We have a special Medicare Part D Appeals Unit to help older and disabled Maine residents with Medicare Part D. There is no cost for this help.

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

1-877-774-7772  
Monday through Friday, 9 a.m. to Noon, 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.

On January 1, 2006, Medicare benefits expanded into the world of prescription drug coverage. Medicare Part D is highly technical and complex. We've designed this website 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." Medicare Part D benefits are provided by private insurance companies. There are prescription-only Medicare Part D plans (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).

There are many stand-alone Medicare Part D plans to choose from in Maine.

You can enroll in a new Medicare Part D plan during Open Enrollment from October 15 to December 7 every year, for enrollment starting the next January. However, if you have “extra help” with your Medicare Part D costs, you have Special Enrollment Periods (SEPs) to change your Part D Plan more often. For more information about these and/or for help enrolling, contact your local Area Agency on Aging.

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.

For example, if you have a Medicare card, you are eligible for Medicare Part D.

NOTE: To Enroll, you will need to know your Medicare Part A and/or Medicare Part B enrollment dates located on your 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?

If you have prescription drug coverage through a private insurance company, or an employer/retiree plan, or VA, or a union plan, you may not need Medicare Part D coverage.

You should have received a letter, or a newsletter, or other information from your insurance provider stating whether your prescription drug coverage qualifies as "creditable coverage."

If you have not received a letter describing whether your prescription drug coverage qualifies as "creditable coverage," contact your insurance plan Administrator or Human Resources department.

"Creditable Coverage" means that your other source of prescription drug coverage is at least as good as Medicare Part D coverage.

If your current prescription drug coverage qualifies as "creditable coverage," you DO NOT need Medicare Part D coverage. However, in some cases such as VA prescription drug coverage, you can keep both.

NOTE: In some cases, you could lose your retiree coverage entirely if you enroll in a Medicare Part D Plan.

 

Where do I go for help with Part D?

For more information on Medicare Part D:

  • Read the current "Medicare & You" handbook that was mailed to you.  
     
  • Go to the Medicare website and click on Drug Coverage (Medicare Part D) at the top of the page.  
     
  • Call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048 (for the hearing impaired).  
     
  • Call your local Area Agency on Aging, based on the county where you live.

For help choosing a Medicare Part D plan:

For information about qualifying or applying 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 your Initial Enrollment Period, unless you have a Special Enrollment Period, you can only change plans once a year, during the Annual Open Enrollment Period, which runs October 15 through December 7 with your new plan starting in January.

Special Enrollment Periods also exist. For example, if you have MaineCare or the Medicare Savings Program in addition to 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 limited Special Enrollment Period. If you lose other prescription drug coverage and it was creditable coverage, you also have a limited 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 (although some plans do not have a deductible), and the co-payments.

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

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. Note: 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 particular Medicare Part D Plan you are in.

Note:  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 (the "Donut Hole"), but 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. Note: If you have “extra help” with Medicare Part D, you do not have a Coverage Gap.

NOTE: Get more information about “extra help”with Medicare Part D costs.

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, or you may need to change to a Medicare Part D Plan that covers the medication.

Or

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.

Among the medications not covered by Medicare Part D at all are the "excluded" drugs, including:

  • 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.

NOTE: If you are a member of MaineCare, the Medicare Savings Program, or the Drugs for the Elderly program (DEL), those programs may pay for some of the drugs listed above. Be sure your pharmacist knows you are in MaineCare, the Medicare Savings program and/or DEL.  

In addition, 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.

To find out which Medicare Part D plan's formulary will best meet your prescription needs, go to the Medicare website Formulary Finder,

OR

Call your local Area Agency on Aging at 1-877-353-3771 or TTY: 1-800-750-5353.

NOTE: If you cannot find a plan that covers all of your drugs, you may be able to enroll in a plan and request an "Exception" (Coverage Determination) to obtain full coverage.

For more information, see our Exceptions (Coverage Determination) page

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

If you have limited income, you may qualify for "extra help" with the cost of the Monthly Premium, Annual Deductible and/or the Co-Payments.

