Prescription Drug Plans Frequently Asked Questions

You have access to online pharmacy services. Be sure to register to review up to 18 months of your prescription history.

A Medicare prescription drug plan is an option, not a requirement. You do not have to enroll in Medicare Part D. However, even if you do not take many prescription drugs now, you may want to enroll in a plan so you’ll have it if you need prescription drug coverage in the future.

You may owe a late-enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

• A Medicare prescription drug plan (Part D)
• A Medicare Advantage plan (Part C), which is similar to an HMO or PPO
• Another Medicare health plan that offers Medicare prescription drug coverage
• Creditable prescription drug coverage

If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. Medicare and Social Security determine how much extra help you are eligible for. Then, your Part D plan will let you know the amount you will pay. If you are not getting this extra help, you can see if you qualify by contacting:

• 1-800-MEDICARE (1-800-633-4227, TTY: 1-877-486-2048), 24 hours a day/seven days a week
• The Social Security Office at 1-800-772-1213 (TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday
• Your State Medicaid Office

The WPS MedicareRx Plan (PDP) conducts drug utilization reviews for all our customers to make sure that they are getting safe and appropriate care. These reviews are especially important for customers who have more than one doctor who prescribes their medications. Drug utilization reviews are conducted each time you fill a prescription, and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Drug allergies
• Possible medication errors
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

• Medicare Part-D Prescription Drug Claims Form

Part D sponsors must provide for an appropriate transition process for certain enrollees who are prescribed Part D drugs that represent ongoing therapy with that drug, but that are nonformulary. The purpose of providing a transition supply is to promote continuity of care and avoid interruptions in drug therapy while a switch to a therapeutically equivalent drug or the completion of an exception request to maintain coverage of an existing drug based on medical necessity reasons can be effectuated.

The transition policy must satisfy the requirements in the following:

• For the purposes of transition requirements, CMS defines non-formulary Part D drugs to mean:
  • Part D drugs that are not on a sponsor’s formulary
  • Drugs previously approved for coverage under an exception once the exception expires
  • Part D drugs that are on a sponsor’s formulary but require prior authorization or step therapy, or that have an approved QL lower than the beneficiary’s current dose, under a plan’s utilization management requirements

• A Part D sponsor’s transition process is necessary with respect to the transition of:
  • New enrollees into prescription drug plans following the annual coordinated election period
  • Newly eligible Medicare beneficiaries from other coverage
  • Enrollees who switch from one plan to another after the start of the contract year
  • Current enrollees affected by negative formulary changes across contract years and Enrollees residing in LTC facilities

You should contact your plan for more information on their specific transition process or visit Medicare.gov.

Typically, you may only enroll in a Medicare prescription drug plan during the annual open enrollment period between Oct. 15 and Dec. 7 of each year. However, there are exceptions that may allow you to enroll in a Medicare prescription drug plan outside of the annual open enrollment period.

If you are a member of a Medicare Advantage plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage plan that will meet your needs. By joining a stand-alone Prescription Drug Plan (PDP), your membership in your Medicare Advantage plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage plan sends you and, if you have questions, contact your Medicare Advantage plan.

If you currently have health coverage from an employer or union, joining a PDP could affect your employer or union health benefits. You could lose your employer or union health coverage. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn't information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Medicare beneficiaries may enroll in Prescription Drug Plans (PDP) through the Centers for Medicare & Medicaid Services (CMS) Online Enrollment Center, located on the official Medicare.gov website.

If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join WPS MedicareRx Plan (PDP), Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help, you can see if you qualify by contacting:

• 1-800-MEDICARE (1-800-633-4227, TTY: 877-486-2048), 24 hours a day, seven days a week
• The Social Security Office at 1-800-772-1213 (TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday
• Your State Medicaid Office

The chart below shows prescription costs for those receiving extra help in 2021 and 2022.

If you qualify for extra help, you pay a reduced monthly premium. If you continue to qualify for the same amount of extra help in 2022, the table below tells how much you will pay for a monthly premium. (This doesn't include any Medicare Part B premium you may have to pay.) If you don't know your level of extra help, can call Medicare.

You may receive (or may have already received) a letter from Medicare or Social Security about your 2022 eligibility for extra help. Read this important information carefully. If you don't know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227, TTY: 877-486-2048), 24 hours a day, seven days a week.

2022 WPS MedicareRx Plan (PDP) Monthly Plan Premium
For people who get extra help from Medicare to help pay for their prescription drug costs

Federal regulations at 42 CFR § 423.1-800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

Go to the CMS website Best Available Evidence Policy page

Medication Therapy Management programs for complex health needs

Plans with Medicare drug coverage must offer Medication Therapy Management (MTM) services to help members use their opioid prescription drugs safely if they meet certain requirements or are in a Drug Management Program. If you qualify, you can get these services at no cost to help you understand your medications and take them safely.

Medication Therapy Management services usually include a discussion with a pharmacist or health care provider to review your medications. These services may vary by plan.

Through the MTM, you may get:

• A comprehensive review of your medications and the reasons why you take them.
• A written summary of your medication review with your doctor or pharmacist.
• An action plan to help you make the best use of your medications (there will be space for you to take notes or write down any follow-up questions.)
• It’s a good idea to schedule your medication review before your yearly wellness visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, take your medication list with you if you go to the hospital or emergency room.

If you take many medications for more than one chronic health condition, contact your drug plan to see if you're eligible for a Medication Therapy Management program.