A good prescription insurance plan is an important part of maintaining your health and overall quality of life.
If you’re 65 or older, or if you have a qualifying disability, you may already know that you’re eligible for Medicare.
- Medicare Part A covers hospital stays and may include medications administered while in the hospital.
- Medicare Part B covers preventive care and other medical services outside of the hospital. It may cover medications administered at the doctor’s office.
But what if your doctor writes a prescription for one or more medications to take at home? For that, you need to enroll in a separate prescription drug plan under Medicare Part D.
What is Medicare Part D? What are your options when it comes to Part D? How do you sign up? How much will it cost you, and will you be able to get the medications you need?
Keep reading for answers to some of the most common questions people have about Medicare Part D.
#1: Are you eligible for Medicare Part D?
You are eligible to sign up for Medicare, including a Part D plan, under the following circumstances:
- When you turn 65. More specifically, you have a 7-month window in which to sign up without incurring a late penalty. The window runs from 3 months before to 3 months after your 65th birthday.
- If you’re younger than 65 but have a qualifying disability.
- If you’re already over 65 and lose private drug coverage, such as through an employer or union.
- If you’re over 65 and lose drug coverage under COBRA.
- If you’re over 65 and return to the United States after living abroad.
- If you’ve been released from prison, and turned 65 while in prison.
Anyone with Medicare can get prescription drug coverage regardless of income. There is no physical exam required, and you cannot be denied for health reasons.
If you already have drug coverage through an employer or labor union, TRICARE or the VA, or the Indian Health Service, you can visit the Medicare website for more details on how Part D works with different types of coverage.
#2: Is Medicare Part D Mandatory?
Suppose you’re over 65 and still get prescription insurance coverage at work. Or you don’t currently take any prescriptions. Do you have to sign up for Medicare Part D anyway?
The short answer is Medicare prescription drug coverage is voluntary for most people. However, it’s a good idea to enroll as soon as you’re eligible for several reasons:
- If you aren’t taking any prescription medications right now, think of prescription coverage like other forms of insurance. If you go ahead and invest in it now, it’ll be there when you do need it in the future.
- If you don’t enroll in Medicare Part D during your initial eligibility period, you can still sign up in the future but you will pay a penalty that will be added to your annual premium.
- If you’re over 65 and still working, you may continue to get prescription coverage through your employer or union. If you stop receiving your private coverage upon retirement, you will have 63 days to enroll in Medicare Part D without incurring a late penalty.
#3: What Medicare Drug Plans Are Available?
You can get Medicare prescription drug plans in one of two ways, depending on whether you’re enrolled in traditional Medicare or a Medicare Advantage Plan, also called Part C:
- Traditional Medicare. When you turn 65, you’re automatically enrolled in Medicare Part A, which covers hospital stays, and Part B, which covers care outside of the hospital. You may also sign up for Medicare Part D, which simply adds prescription drug coverage to these original Medicare plans.
- Medicare Advantage Plan. If you choose Medicare Part C, you may sign up for an approved Medicare Health Plan that includes prescription coverage.
#4: What Does Medicare Part D Cover?
You can compare different Part D plans to see which medications they cover. Each plan publishes a list called a formulary, which organizes covered drugs into four tiers:
- Tier 1 includes generic drugs. These medications tend to be the least expensive.
- Tier 2 includes medium-cost “preferred” brand name medications.
- Tier 3 includes more expensive “nonpreferred” brand names.
- Tier 4 includes very expensive and rarely prescribed medications. All plans charge a % of the cost for the most expensive drugs in this tier.
If your doctor decides that you need a medication from a higher tier, you may be able to qualify for an exception to get a lower cost.
The plan you choose may change its formulary during the year. If this happens, the company must provide you with a written notice at least 60 days prior to the change, and must provide notice upon refill, along with a 60-day supply of the drug under pre-change rules.
You’ll also want to be aware of common restrictions found in Medicare Part D plans. To apply for an exception to these restrictions, your doctor must supply a statement that a more expensive medication and/or larger quantity are necessary to treat your condition.
- Prior authorization. This means you must get the plan’s prior approval before it will cover a particular medication.
- Step therapy. A plan may require you to take a generic or less expensive drug first. You may only take a more expensive medication if a cheaper one doesn’t work.
- Quantity limits. Your plan may only cover the dosage or quantity of a medication considered “normal.”
#5: How Much Does Medicare Part D Cost?
Premiums are set by individual drug plans. Your Medicare Part D cost will depend on which prescription medications you take and the plan you choose.
Some costs will also vary based on your income. Here’s a summary of what you pay:
- Monthly premium
- Annual deductible
- Copay or percentage on prescriptions
- Percentage of costs in the so-called “doughnut hole” coverage gap
- No more than 5% of drug costs in the “catastrophic period” after you’ve reached your out-of-pocket spending limit for the calendar year
There’s lots of variance in the costs and benefits of individual plans, so shop around to find the one that meets your needs. Compare premiums and deductibles, which medications are covered, copays and pharmacies included in the plan network.
If you have trouble affording the costs of your medications, you may qualify for Medicare Extra Help.
#6: When Does Medicare Part D Enrollment Take Place?
There are two occasions when you can enroll in a Medicare prescription drug plan:
- When you first get Medicare. See answers to Question 1 about eligibility.
- During the annual Medicare Part D open enrollment between October 15 and December 7. Because plans often change from year to year, it’s a good idea to shop around even if you’re happy with your current plan.
#7: How Can You Sign up for Medicare Part D?
If you’re new to Medicare, you’ll start by deciding which type of plan is best for you — Traditional Medicare or a Medicare Advantage Plan.
If you’re already enrolled, you don’t have to re-enroll, but you will want to review your plan once a year and make changes as plans change and your own needs evolve.
There are 4 ways to join a Medicare prescription coverage plan:
- Enroll online
- Complete a paper enrollment form
- Call the plan
- Call 1-800-MEDICARE (633-4227)
You can also get help by contacting us at Integrity Pharmacy. As part of our Medication Management plan, we will assist you in reviewing Medicare Part D plans and selecting the right prescription coverage plan for you.