicare Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice,  
contact the Medicare Part D Unit at  
Legal Services for Maine Elders at  
1-877-774-7772.

Get more information about requesting an Exception.

What if I can't get my drug because my doctor did not obtain prior authorization from my Medicare Part D plan?

First, contact your doctor.

Explain to your doctor that your Medicare Part D plan refused to cover your drug because you did not obtain a Prior Authorization.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Medicare Part D plan to request a Prior Authorization/Coverage Determination.

For questions or advice,  
contact the Medicare Part D Unit at  
Legal Services for Maine Elders at  
1-877-774-7772.

Get more information about requesting a Coverage Determination.

What if my doctor prescribed a dosage that is not covered by my Medicare Part D plan?

First, contact your doctor.

Explain to your doctor that your Medicare Part D plan refused to cover your drug because the prescribed dosage is higher than the plan will normally cover. Find out whether your doctor will prescribe a substitute drug or a different dosage that is on your Medicare Part D plan's formulary.

If your doctor believes that you must have the prescribed dosage, then ask your doctor to contact your Medicare Part D plan to request an "Exception"(Coverage Determination) and to explain why the dosage is medically necessary.

NOTE: You have a RIGHT to request an Exception (Coverage Determination).

For questions or advice,  
contact the Medicare Part D Unit at  
Legal Services for Maine Elders at  
 1-877-774-7772.

Get more information about requesting an Exception (Coverage Determination).

What if my doctor prescribed a form (liquid versus pill) or type (generic versus brand) of drug that is not covered by my Medicare Part D plan?

First, contact your doctor.

Explain to your doctor that your Medicare Part D plan refused to cover your drug because the form or type prescribed is not on the plan's formulary. Find out whether your doctor will prescribe a different form or type of drug that is on your Medicare Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Medicare Part D plan to request an "Exception" and to explain why the type or form of your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice,  
contact the Medicare Part D Unit at  
Legal Services for Maine Elders at  
1-877-774-7772.

Get more information about requesting an Exception.

Changing Plans and Other Issues

What if I can't afford my drug?

If you have limited income, you may qualify for "extra help" with the cost of your drug.  In order to receive "extra help," you MUST APPLY for it, UNLESS you are already enrolled in:

  • Medicare and Medicaid (MaineCare), OR
  • Medicare and the Medicare Savings Program (the QMB, SLMB, or QI levels), OR
  • Medicare and SSI (Supplemental Security Income)

Maine's Area Agencies on Aging (AAAs) or Maine's Department of Health and Human Services can give you more information about MaineCare or the Medicare Savings/Buy In Program.  Your local AAA can help you apply.  

Learn more about who is eligible for help from the Medicare Savings Program.

If you do not qualify for help with costs:

Call your doctor and tell them that you cannot afford your drug.  Ask if they can prescribe a substitute drug that you can afford.

What if my Medicare Part D plan removes my drug from its formulary?

In most cases, your Medicare Part D plan must provide written notice to you at least 60 days prior to the effective date of the change in its formulary. In a few situations, for example if the FDA suddenly raises major safety issues, the Plan can stop covering the drug without 60 days' notice.

NOTE: Your Medicare Part D plan cannot change the drugs it covers from November 15- March 3 of each year.

If your Medicare Part D plan does not give you written notice of these changes and refuses to cover a 60-day supply of your drug, contact:

LSE's Medicare Part D Appeals Unit  
1-877-774-7772

Contact your doctor if you get a notice from your Medicare Part D Plan, or otherwise find out about coverage change that affects you.  Tell them that your Medicare Part D plan no longer covers your drug.  Ask your doctor if they can prescribe a substitute drug that is covered by your plan. 

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Medicare Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice,  
contact the Medicare Part D Appeals Unit of  
Legal Services for Maine Elders at  
1-877-774-7772.

Get more information about requesting an Exception.

Can I get my prescription filled at a pharmacy that is not within my Medicare Part D plan's network?

You may be able to obtain your drug from a non-network pharmacy, BUT ONLY IF:

  • You cannot reasonably be expected to obtain your drug at a network pharmacy,

    And

  • You do not use a non-network pharmacy on a regular basis.

