Asking your Medicare Part D prescription drug plan for reimbursement for non-network pharmacy purchases is similar to asking for a refund of overpaid premiums and copayments

The following is information from a Centers for Medicare and Medicaid Services (CMS) "tip sheet" explaining how people with Medicare can get reimbursed by their Medicare drug plan - along with a few additional notes and references to your Medicare Part D plan's Evidence of Coverage document.

How to get reimbursed from a Medicare drug plan ...

A Medicare drug plan will reimburse people with Medicare who pay for formulary prescriptions that should be covered by their plan.  To get reimbursed, the person should take the following steps (first check with your Medicare Part D plan's Member Services department to see if a network pharmacy is nearby - the toll-free number for Member Services is printed on your Member ID card):

1. Save the original receipt from the drug purchase. If the person no longer has the original receipt, he or she can contact the pharmacy and ask for a replacement receipt or other proof of purchase.
   
   
2. Call the plan's customer service number on the membership card, read the plan's printed materials, or look on the plan's member website to find out about the reimbursement process.
   
   We have the telephone number for most Member Services departments online, just click on the plan’s name when using our Medicare Advantage Plan Finder or MA-Finder (enter your ZIP to begin) or our stand-alone Medicare Part D Plan Finder or PDP-Finder (choose your state to begin).
   
   
3. Get a copy of the plan's claim submission or reimbursement form, if needed.
   
   
4. Fill out the form and submit it to the plan with the original or replacement receipt [-- remember to keep a copy of your receipts and the reimbursement form that you submit].

Important!
Remember to refer to your Medicare plan Evidence of Coverage document for plan-specific rules about getting reimbursed for out-of-network pharmacy purchases..  Specifically, please see Chapter 3. Using the plan’s coverage for your Part D prescription drugs, Section 2.5 " When can you use a pharmacy that is not in the plan’s network?" - and - Chapter 5, Section 2.1 "How and where to send us your request for payment?" of your Evidence of Coverage document - the following is the "model" language provided by CMS.)

Chapter 3. Using the plan’s coverage for your Part D prescription drugs
Section 2.5 When can you use a pharmacy that is not in the plan’s network?

"Your prescription may be covered in certain situations

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. [Insert if applicable: To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.] If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• [Plans should insert a list of situations when they will cover prescriptions out of the network and any limits on their out-of-network policies (e.g., day supply limits, use of mail order during extended out of area travel, authorization or plan notification).]

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. (Phone numbers for Member Services are printed on the back cover of this booklet [and your Member ID card].) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.  [emphasis added]

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.)"

Chapter 5, Asking us to pay our share of the costs for covered drugs
Section 2 How to ask us to pay you back
Section 2.1 How and where to send us your request for payment

"Send us your request for payment, along with your receipt documenting the payment you have made. It’s a good idea to make a copy of your receipts for your records.

[If the plan has developed a specific form for requesting payment, insert the following language: To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment.

• You don’t have to use the form, but it will help us process the information faster.
  
  
• Either download a copy of the form from our website ([insert URL]) or call Member Services and ask for the form. (Phone numbers for Member Services are printed on the back cover of this [Evidence of Coverage] booklet.)]
  

Mail your request for payment together with any receipts to us at this address:  [Insert address]

[If the plan allows members to submit oral payment requests, insert the following language:

You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look for the section called [plans may edit section title as necessary] Where to send a request that asks us to pay for our share of the cost of a drug you have received.]

[Insert if applicable: You must submit your claim to us within [insert timeframe] of the date you received the service, item, or drug.]

Contact Member Services if you have any questions (phone numbers are printed on the back cover of this booklet). If you don’t know what you should have paid, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us."

Other common reimbursement scenarios include

(1) What if someone who qualifies for the low-income subsidy (LIS), but doesn't have proof is charged an incorrect deductible or copayment amount?

To avoid paying incorrect amounts, people who qualify for LIS should provide the pharmacy with the following documents as proof they qualify:

• A copy of their yellow, green, or purple automatic enrollment letter from Medicare
• Their "Notice of Award" from Social Security
• Their Medicaid card (if they have one) or any document that shows they have Medicaid
• A bill from an institution (like a nursing home) or a copy of a state document showing Medicaid payment to the institution for at least a month
• A screen print from their state's Medicaid systems showing that they lived in the institution for atleast a month

If proof isn't available, a person who qualifies for LIS should contact their State Medical Assistance (Medicaid) office or Social Security to get at least one of the documents mentioned here. The person can call 1-800-MEDICARE (1-800-633-4227) to get the telephone number for their Medicaid office. TTY users should call 1-877-486-2048.  People who qualify for the LIS who aren't charged the correct deductible or copayment amount should contact their Medicare drug plan to find out how to submit a claim for reimbursement. They should save the original receipt from the purchase in case they need to submit it with the claim. The Medicare drug plan will refund any amount that is due.

