Medicare Eligibility

It's important to know when you are eligible to enroll in Medicare. If you miss your window, you may have to pay more to join, or you may have fewer choices.

If you are a retiree covered by an employer-sponsored health care plan, it may be a good idea stay in your current plan. Before you evaluate your choices, check with a human resources or union representative at your former employer to make sure you understand the full extent of your current medical coverage.

Medicare Parts A and B (sometimes called "Original Medicare")

Who is eligible for Medicare Parts A and B?

  • Most people 65 and older, who are U.S. citizens or legal residents who have lived here for at least five consecutive years.
  • People under age 65 with certain disabilities.
  • People of all ages with end-stage renal disease.

Medicare Advantage

To be eligible for Medicare Advantage plans, people ages 65 and older or with qualifying disabilities must:

  • Have both Medicare Part A and Part B.
  • Continue to pay the Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.
  • Reside in the service area of the plan.
  • Not have end-stage renal disease (ESRD). (Exceptions apply.)

Medicare Part D Plans

You are eligible for a Part D plan if:

  • You are entitled to Medicare benefits under Part A or enrolled in Medicare Part B.
  • You reside in the service area of the Part D plan, which includes the United States, Washington, D.C. and United States territories.

Rules about Part D eligibility include:

  • You may be enrolled in only one Medicare prescription drug plan (Part D) at a time.
  • You must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid or by another third party.
  • If you are enrolled in a Medicare Advantage HMO, POS, PPO or Private Fee-for-Service (PFFS) plan that includes Medicare prescription drug coverage and you enroll in a PDP, you will be automatically disenrolled from the HMO, POS, PPO or PFFS plan.
  • If you are in a PFFS plan that does not provide Medicare prescription drug coverage, or a Medicare Advantage Medical Savings Account (MSA) plan, you may enroll in a Medicare Part D prescription drug plan. Additionally, if you are in an 1876 Cost plan, you may enroll in a prescription drug plan.

Medicare Supplement Insurance plans

If you choose Medicare Parts A and B (sometimes called "Original Medicare"), you can add a Medicare Supplement Insurance policy, to get additional coverage.

Medicare guarantees you the right to buy any Medicare Supplement Insurance policy available where you live during the six months after you turn 65 and enroll in Medicare Part B. This is also called your open enrollment period. The insurer can't consider your medical history or current health in setting the premium during this time. There are certain situations in which you have the right to buy a policy, regardless of your health, after your open enrollment period ends.

Questions? Call UnitedHealthcare at:
1-877-699-5710
(TTY 711)
Hours: 8 a.m.-8 p.m. local time,
7 days a week

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Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental plan (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage, vision and hearing coverage and fitness programs.

Creditable Coverage

Refers to prescription drug coverage that offers benefits the same as or better than coverage available through Medicare.

Tier 1: Preferred Generic. Lowest Copay.

This tier includes lower-cost, commonly used generic drugs. Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2: Non-Preferred Generic. Low Copay.

This tier includes most generic drugs. Use Tier 2 drugs, instead of Tier 3 or 4, to help reduce your out-of-pocket costs.

Tier 5 : Specialty Tier. Coinsurance.

This tier includes unique and/or very high-cost drugs. You pay a percentage of the total drug cost, called coinsurance.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Tier 3: Preferred Brand. Medium Copay.

This tier includes many common brand name drugs, called preferred brands, and some higher-cost generic drugs. Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Drug List tool tip

A list of drugs covered by your Medicare Part D plan. A drug list may also be referred to as a covered prescription drugs list (CML), a preferred drug list (PDL), a select drug list or a formulary. These drugs are dispensed through participating network pharmacies to covered members. Drug lists may differ between Medicare prescription drug plans.


Carefully weigh the differences in drug lists against the plan costs and other features when choosing a plan that may best meet your needs. A drug list may change during the year.

Tier 2: Low Copay

This tier includes most generic drugs. Use Tier 2 drugs, instead of drugs in Tiers 3 or 4 to help reduce your out-of-pocket costs.

Coverage Gap Stage:

During the Coverage Gap Stage, you (or others on your behalf) will pay no more than 72% of the total cost for generic drugs or 47.5% of the total cost for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $4,550 in year-to-date out-of-pocket costs.

You may pay less if your plan has better coverage in the gap.

Always use your Medicare Part D member ID card during the coverage gap to get the plan's discounted drug rates. The money you spend using your card counts toward your out-of-pocket costs.

Out-of-Pocket Costs:

The amount you (or others pay on your behalf) pay for prescription drugs starting January 1, 2013 not including premiums.

Premium (or monthly premium)

The monthly fee you pay for Medicare coverage.

Deductible/annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drug costs before Medicare or the plan begins to pay.

Deductible/Annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drugs costs before the insurance company or Medicare begins to pay.

Coinsurance

A kind of cost sharing where you pay a percentage of the cost of a service. For example, a plan might pay 75% and you would pay 25%. In Medicare Advantage, coinsurance varies depending on the plan.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an annual check-up.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an office visit.

Primary Care Physician's name and ID

Your primary care physician (PCP) plays an important role in your health care, and we want you to have the opportunity to select one you are comfortable with. Your PCP can:

  • Help you make good lifestyle choices to maintain and improve your health.
  • Serve as a direct point of contact in case of an emergency.
  • Manage the drugs prescribed to you and identify potential adverse interactions.
  • Coordinate the care of specialists who may diagnose and treat your conditions.
  • Help ensure that you are getting the care you need while helping to minimize your out-of-pocket costs.

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