Prescription Drug Coverage (also known as Medicare Part D)

What Part D Plans Cover

  • Offered by private companies contracting with Medicare
    • Each plan has a list of drugs it covers and a list of pharmacies beneficiaries may use
  • Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost.
    • For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
  • In some cases, if your drug is on a higher tier and your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

How Part D Works

  • Prescription drug coverage
  • Everyone with Medicare may join
    • If turning 65 can sign up to 3 months before, and up to 3 months after birthday (3-1-3)
    • During Annual Enrollment Period (October15- December 7th)
    • Special enrollment Period (SEP)

Two Ways to Get Medicare Drug Coverage

1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

Note: both types of plans are called “Medicare drug plans.” In either case you must live in the service area of the Medicare drug plan you want to join.

Enrolling in Part D

  • For most people, next chance to join or switch is October 15th-December 7th
    • The new plan will take effect January 1
  • Contact the plan directly by phone, online or call 1-800-Medicare or 1-800-548-9034 (SHIP Hotline) for assistance in enrolling

Late Enrollment Penalty

  • There is a penalty if you don’t join a plan when you are first eligible. If you join later you pay:
    • o 1% extra premium for each month you were eligible but didn’t enroll in a plan
  • Have to pay this penalty as long as you are enrolled in Part D plan
  • If eligible for Extra Help and subject to the penalty, it will be waived.

How Can You Prepare To Enroll?

  • September- Emeritus need to know what plan covers and how much it will cost
  • October - Shop and compare plans
  • October - December-switch plans if you want by the first week of December to begin new plan effective January 1st

Joining a Medicare Drug Plan May Affect Your Medicare Advantage Plan

If your Medicare Advantage Plan includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you'll be dis-enrolled from your Medicare Advantage Plan and returned to Original Medicare.

Medicare Drug Plan Coverage Rules

  • Prior authorization - You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
  • Quantity limits - Limits on how much medication you can get at a time.
  • Step therapy - You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.

If you or your prescriber believe that one of these coverage rules should be waived, you can ask for an exception.

If you have questions about Medicaid, you can call your State Medicaid office for more information.

Visit www.medicare.gov/contacts or call 1-800-MEDICARE (1-800-633-4227) to get the telephone number. TTY users should call 1-877-486-2048.