Table of Contents:
- What is Medicare Part D?
- Medicare Part D Glossary of Terms
- Medicare Part D Coverage
- Medicare Part D Costs
- Medicare Part D and Other Insurance Plans
WHAT IS MEDICARE PART D?
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.
Medicare Part D Glossary
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.
MEDICARE PART D COVERAGE
What Do Medicare Part D Plans Cover?
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.
What if Part D Doesn’t Cover My Preferred Prescription?
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:
- Give you notice at least 30 days before the effective date of the change; or
- Provide written notice of the change and at least one month’s supply of the medication at the time a refill is requested.
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.
What is the Medicare Part D Donut Hole?
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.
MEDICARE PART D COSTS
What are the Costs of Medicare Drug Coverage?
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.
- Annual deductible
- Coinsurance or copayments
- Coverage gap costs
- Extra Help costs
- Late enrollment penalties
Extra Help for Medicare Part D Coverage
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.
Do I Qualify for Extra Help?
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.
Is There a Late Enrollment Penalty for Medicare Part D Plans?
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.
How much is the Part D penalty?
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
How do I know if I owe a Part D penalty?
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
MEDICARE PART D AND OTHER INSURANCE PLANS
How Does Part D Work with Other Insurance?
- Employer or Union Health Coverage: If you have drug coverage based on current or past employment, your employer or union will notify you each year to let you know if your drug coverage is creditable.
- Medicare Supplement Insurance (Medigap) policy with prescription drug coverage: It may be to your advantage to join a Medicare drug plan because most Medigap plans do not provide prescription drug coverage. You may pay more if you decide to join a drug plan later.
- Medicaid: Drug costs are covered by Medicaid. You’ll need to join a Medicare drug plan for Medicare to pay for your drugs.
- Supplemental Security Income Benefits: If you get benefits or help from your state Medicaid program paying your Medicare premiums, you will need to join a Medicare drug plan for Medicare to cover your drugs. You automatically qualify for Extra Help with prescription drug costs.
- State Pharmaceutical Assistance Program: Each state decides how its State Pharmaceutical Assistance Program (SPAP) works with Medicare prescription drug coverage.
- Federal Employee Health Benefits (FEHB) Program: These plans include creditable prescription drug coverage, so you don’t need to get Medicare drug coverage.
- Veterans’ Benefits: You might be able to get drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you can’t use both types of coverage for the same drug at the same time.
- TRICARE (military health benefits): You don’t need to join a Medicare plan if you have TRICARE. But if you do, your Medicare drug plan pays first, and TRICARE pays second.
- Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): You may join a Medicare drug plan, but if you do, you won’t be able to use the Meds by Mail program which can give your maintenance drugs to you at no charge (no premiums, deductibles, and copayments).
- Indian Health Services: If you get drugs through an Indian health facility, you’ll continue to get drugs at no cost to you, and your coverage won’t be interrupted. Joining a Medicare drug plan or Medicare Advantage Plan with drug coverage may help your Indian health facility because the plan pays the Indian health facility for the cost of your drugs.
Do Medicare Advantage Plans Cover Prescription Drugs?
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.
How to Join a Medicare Drug Plan
Once you choose a Medicare drug plan, enroll one of these five ways:
- Enroll on the Medicare Plan Finder or on the plan’s website
- Complete a paper enrollment form
- Call the plan
- Call Twin City Underwriters: Phone: (651)-444-1190; Toll Free: 800-507-6778
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.
We’re Here to Help!
Questions about Medicare Part D prescription drug coverage? Twin City Underwriters offers free informational Medicare webinars and one-on-one meetings with agents where you can ask questions and get personal answers. We can help you select the right prescription drug 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.