Medicare Part D Prescription Drug plans
Prescription Drug Coverage
Beginning in 2006, insurance coverage for prescription medications was made available for people with Medicare. Medicare Part D Prescription Drug plans often require you to pay for some of your prescription drugs before the plan begins to pay. Generic medications typically are more affordable as compared to name brand medications. Each Part D plan features a Formulary – a listing of all prescription medications that are covered by the plan. Prescription Drug plans are run by private insurance companies that follow rules set by Medicare.
Key Facts
- Available to anyone who is enrolled in Medicare (Part A or Part B or Parts A & B)
- Provided by private insurance companies contracted with Medicare.
- You are only allowed to have one Prescription Drug plan at a time.
- You must live in the service area of the Part D plan you want to join.
- If you don’t enroll when you are first eligible you will pay a penalty of 1% for every month that you did not enroll.
- You can get “Extra Help” which is a low-income subsidy (LIS) Medicare program that helps people with limited income and resources pay for Medicare prescription drug costs.
Important Restrictions and Limitations
- Prior Authorization: The plan you enroll in may require prior authorization for certain medications. Your prescriber may need to show that the prescription drug is medically necessary for the plan to cover it.
- Formulary: Each Medicare Part D Prescription Drug plan has its own list of covered medications. The list of prescription drugs covered by your plan can add or remove medications it covers every year. Prescription drugs are placed in different “tiers” representing different costs.
- Tier 1 – preferred generic
- Tier 2 – non-preferred generic
- Tier 3 – preferred brand name
- Tier 4 – non-preferred brand name
- Tier 5 – Specialty tier
- Quantity Limits: The plan you enroll in only covers a specific amount and type of prescription drug over a specific timeframe.
- Step Therapy: Your Prescription Drug plan may require you first try certain prescription drugs that have been proven for most people with your condition before you can move up a “step” to a more expensive prescription drug. If you have already tried a similar medication and they didn’t work, your prescriber can contact the plan to ask for an exception. If approved your plan will cover the step-therapy prescription drug.
- Safety Checks: Prior to filling your prescriptions, your Part D plan works with pharmacies to perform additional safety checks, like checking for prescription drug interactions, incorrect dosages, and unsafe amounts of certain medications (like opioids and benzodiazepines).
- Prescription Drug Management Programs: Some Medicare Part D plans have a program in place to help you use these opioids and benzodiazepines safely. If you get opioids from multiple doctors or pharmacies, your plan will contact the doctors who prescribed these medications to make sure they are medically necessary and that you’re using them appropriately.
How Medicare Part D Prescription Drug Coverage Works
Medicare Part D Prescription Drug plan costs will vary depending on:
- Your prescriptions and whether they’re on your plan’s formulary (list of covered prescription drugs) and depending on what “tier” the prescription drug is in.
- Which phase of your prescription drug benefit that you’re in (some examples include whether or not you met your deductible, if you’re in the catastrophic coverage phase, etc.).
- The plan you choose. Remember, plan coverage and costs can change each year.
- Which pharmacy you use.
Whether or not you get Extra Help paying your Medicare Part D costs