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What is Medicare Part D?

Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.

 

List of covered prescription drugs (formulary)

 

Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.

The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an Exception.

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.

Plans offering Medicare prescription drug coverage under Part D may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards.

For other changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:

  • Give you written notice at least 30 days before the date the change becomes effective.
  • At the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change.

For 2019 and beyond, drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re taking these drugs, you’ll get information about the specific changes made to generic drug coverage afterwards.

You may need to change the drug you use or pay more for it. You can also ask for an exception. Generally, using drugs on your plan’s formulary will save you money. If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generic drugs instead of brand-name drugs may save you money.

 

Generic drugs
 

The Food and Drug Administration (FDA) says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:

  • dosage form
  • safety
  • strength
  • route of administration
  • quality
  • performance characteristics
  • intended use

Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber about your generic drug coverage.

 

Tiers
 

To lower costs, many plans offering prescription drug coverage place drugs into different “Tiers” on their formularies. 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.

Here’s an example of a Medicare drug plan’s tiers (your plan’s tiers may be different):

  • Tier 1—lowest Copayment : most generic prescription drugs
  • Tier 2—medium copayment: preferred, brand-name prescription drugs
  • Tier 3—higher copayment: non-preferred, brand-name prescription drugs
  • Specialty tier—highest copayment: very high cost prescription drugs

In some cases, if your drug is in a higher (more expensive) tier and your prescriber 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.

Remember, this is only an example—your drug plan’s tiers may be different.

Q: Does Medicare include coverage for prescription drugs?
A: No. If you have Original Medicare and want drug coverage, you may want to think about joining an optional stand-alone Part D plan. This is a private insurance plan that covers prescription drugs only.  Many Medicare Advantage plans already include Part D.
Q: What are Medicare Part D (Prescription Drug) plans?
A: These plans are a voluntary way for people with Medicare to have prescription drug coverage. Most people must enroll to have Part D – it is usually not automatic. The plan may be a stand-alone plan, or be included as part of a Medicare Advantage plan.
 

What do Part D plans cover? Prescription drug costs only. Each plan has a formulary, or list of drugs it covers. It may have rules about how it covers specific drugs. For certain medications, the plan may have quantity limits, or requirements that you try other drugs first. 
Who can buy Part D plans? Anyone with Medicare Part A, Part B, or both. You also must live in the plan’s service area. You can only have one Part D plan at a time. 
What do Part D plans cost? Costs vary widely. Part D plans have a monthly premium, and also can have deductibles and copayments or coinsurance. People with income above $85,000 (single) and $170,000 (couple) pay higher premiums. 
Most plans include a coverage gap (donut hole) after your prescription costs meet a certain amount in the Initial Coverage Level. You may pay a higher coinsurance amount during the coverage gap. You still pay your premiums for Medicare Part B (and Part A, if any). 
Your costs for Part D also can vary widely based on the: 

  • Plan you select 
  • Medications you take 
  • Pharmacies you use to get prescriptions filled 


If you have a late-enrollment penalty for Part D, the plan will add this to your premium.

Medicare contracts with private companies to offer this drug coverage. Premiums, deductibles, co-payments, co-insurance and specific drugs covered vary depending on which drug plan you choose.
Q: Once I choose a Part D plan, do I have to keep it forever?
A: No. You can change plans every fall. Your new plan will start Jan. 1. Some people also get more chances to change, or special enrollment periods for other events (such as moving, losing group insurance, or qualifying for help with costs). To switch plans, just enroll in the new plan (Medicare will notify your old plan). 
Q: What is the Late Enrollment Penalty (LEP)?
A: While Part D is optional, some people who join Part D later than when they first qualify may have to pay a late-enrollment penalty.   
Q: What questions should I ask when selecting a Part D Plan?
A: 
  • Are all my medications on the formulary?
  • Do any of my medications have limitations, such as requiring use of tiers, prior approval, step therapy, or quantity limits?
  • What pharmacies can use with this plan?
  • Will I have different costs depending on which ones I go to?
  • What is the monthly premium for the plan?
  • Do I have to meet a deductible before the plan starts to provide coverage? If yes, how much is it? How long does it look like it will take me to reach that amount?
  • What will I have to pay each month for my medications? Will there be any variation month to month, such as when I reach the coverage gap?
  • If I get medications by mail order, will this save me money? Yes No Can I get my medications in 90-day supplies? Will this save me money?
  • What is the total yearly cost to me for the plan (premiums, deductible, co-payments, etc)?
Q: When may I join a Part D plan?
A: You may sign up for a drug plan during your initial enrollment period when you first become eligible for Medicare (three months before the month you turn age 65, the month you turn 65, and until the end of the third month after you turn age 65). If you get Medicare due to a disability, you will have the same 7 month window of time but it will be based on the month that your Medicare begins. If you don’t sign up for a drug plan when you are first eligible, you may pay a penalty when you later start a drug plan. If you already have Medicare, you can join Part D every fall from October 15 through December 7. The plan starts Jan. 1.  You also may have special enrollment periods to join Part D at other times in the year, such as if you lose creditable coverage, move, or if you receive Extra Help such as the Medicare Savings Programs or Medicaid.
Q: How do I join a Part D plan?
A: Sign up first for Original Medicare with Social Security. Then join the Presciption Drug Plan (Part D):
  • By speaking with one of our licensed agents at (920) 858-8752

 or

Everyone with Medicare, regardless of income, health status, or prescription drugs used, can get prescription drug coverage.
 
You may sign up for a drug plan during your initial enrollment period when you first become eligible for Medicare (three months before the month you turn age 65, the month you turn 65, and until the end of the third month after you turn age 65). If you get Medicare due to a disability, you will have the same 7 month window of time but it will be based on the month that your Medicare begins. If you don’t sign up for a drug plan when you are first eligible, you may pay a penalty when you later start a drug plan.
 
Q: Are there programs to help me pay for Medicare and my Part D Plan?
A: Yes. These programs are typically based on your income level. Contact Social Security and/or your state’s Medicaid to see if your qualify.

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Allboc Insurance Solutions, LLC is a licensed and certified representative of a Medicare Advantage (HMO, PPO, and PFFS) organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in any plan depends on contract renewal. By completing the contact form above or calling the number listed above, you will be directed to a licensed sales agent who can answer your questions and provide information about Medicare Advantage, Part D or Medicare supplement insurance plans. Availability of carriers and products are dependent on your resident zip code.

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