Otherwise, your Medicare Part D plan can refuse to cover your prescription at a non-network pharmacy.

NOTE: If you obtain your drug from a non-network pharmacy, you may be required to pay the difference between the non-network pharmacy's price and your Medicare Part D plan's allowance.

For questions or advice,  
contact the Medicare Part D Unit at  
Legal Services for Maine Elders at  
1-877-774-7772

What if my drug is not covered by Medicare Part D?

You may need to pay out-of-pocket for drugs specifically excluded from Medicare Part D coverage, which include the following:

  • Over-the-counter drugs;
  • Drugs when used for anorexia, weight-loss or weight-gain;
  • Drugs to relieve cough/cold symptoms;
  • Drugs to promote hair growth;
  • Fertility drugs;
  • Prescription vitamins and mineral products, with the exception of prenatal vitamins and fluoride;
  • Cosmetic drugs;
  • Drugs that must be monitored by testing services that only the manufacturer provides, such as certain anti-psychotics;
  • Drugs used for treatment of sexual or erectile dysfunction (ED). However, ED drugs are Medicare Part D drugs if used for medically accepted indications approved by the FDA other than sexual or erectile dysfunction (such as pulmonary hypertension).

Call your local Area Agency on Aging, the Maine State Health Insurance Assistance Program (SHIP) at 1-877-353-3771, or TTY: 1-800-750-5353 for more information.

NOTE: If you have Maine Care, or the Drugs for the Elderly (DEL) program, drugs on the above list may be covered by that program. Be sure your pharmacist knows you have MaineCare or DEL.

For questions or advice,  
contact the Medicare Part D Appeals Unit of  
Legal Services for Maine Elders at  
1-877-774-7772

Can I change plans?

If you enrolled in a Medicare Part D plan that you are not happy with or that is not meeting your prescription needs, you can change to a different Medicare Part D plan. However, there are rules as to when you can change Medicare Part D plans, depending on your circumstances.

Most people can only change to a new Medicare Part D plan once a year.  You must enroll in the new plan between October 15th and December 7th. Your new plan will be effective January 1.

NOTE: Be sure to review your Medicare Part D Plan every fall. Plans change the drugs they will cover and often change their premiums and co-pays every January 1.

There are some Special Enrollment Periods for special circumstances. For example, if you move into or out of a nursing home, you have two months after you move to join a new Medicare Part D Plan.  If you involuntarily lose other creditable prescription drug coverage, you have two months to join a Medicare Part D Plan. 

For more information on Special Enrollment Periods, call 1-800-MEDICARE, your local Area Agency on Aging or our Medicare Part D Unit 1-877-774-7772.

NOTE: If you have Medicare and either MaineCare, a Medicare Savings Program (the “Buy In”), or LIS through Social Security, you have Special Enrollment Periods to change your Part D Plan more often. But you need to enroll in a “benchmark” plan, or you will have to pay part (or a larger part) of the premium yourself.

Contact your local Area Agency on Aging (the Maine State Health Insurance Assistance Program (SHIP)) at 1-877-353-3771, or TTY: 1-800-750-5353, for more information.

For more information:

Contact your local Area Agency on Aging

If you live in Maine and have Medicare and want to learn more about your new Medicare benefits, contact your local Area Agency on Aging by calling:

1-877-353-3771

Find all five regional Area Agency on Aging offices on the web: 
Aroostook Area Agency on Aging (serving Aroostook County) 
Eastern Area Agency on Aging (serving Piscataquis, Penobscot, Washington, & Hancock Counties) 
Spectrum Generations (serving Kennebec, Waldo, Knox, Lincoln, Sagadahoc, Somerset, towns of Brunswick & Harpswell) 
SeniorsPlus (serving Androscoggin, Franklin, Oxford Counties) 
Southern Maine Agency on Aging (serving Cumberland and York Counties)

Or find contact information for all offices here.

senior coupleRead more information about 
Health Care Reform for Older People with Medicare

health care reform Maine outreach campaign logoNot an older person? 
Go here for information about 
Health Care Reform for adults, children and families