Original Medicare does not cover most prescription medications. In order to access prescription drug coverage, you must purchase a Medicare Part D plan. This is a prescription drug plan (PDP) in which you buy Part D coverage from a private insurance company that has a contract with Medicare. This provides coverage for prescriptions that are filled at pharmacies in retail and health care facilities.
PDP: Prescription Drug Plan.
Co-insurance:The amount you may be required to pay as your share of the cost for services after you pay any deductibles. It is usually a percentage.
Co-pay: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage.
Formulary: A Medicare Part D plan’s list of covered medications.
Donut Hole: The coverage gap that is inherent in most Medicare PDP plans. This is a temporary limit on what the plan will cover, and it begins after you have reached a specified limit for spending on covered drugs.
Extra Help: A program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.
All Medicare Part D plans are required to cover an extensive range of prescription drugs that are typically taken by people with Medicare. This includes most drugs in certain protected classes, such as drugs to treat cancer or HIV/AIDS. Each plan has its own list of covered medications, or formulary. Plans generally place drugs into different tiers with corresponding cost levels. In most cases, a medication in a lower tier costs less than one in a higher tier.
Does Medicare Part D Cover Insulin?
Beginning January 1, 2021, people who take insulin may be able to get Medicare drug coverage that offers insulin savings. You could pay no more than $35 for a 30-day supply, depending on the details of your Part D plan. Learn more about insulin coverage through Medicare Part D, and contact us to discuss your needs and options
All Part D plans generally must cover at least two drugs in each drug category, but plans can choose which to cover. Coverage can include both name-brand and generic medications, but there is no requirement to cover a generic.
Does Part D Cover a Shingrix or Zostavax Shingles Vaccine?
Medicare Part D covers a shingles vaccine, but there may be a copay or up-front payment required. Visit this blog post to learn more.
If a medication isn’t covered by your Part D plan, you can request an exception. Your health care provider will be asked to provide a supporting statement explaining the medical reason for that specific medication.
If a Part D plan makes changes to coverage of a drug you’re taking, the plan must:
Learn more about Medicare Part D at a FREE informational webinar. Visit our calendar of events to register for the webinar that fits into your schedule.
When people talk about the Medicare “donut hole,” they’re referring to the coverage gap that is inherent in most Medicare PDP plans. This is a temporary limit on what the plan will cover, and it begins after you have reached a specified limit for spending on covered drugs. (In 2021, this limit is $4,130. The amount may change every year.
Blog post: WHAT IS THE MEDICARE DONUT HOLE?
Not all Medicare recipients enter the coverage gap. Those who get help paying Part D costs aren’t subject to a spending limit.
Once you reach the “donut hole,” you’ll pay up to 25% of the cost for your plan’s covered brand-name prescription drugs. Some plans may offer lower costs. The discount for each specific medication will be based on the price that your Part D plan has set at the pharmacy.
There is a premium for Part D. In addition, Part D plans include co-insurance in the form of co-pays, deductibles, or co-insurance as a percentage of the cost of the medications. The formulary on each PDP is different. When choosing a plan, you will want to ensure your current prescriptions are on the formulary.
Under a Medicare Part D plan, there are payments required throughout the year. Some may not apply to your specific situation.
Extra Help is a program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance. If you get Extra Help but you’re not sure if you’re paying the right amount, call your drug plan. Your plan may ask you to give information to help them check the level of Extra Help you should get.
Depending on your situation, you may automatically qualify for Extra Help. This is determined by income and resources, and whether you receive Medicaid and/or Supplemental Security Income. If you don’t automatically qualify for Extra Help, you can apply at any time.
Once you qualify for Extra Help, you’ll have it as long as you meet current income and resource limits. If there are changes to your financial situation, you may no longer qualify.
If you have 63 or more consecutive days without Medicare or other creditable drug coverage at any time after your Initial Enrollment Period ends, you may receive a late enrollment penalty. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.
The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. The amount may change every year
If you don’t agree with the late enrollment penalty, you can ask for a reconsideration. Your drug plan will send you information about how to request a reconsideration. In general, Medicare’s contractor makes reconsideration decisions within 90 days
If you join a Medicare Advantage Plan, you’ll usually get drug coverage through that plan. Certain types of plans can’t offer drug coverage (like Medical Savings Account plans) or choose not to offer drug coverage (Private Fee-for-Service plans). If you have one of these plans, you can join a separate Medicare drug plan.
Talk to your current plan if you have any questions about what will happen with your coverage.
Once you choose a Medicare drug plan, enroll one of these ways:
When you join a Medicare drug plan, you’ll give your Medicare Number and date your Part A and/or Part B coverage started. This information is on your Medicare Card.
Get all the answers to your Medicare questions in our Medicare Resource Guide.
Do you have questions about Medicare, and which plan is right for you? Twin City Underwriters offers free informational Medicare webinars and one-on-one consultations with agents where you can ask questions and get personal answers. We can help you select the right coverage for your needs. To attend a webinar or set up an appointment, call us toll free at 1-800-507-6778 or send us a message.
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