(2)  How will pharmacies be reimbursed for payments they made on behalf of people with Medicare and Medicaid who live in long-term care facilities and qualify for the $0 copayment?

People with Medicare and Medicaid who reside in long-term care facilities may not have to pay copayments for their prescription drugs. Pharmacies will receive a one-time payment for the amount of any uncollected copayments for people who were mistakenly identified as having to pay copayment amounts. The pharmacy will need to send the prescription drug plan a spreadsheet with claim information. Processes may vary among Medicare drug plans. Following the Medicare drug plan's directions will help ensure timely reimbursements.

(3)  What should people do if a higher premium amount is deducted from their Social Security benefit?

If there is a premium overpayment, such as when a person changes to a lower premium plan and the premium change doesn't immediately go into effect, Social Security will automatically refund the premium overpayment. The person will get a refund check separate from his or her regular monthly Social Security benefit. It may take two to three months to get a refund.

(4)  Why would someone have two premiums deducted in one month?

People who enroll in a Medicare drug plan at the end of the month may be charged in one month for multiple premium payments. For instance, people who enrolled in a Medicare drug plan in the last two or three weeks of December with an effective date of January 1, 2009, may be billed in February for both January and February premiums. Depending on which payment method was selected, one of the following will occur:

• They will get a bill for 2 months of premiums. (Note: Plans generally send bills at either the beginning or the end of the month. It varies by plan.)
• They will have 2 months of premiums withdrawn from the selected account. This could show as two separate withdrawal amounts, or one withdrawal at double the amount, depending on the plan. (Note: These withdrawals generally happen at either the beginning or the end of the month.)
• They will have 2 months of premiums withheld from their monthly Social Security payment.

(5)  What happens if a person who qualified for the low-income subsidy (LIS) is charged a premium? People who qualified for the full LIS should generally pay no monthly prescription drug premium. However, if they select a plan that doesn't have a $0 premium for people qualifying for the full LIS, they will have to pay a small premium amount. Also, if they join a Medicare drug plan with supplemental benefits, they will pay the plan's supplemental premium. People who qualified for the partial subsidy may pay no premium or a reduced premium for a basic plan, depending on income. Drug plan sponsors have been instructed not to bill a new member until Medicare tells the plan what the member's premium should be. However, in some cases, plans might mistakenly send bills for full plan premiums to certain members who qualify for LIS or to members who qualify retroactively for LIS. Plans also have been directed not to disenroll members for failure to pay their premium bill if the person might qualify for the full or partial LIS amount. People who get a notice that says they will be disenrolled for non-payment of premiums should call their plan. If the Medicare drug plan billed a member who should have a reduced or $0 premium and the member paid the premium, the Medicare drug plan will refund the amount overpaid as soon as possible. The member can call the customer service number on the membership card, read the plan's printed materials, or look on the plan's member website to find out about the reimbursement process.

(6)  What happens if people choose the premium withholding, but they also have a secondary insurer that pays part of the drug plan premium?

People who get a premium benefit from a secondary insurer (a plan other than their Medicare drug plan), such as an employer health plan or a State Pharmacy Assistance Program (SPAP), will have the entire monthly premium withheld if they choose the Social Security premium withholding option. The Medicare drug plan will give the member a refund for the amount the employer health plan or SPAP would have paid. For example, if a member with a $20 drug plan premium has a SPAP premium benefit of $10 per month and the member chooses premium withholding, Social Security will withhold the full $20. The Medicare drug plan will refund the member $10. Plans shouldn't convert a member with secondary coverage to direct billing, unless the member requests it, but they may encourage members to choose this method of billing. If a member chooses direct billing, he or she will get a bill for the correct premium amount. The SPAP or employer will pay its share directly to the plan.

(7)  What happens if a person is in a Medicare Advantage Plan that lowers the Medicare Part B premium, but the person is charged the full premium amount?

Some Medicare Advantage Plans pay some or all of their members' Medicare Part B premium as part of the plan's enrollment. It may take up to 2 months for a member to see an increase in his or her Social Security check equal to the amount of the reduction in the Part B premium. If a member didn't see an increase, the incorrect withholding amount will be repaid to the member all at once. Depending on the payment method a member selected, one of the following will occur:

• They will have their regularly scheduled Social Security benefit payment increased.
• They will get a refund check from the plan or from Social Security.

The member should call his or her plan if the increase isn't received or refunded.