If you have Medicare and full Medicaid, you will usually get your drugs covered by the Medicare prescription drug benefit (Part D) and the Extra Help program. Extra Help is the federal program that pays for most of the costs of Medicare drug coverage if you meet the eligibility requirements. In some limited cases, Medicaid may cover drugs that Medicare does not cover.

The process of getting Part D works differently depending on whether you had Medicare or Medicaid first.  

If you have Medicare and then you also become eligible for Medicaid or SSI:

  • Medicare will automatically enroll you in a Part D plan with Extra Help that will begin within two months of your eligibility for Medicaid or SSI.  You will be enrolled in a benchmark Part D plan, so you will not have to pay a premium. A benchmark plan is a plan that is at or below the amount that Extra Help will pay for a Part D plan premium in your state. You will also not have to pay a late enrollment penalty if you enrolled late into Part D. Medicare will send you a yellow notice telling you which plan it has enrolled you in and what its costs are.   
  • If this plan does not fit your needs, you should choose another plan. When choosing a plan, it is important to find a plan that has your drugs on its formulary with as few restrictions as possible. A formulary is a list of drugs that the plan covers. Examples of restrictions are when a plan requires you to get permission before you can get the drug, or when a plan limits the amount of a drug you can get. Having Extra Help allows you to change your drug plan at anytime.  

If you have certain types of retiree coverage you may not need to enroll in a Part D plan.  Some retiree plans do not work with Part D, and if you enroll in a Part D plan you may lose your retiree or union coverage. If you have prescription drug insurance through an employer, check with your employer to see if you can get a Part D plan and still keep your current coverage. If you cannot have both, you will want to think carefully about whether you should get a Part D plan, especially if your employer plan covers more than just prescription drugs. This is also important if it covers your spouse or dependents who are not eligible for Medicare coverage. If you choose not to take Part D, you will need to contact your state Medicaid office to find out what steps you should take to decline Part D coverage and still keep your Medicaid.

  • Medicare will also enroll you in the low-income newly-eligible transition program (LI NET) to give you temporary coverage until your new Part D plan is active. LI NET must cover all your prescriptions, at any pharmacy, as long as they are not excluded from Medicare coverage by law.
    • Sometimes your Medicaid start date will be retroactive. This means that it might actually begin three to six months before your Medicaid was approved. If you get your Medicaid retroactively, LI NET must cover the prescriptions you have already paid for yourself back to the month your Medicaid or SSI started (the retroactive period).  You will only need to pay your Extra Help copay.  To get reimbursed you should send copies of receipts and proof of your Medicaid eligibility or SSI eligibility to your plan and ask that they pay you back. For example, if you learn that you were approved for Medicaid in April, but the Medicaid start date is retroactive to January, LI NET will reimburse you up to the Extra Help copay amount for drugs you paid from January until your Part D plan starts.  
    • When you are at the pharmacy, you should show the yellow letter you received from Medicare to the pharmacist to prove that LI NET should cover you. You can also use other forms of proof (Best Available Evidence) such as your Medicaid card or a letter from Medicaid.

If you already had a Part D plan before you qualified for Medicaid or SSI, Medicare will not enroll you in another plan. Your Part D plan should automatically pay you back for anything you paid above the Extra Help copayment amount after you qualified for Medicaid or SSI. You should receive a check in the mail from your plan. If you are in a plan that is above the benchmark amount you may want to consider switching to a plan that is at or below the benchmark amount that has your drugs on its formulary and covers them with little or no restrictions. If you stay in your plan that is above the benchmark amount, you will have to pay the amount above the benchmark amount.

If you have Medicaid when you become eligible for Medicare:

If you had Medicaid before you became eligible for Medicare, your drug coverage will usually change once you become eligible for Medicare. When you have Medicare, Medicaid will no longer cover drugs that Medicare covers. In some limited cases, Medicaid may provide coverage for drugs that Medicare does not cover, but in most cases you will receive your drugs through a Medicare Part D prescription drug plan.

  • Medicare will automatically enroll you in a benchmark Part D plan, so you will not have to pay a premium. A benchmark plan is a plan that is at or below the amount that Extra Help will pay for a Part D plan premium in your state. This plan will start when your Medicare starts. Medicare will send you a yellow notice telling you which plan it has enrolled you in and what its costs are. 
  • If this plan does not fit your needs, you should choose another plan. When choosing a plan it is important to find a plan that has your drugs on its formulary with as few restrictions as possible. A formulary is a list of drugs that the plan covers. Examples of restrictions are when a plan requires you to get permission before you can get the drug, or when a plan limits the amount of a drug you can get. Having Extra Help allows you to change your drug plan at anytime. 

If you have certain types of retiree coverage you may not need to enroll in a Part D plan.  Some retiree plans do not work with Part D, and if you enroll in a Part D plan you may lose your retiree or union coverage. If you have prescription drug insurance through an employer, check with your employer to see if you can get a Part D plan and still keep your current coverage. If you cannot have both, you will want to think carefully about whether you should get a Part D plan, especially if your employer plan covers more than just prescription drug. This is also important if it covers your spouse or dependents who are not eligible for Medicare coverage. If you choose not to take Part D, you will need to contact your state Medicaid office to find out what steps you should take to decline Part D coverage and still keep your Medicaid.

  • If the pharmacist cannot verify that you have Part D when you try to get a prescription filled, LI NET should cover your prescriptions until your Part D coverage starts.  
    • You should show the pharmacist the yellow letter from Medicare to prove LI NET should cover you. You can also use other forms of proof (Best Available Evidence) such as your Medicaid card or a letter from Medicaid.