NOTE: 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 (at the  QMB, SLMB, or QI level), OR
  • Medicare and SSI (Supplemental Security Income)

For information about qualifying or applying for "extra help" paying your Medicare Part D costs:

  • Contact your local Area Agency on Aging and  tell them you want information or help applying for the Medicare Savings Program and/or for MaineCare. OR  
     
  • Contact the Department of Health and Human Services and tell them you would like to apply for the Medicare Savings Program and/or for MaineCare.

Getting Prescriptions

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

To find out why your prescription was not filled:

  • You could ask the pharmacist for an explanation.

    The pharmacist may or may not be able to explain the reason why you were denied coverage. Depending on the reason for the denial, you may be entitled to request an Exception (Coverage Determination); to obtain your drug. If your Coverage Determination is denied, you have the right to Appeal the denial.

    There are several reasons why your Medicare Part D plan might refuse to cover your drug. Use the links at the bottom of this page to find out what to do next.

  • If the pharmacist does not give you a reason for the denial, or if you want an official denial so you can start the Appeal Process, you, or your representative or your doctor, should contact your Medicare Part D plan and request a "Coverage Determination."

    A "Coverage Determination" is your Medicare Part D plan's official decision about the prescription drug benefits you are entitled to receive.

If you need assistance requesting a "Coverage Determination," you can ask your prescribing doctor or someone you trust to request a "Coverage Determination" for you.

NOTE:If someone other than your prescribing doctor is going to request a "Coverage Determination" for you, you will need to submit a written statement to your Medicare Part D plan authorizing someone to act for you.  
You can get a Standard Authorization Form from the Centers for Medicaid and Medicare Services (CMS).

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.

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.

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.

If your Medicare Part D plan grants the request for an Expedited Coverage Determination, it must contact you within 24 hours to explain the reason why it would not cover your drug.

What if the Coverage Determination is unfavorable?

There are several reasons why your Medicare Part D plan might refuse to cover your drug. Follow the links below to find out what to do next.

My Part D plan denied my doctor's request for a Coverage Determination and determined that my drug was not medically necessary

My drug is not on my Medicare Part D plan's formulary

My doctor did not obtain a prior authorization from my Medicare Part D plan

My doctor prescribed a dosage that is not covered by my Medicare Part D plan

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

My Medicare Part D plan removed my drug from its formulary

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

My drug is not covered by Medicare Part D


 

For questions or assistance,

contact the Medicare Part D Unit at  
Legal Services for the Elderly  
1-877-774-7772

 

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 the Elderly 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 the Elderly 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 the Elderly 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 the Elderly 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 the Elderly 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.

NOTE: In order to receive "extra help," you MUST APPLY for it, UNLESS you are already enrolled in:

  • Medicare and Medicaid (MaineCare), OR
  • Medicare and one of the three Medicare Savings Programs, also known as QMB, SLMB, or QI, OR
  • Medicare and SSI

For more information, or to apply for "extra help":

Get more details on who is eligible for "extra help" through the Medicare Savings Program.

If you do not qualify for "extra help," contact your doctor or our Medicare Part D Appeals Unit (1-877-774-7772).

Explain to your doctor that you cannot afford your drug. Find out whether your doctor will prescribe a substitute drug that you can afford.

If your doctor believes that you must have the prescribed drug, and not one of the cheaper drugs that your Medicare Part D Plan covers, then contact our Medicare Part D Appeals Unit and we will help your doctor request an "Exception" from your Medicare Part D Plan.

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 remove a drug of its Formulary without providing 60 days notice.

NOTE: Your Medicare Part D plan cannot change its formulary from November 15- March 3 of each year.

If your Medicare Part D plan fails to provide you with written notice of a change in its formulary, and refuses to provide you with a 60-day supply of your drug, contact:

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

If you receive notice from your Medicare Part D plan, or otherwise find out about formulary change that affects you, contact your doctor.

Explain to your doctor that your drug is no longer on your Medicare Part D plan's 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 Appeals Unit of  
Legal Services for the Elderly 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 the Elderly 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 the Elderly 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, and must enroll in the new plan between October 15th and December 7th. The new Plan will then 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 various Special Enrollment Periods for special circumstances. For example, if you move into or out of a nursing home, you have 2 months after the move to join a new Medicare Part D Plan. Likewise, if you involuntarily lose other creditable prescription drug coverage, you have 2 months to join a Medicare Part D Plan. For more information on Special Enrollment Periods, contact 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.

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