Medicare Part D
Medicare Part D is available to anyone who qualifies for Original Medicare.
Purchasing a standalone Part D plan or receiving one through a Medicare Advantage plan from a private insurance company is the only way to receive this prescription drug benefit.
If you decide not to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty if you join later, unless one of these applies:
- You have other creditable prescription drug coverage
- You get “Extra Help”
How Medicare Part D works
Each Part D plan must meet a certain standard of coverage set by Medicare. Plans have a list of prescription drugs they cover (called a formulary) and place drugs into different “tiers” on these formularies.
The formulary includes at least two drugs in the most commonly prescribed categories and classes.
The formulary might not include the specific drug you are used to taking. However, in most cases, a similar one should be available. If you or your doctor believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.
Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
In some cases, if your drug is in a more expensive tier and your doctor thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment.
How to use your Part D card
When you have to use your Part D card in person, you’ll need your red, white, and blue Medicare card, your photo ID, and your Part D membership card.
Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. Now, to avoid waste or unwanted costs, plans have to get your approval to deliver a prescription (new or refill) unless you ask for the refill or request the new prescription. Some plans may ask you for your approval every year so that they can send you all new prescriptions without asking you before each delivery. Other plans may ask you before each delivery.
Medicare drug plans have contracts with network pharmacies. These pharmacies have agreed to provide members of Part D plans a discounted price. In some Part D plans, your prescriptions are only covered if you get them filled at network pharmacies.
Along with retail pharmacies, your plan’s network might include preferred pharmacies, a mail-order program, or an option for retail pharmacies to supply a 2- or 3-month supply.
- Preferred pharmacies: You may save money on your out-of-pocket prescription drug costs at a preferred pharmacy because it has agreed with your plan to charge less.
- Mail-order programs: Get up to a 3-month supply of your covered prescription drugs sent directly to your home.
2- or 3-month retail pharmacy programs: Participating retail pharmacies that offer a 2- or 3-month supply of covered prescription drugs.
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Medicare Part D
Medicare Part D is a private insurance plan that covers your prescription drugs.
Original Medicare does not come with this kind of coverage. You’ll have to purchase a standalone plan or receive it through a Medicare Advantage plan.
What does Medicare Part D cover?
Each Part D plan is required to provide a standard level of coverage set by Medicare.
The list of drugs covered on your plan is called a formulary.
Plans also typically place the drugs covered into different “tiers” on the formulary.
Both brand-name prescription drugs and generic drugs are included and that’s normally how the tiers are decided. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes.
A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.
However, they have to give you at least 30 days notice unless the FDA says the drug is unsafe or its maker withdraws it from the market.
Are there any drugs not covered?
There are some drugs that will not be covered under any prescription drug plan:
- Weight loss or weight gain drugs
- Any drugs for hair growth
- Fertility drugs
- Drugs for erectile dysfunction
- Any over-the-counter drugs
The costs associated with Part D
Your premium will depend on your area, but there are a few costs associated with a prescription drug plan you can compare when shopping plans:
- Late enrollment fee
You will fare much better if you sign up when you are first eligible — when you are first eligible for Medicare. Your initial enrollment period spans the three months before you turn 65 and the three months after your 65th birthday.
There are drugs all plans are required to cover
Each Part D plan is required to cover all drugs in the following categories:
- HIV/AIDS treatment
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Anticancer drugs (unless they are being covered under Part B)
Most vaccines are also covered under Part D unless they were already paid for under Part B.
Missed your initial enrollment period?
You can always purchase a plan during the annual election period that runs from October 15 through December 7.
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